The World Health Organization’s most recent guideline for the treatment of HIV recommends ART for all individuals living with HIV. Although this new recommendation is gaining traction among wealthier countries, many countries have not yet adopted this guideline. Instead, those countries follow a strategy of providing ART only to people with low CD4+ T-cell counts, which was necessary early in the HIV epidemic, but it is unclear whether the use of CD4 counts was based on sound science and logic.
Botswana has made substantial progress towards meeting the UNAIDS 90-90-90 target by 2020 under which 90% of people living with HIV will know their status, 90% of these will be on anti-retroviral therapy (ART), and 90% of these will have viral loads below 400/µL. In this paper we use a previously published model for Botswana to assess the future impact of their HIV control programme on new HIV infections, AIDS related mortality and the costs of doing this. We show that while treatment will have a major impact on incidence and mortality and will lead to net cost savings, prevention will lead to further small reductions in incidence and mortality, but will entail significant cost increases.
Africa and Asia have the highest prevalence of Hepatitis B virus (HBV) worldwide. Mother-to-child transmission (MTCT) is the most common route of transmission in high prevalence areas. There are three different prevention strategies available to prevent HBV MTCT: Vaccine, Hepatitis B Immunoglobulin and Antiviral therapy during pregnancy. Strategic investment now could see the eradication of HBV MTCT in Africa and ultimately potentially the elimination of this major public health problem.
As coverage of paediatric ART increases and guidelines for ART initiation change, it will be necessary to determine how best to monitor ART. Routine monitoring of HIV viral load is common practice in ART programmes in high-income countries, but, in sub-Saharan Africa, most ART programmes rely on CD4 cell measurements or clinical monitoring to detect treatment failure. We conducted a computer simulation of HIV-positive children to predict the effect of different ART monitoring strategies.
While in the past antiretroviral treatment (ART) for children aged 2-5 years was started only when the CD4 count or CD4% fell below a critical threshold, or a clinically severe event occurred, the new WHO 2013 guidelines recommend immediate treatment initiation regardless of the child’s immune status. Scientific evidence which can guide policies is sparse and conducting trials on the optimal timing of ART initiation is lengthy, costly, and ethically difficult. Instead, routinely captured observational data can be used to answer this question if the statistical analysis makes use of methods which allow a causal interpretation. One of these methods which allows causal interpretations is called “g-computation”.
Expanding ART coverage to healthier HIV patients is widely regarded as a potential strategy for addressing the rampant TB epidemic in high HIV-TB burden settings. Estimating the population-level impact of ART expansion on TB disease has proven challenging. We set out to estimate the potential effects of changing HIV treatment policy on TB outcomes in South Africa, comparing the results of three independent TB models. This project was part of a broader effort to shed light on the consequences of HIV policy changes, through model comparison and consensus building, a process pioneered in the HIV modelling field by the HIV Modelling Consortium.
On the occasion of AIDS 2014, the twentieth International AIDS Conference in Melbourne, SACEMA released a policy brief on the ongoing debate about appropriate initiation of antiretroviral therapy for HIV positive people.
Kaposi sarcoma (KS) is the most common tumour in HIV-infected individuals in Africa and is preceded by infection with Kaposi sarcoma herpes virus (KSHV). The influence of KS on response to ART is not well defined in resource-limited settings. Additionally, it is unclear if co-infection with oncogenic viruses such as KSHV places untreated HIV-infected patients at increased risk even without clinically apparent illness. The analysis presented here aimed to determine the effect of clinical disease due to KS and also to estimate the impact of co-infection with KSHV among HIV-1 infected adults receiving ART.
In recent years, scientific innovations in HIV control have expanded the range of available interventions – male circumcision, topical microbicides, oral pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) have all sparked significant interest due to their potential effectiveness and versatility. While all these options are potentially available, resources remain limited and choosing which interventions to implement at scale is a difficult task, given the complex nature of disease transmission, the impact of behaviour in epidemic dynamics, and the different costs of these programs. Here we analyse the effects of scaling up PrEP and ART for HIV prevention in South Africa, to help decision makers understand how these interventions would work if considered independently or in combination.
In 2011, the Ministry of Health in Swaziland joined forces with the WHO, the Global Fund and SACEMA to do the first in depth health programmes progress evaluation using triangulation from key empirical data sources. The focus was on key questions like: Given increasing coverage of ART, has ART reduced adult and/or infant mortality?; Can TB trends be related to trends in HIV prevalence, ART coverage and combined TB/HIV interventions?; Can trends in infant mortality be related to uptake of PMTCT?