title: Incidence of Opportunistic Infections and the Impact of Antiretroviral Therapy Among HIV-Infected Adults in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis.
abstract: To understand regional burdens and inform delivery of health services, we conducted a systematic review and meta-analysis to evaluate the effect of antiretroviral therapy (ART) on incidence of key opportunistic infections (OIs) in human immunodeficiency virus (HIV)-infected adults in low- and middle-income countries (LMICs).
  
  
  
  Eligible studies describing the cumulative incidence of OIs and proportion on ART from 1990 to November 2013 were identified using multiple databases. Summary incident risks for the ART-naive period, and during and after the first year of ART, were calculated using random-effects meta-analyses. Summary estimates from ART subgroups were compared using meta-regression. The number of OI cases and associated costs averted if ART was initiated at a CD4 count ≥200 cells/µL were estimated using Joint United Nations Programme on HIV/AIDS (UNAIDS) country estimates and global average OI treatment cost per case.
  
  
  
  We identified 7965 citations, and included 126 studies describing 491 608 HIV-infected persons. In ART-naive patients, summary risk was highest (>5%) for oral candidiasis, tuberculosis, herpes zoster, and bacterial pneumonia. The reduction in incidence was greatest for all OIs during the first 12 months of ART (range, 57%-91%) except for tuberculosis, and was largest for oral candidiasis, Pneumocystis pneumonia, and toxoplasmosis. Earlier ART was estimated to have averted 857 828 cases in 2013 (95% confidence interval [CI], 828 032-874 853), with cost savings of $46.7 million (95% CI, $43.8-$49.4 million).
  
  
  
  There was a major reduction in risk for most OIs with ART use in LMICs, with the greatest effect seen in the first year of treatment. ART has resulted in substantial cost savings from OIs averted.
authors.affiliation: Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom.|International Center for AIDS Care and Treatment Programs, Columbia University, New York, New York.
authors.forename: Andrea
authors.initials: A
authors.lastname: Low
authors.affiliation: HIV Department, World Health Organization, Geneva, Switzerland.
authors.forename: Georgios
authors.initials: G
authors.lastname: Gavriilidis
authors.affiliation: Medical Research Council Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, United Kingdom.
authors.forename: Natasha
authors.initials: N
authors.lastname: Larke
authors.affiliation: Department of Family Medicine.
authors.forename: Marie-Renee
authors.initials: MR
authors.lastname: B-Lajoie
authors.affiliation: Department of Pediatrics, McGill University, Montreal, Canada.
authors.forename: Olivier
authors.initials: O
authors.lastname: Drouin
authors.affiliation: Department of Centerfor Modeling and Analysis, Avenir Health, Glastonbury, Connecticut.
authors.forename: John
authors.initials: J
authors.lastname: Stover
authors.affiliation: Department of Maternal, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland.
authors.forename: Lulu
authors.initials: L
authors.lastname: Muhe
authors.affiliation: HIV Department, World Health Organization, Geneva, Switzerland.
authors.forename: Philippa
authors.initials: P
authors.lastname: Easterbrook
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000453:epidemiology*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003906:Developing Countries; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D015994:Incidence; D014376:Tuberculosis / Q000453:epidemiology
chemical_list: D044966:Anti-Retroviral Agents
keywords: HIV-1; antiretroviral therapy; low- and middle-income countries; opportunistic infections; tuberculosis