THE POPULATION LEVEL IMPACT OF HIV TREATMENT IN THE TEST-AND-TREAT ERA

Lesko, Catherine

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March 19, 2019

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Lesko, Catherine
- Affiliation: Gillings School of Global Public Health, Department of Epidemiology

Abstract

Antiretroviral therapy (ART) reduces mortality and prevents secondary transmission of HIV. Treatment guidelines now recommend initiating ART immediately following HIV diagnosis. The impact of this test-and-treat strategy on survival among HIV-infected persons in the United States (US) is unknown. First, published estimates of the effect of ART have been based on cohorts that are not representative of this target population. Second, evidence as to whether racial/ethnic/sex disparities in survival persist following ART initiation is mixed. In this dissertation, I estimated 5-year mortality risks for ART initiators versus non-initiators among 12,547 patients in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) using the complement of weighted Kaplan-Meier survival functions. I subsequently standardized estimates to persons diagnosed with HIV in the US between 2009 and 2011, enumerated using national surveillance data from the Centers for Disease Control and Prevention. Furthermore, I calculated the 10-year all-cause mortality risk among 10,017 ART initiators, stratified by race/ethnicity and sex, from weighted Kaplan-Meier survival functions. The 5-year mortality among ART initiators in the CNICS was 10.6% (95% CI: 9.3%, 11.9%) compared to 28.3% (95% CI: 19.1%, 37.5%) among non-initiators. ART initiation lowered 5-year mortality by -19.1% (95% CI: -30.5%, -7.8%) among recently HIV-diagnosed persons in the US. This effect was similar to the effect of ART estimated in the CNICS (risk difference: -17.7%, 95% CI: -27.0%, -8.4%). The overall 10-year mortality risk among ART initiators was 20.2% (95% confidence interval (CI): 19.2%, 21.3%). Black men and women experienced standardized 10-year all-cause mortality risks that were 7.2% (95% CI: 4.3%, 10.1%) and 7.9% (95% CI: 3.9%, 12.0%) larger than white men. White women, Hispanic men, and Hispanic women all had lower 10-year mortality than white men. ART initiation substantially lowers mortality among persons in the CNICS and this benefit is expected to be similar among persons recently diagnosed with HIV in the US. However, survival following ART initiation differs by race/ethnicity. Effective interventions are needed to ensure that the goal of the National HIV/AIDS Strategy to overcome health disparities becomes a reality.

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