Modeling the impact of early antiretroviral therapy for adults coinfected with HIV and hepatitis B or C in South Africa.
OBJECTIVE
There has been discussion about whether individuals coinfected with HIV and hepatitis C virus (HCV) or hepatitis B virus (HBV) (∼30% of all people living with HIV) should be prioritized for early HIV antiretroviral therapy (ART). We assess the relative benefits of providing ART at CD4 count below 500  cells/μl or immediate ART to HCV/HIV or HBV/HIV-coinfected adults compared with HIV-monoinfected adults. We evaluate individual outcomes (HIV/liver disease progression) and preventive benefits in a generalized HIV epidemic setting.


METHODS
We modeled disease progression for HIV-monoinfected, HBV/HIV-coinfected, and HCV/HIV-coinfected adults for differing ART eligibility thresholds (CD4 <350  cells/μl, CD4 <500  cells/μl, immediate ART eligibility upon infection). We report disability-adjusted life-years averted per 100 person-years on ART (DALYaverted/100PYonART) as a measure of the health benefits generated from incremental changes in ART eligibility. Sensitivity analyses explored impact on sexual HIV and vertical HIV, HCV, and HBV transmission.


RESULTS
For HBV/HIV-coinfected adults, a switch to ART initiation at CD4 count below 500  cells/μl from CD4 below 350  cells/μl generates 9% greater health benefits per year on ART (48 DALYaverted/100PYonART) than for HIV-monoinfected adults (44 DALYaverted/100PYonART). Additionally, ART at CD4 below 500  cells/μl could prevent 25% and 32% of vertical transmissions of HIV and HBV, respectively. For HCV/HIV-coinfected adults, ART at CD4 below 500  cells/μl generates 10% fewer health benefits (40 DALYaverted/100PYonART) than for HIV monoinfection, unless ART reduces progression to cirrhosis by more than 70% (33% in base-case).


CONCLUSIONS
The additional therapeutic benefits of ART for HBV-related liver disease results in ART generating more health benefits among HBV/HIV-coinfected adults than HIV-monoinfected individuals, whereas less health benefits are generated amongst HCV/HIV coinfection in a generalized HIV epidemic setting.
aSchool of Social and Community Medicine, University of Bristol, Bristol bSocial and Mathematical Epidemiology Group, London School of Hygiene and Tropical Medicine cDepartment of Health Services Research and Policy, London School of Hygiene and Tropical Medicine dDepartment of Infectious Disease Epidemiology, Imperial College London eBlizard Institute of Molecular Medicine, Queen Mary's University of London, London, UK fKirby Institute, University of New South Wales, Sydney, Australia gDepartment of HIV/AIDS, World Health Organization, Geneva, Switzerland.
Natasha K
NK
Martin
Angela
A
Devine
Jeffrey W
JW
Eaton
Alec
A
Miners
Timothy B
TB
Hallett
Graham R
GR
Foster
Gregory J
GJ
Dore
Philippa J
PJ
Easterbrook
Rosa
R
Legood
Peter
P
Vickerman
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044966:Anti-Retroviral Agents / Q000008:administration & dosage*; D000998:Antiviral Agents / Q000008:administration & dosage*; D004359:Drug Therapy, Combination / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology / Q000635:transmission; D006509:Hepatitis B / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D006526:Hepatitis C / Q000150:complications / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D055502:Secondary Prevention / Q000379:methods; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome
D044966:Anti-Retroviral Agents; D000998:Antiviral Agents