Predicting the long-term impact of antiretroviral therapy scale-up on population incidence of tuberculosis.
OBJECTIVE
To investigate the impact of antiretroviral therapy (ART) on long-term population-level tuberculosis disease (TB) incidence in sub-Saharan Africa.


METHODS
We used a mathematical model to consider the effect of different assumptions about life expectancy and TB risk during long-term ART under alternative scenarios for trends in population HIV incidence and ART coverage.


RESULTS
All the scenarios we explored predicted that the widespread introduction of ART would initially reduce population-level TB incidence. However, many modelled scenarios projected a rebound in population-level TB incidence after around 20 years. This rebound was predicted to exceed the TB incidence present before ART scale-up if decreases in HIV incidence during the same period were not sufficiently rapid or if the protective effect of ART on TB was not sustained. Nevertheless, most scenarios predicted a reduction in the cumulative TB incidence when accompanied by a relative decline in HIV incidence of more than 10% each year.


CONCLUSIONS
Despite short-term benefits of ART scale-up on population TB incidence in sub-Saharan Africa, longer-term projections raise the possibility of a rebound in TB incidence. This highlights the importance of sustaining good adherence and immunologic response to ART and, crucially, the need for effective HIV preventive interventions, including early widespread implementation of ART.
Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom ; TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Peter J
PJ
Dodd
Gwenan M
GM
Knight
Stephen D
SD
Lawn
Elizabeth L
EL
Corbett
Richard G
RG
White
D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000009:adverse effects / Q000627:therapeutic use; D023241:Antiretroviral Therapy, Highly Active / Q000009:adverse effects*; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D008962:Models, Theoretical; D062486:Public Health Surveillance; D014376:Tuberculosis / Q000453:epidemiology* / Q000209:etiology*
D019380:Anti-HIV Agents