Expansion of HAART Coverage Is Associated with Sustained Decreases in HIV/AIDS Morbidity, Mortality and HIV Transmission: The “HIV Treatment as Prevention” Experience in a Canadian Setting

• Published in: PloS one Vol. 9; no. 2; p. e87872
• Main Authors: Montaner, Julio S.G., Lima, Viviane D., Harrigan, P. Richard, Lourenço, Lillian, Yip, Benita, Nosyk, Bohdan, Wood, Evan, Kerr, Thomas, Shannon, Kate, Moore, David, Hogg, Robert S., Barrios, Rolando, Gilbert, Mark, Krajden, Mel, Gustafson, Reka, Daly, Patricia, Kendall, Perry
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 12.02.2014; Public Library of Science (PLoS)
• Subjects: Acquired immune deficiency syndrome; Acquired Immunodeficiency Syndrome - drug therapy; Acquired Immunodeficiency Syndrome - mortality; Acquired Immunodeficiency Syndrome - prevention & control; AIDS; AIDS treatment; Analysis; Antiretroviral agents; Antiretroviral drugs; Antiretroviral Therapy, Highly Active - methods; Antiretroviral Therapy, Highly Active - statistics & numerical data; Canada; CD4 antigen; CD4-Positive T-Lymphocytes - cytology; Communicable Disease Control; Consolidation; Cost analysis; Disease control; Disease prevention; Disease Progression; Disease transmission; Drug resistance; Drug Resistance, Viral; Drug therapy; Drugs; Epidemics; Expansion; Health aspects; Health sciences; Highly active antiretroviral therapy; HIV; HIV Infections - drug therapy; HIV Infections - mortality; HIV Infections - prevention & control; Human immunodeficiency virus; Humans; Incidence; Laboratories; Leadership training; Load resistance; Longitudinal Studies; Medical diagnosis; Medical tests; Medicine; Methods; Morbidity; Mortality; Patient compliance; Personal health; Poisson density functions; Poisson Distribution; Population; Prevalence; Prevention; Public health; Registries; Regression Analysis; Regression models; Statistical analysis; Sustainability; Sustainable development; Therapy; Treatment Outcome; Viral Load
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0087872

There has been renewed call for the global expansion of highly active antiretroviral therapy (HAART) under the framework of HIV treatment as prevention (TasP). However, population-level sustainability of this strategy has not been characterized. We used population-level longitudinal data from province-wide registries including plasma viral load, CD4 count, drug resistance, HAART use, HIV diagnoses, AIDS incidence, and HIV-related mortality. We fitted two Poisson regression models over the study period, to relate estimated HIV incidence and the number of individuals on HAART and the percentage of virologically suppressed individuals. HAART coverage, median pre-HAART CD4 count, and HAART adherence increased over time and were associated with increasing virological suppression and decreasing drug resistance. AIDS incidence decreased from 6.9 to 1.4 per 100,000 population (80% decrease, p = 0.0330) and HIV-related mortality decreased from 6.5 to 1.3 per 100,000 population (80% decrease, p = 0.0115). New HIV diagnoses declined from 702 to 238 cases (66% decrease; p = 0.0004) with a consequent estimated decline in HIV incident cases from 632 to 368 cases per year (42% decrease; p = 0.0003). Finally, our models suggested that for each increase of 100 individuals on HAART, the estimated HIV incidence decreased 1.2% and for every 1% increase in the number of individuals suppressed on HAART, the estimated HIV incidence also decreased by 1%. Our results show that HAART expansion between 1996 and 2012 in BC was associated with a sustained and profound population-level decrease in morbidity, mortality and HIV transmission. Our findings support the long-term effectiveness and sustainability of HIV treatment as prevention within an adequately resourced environment with no financial barriers to diagnosis, medical care or antiretroviral drugs. The 2013 Consolidated World Health Organization Antiretroviral Therapy Guidelines offer a unique opportunity to further evaluate TasP in other settings, particularly within generalized epidemics, and resource-limited setting, as advocated by UNAIDS.