When to Start ART in Africa — An Urgent Research Priority

The history of the HIV–AIDS epidemic was profoundly altered by the introduction of antiretroviral therapy (ART). More than 8 million people in low-income and middle-income countries have received lifesaving ART over the past decade, yet in 2011 an estimated 34 million people were living with HIV infection, 6.8 million were eligible for treatment but lacked access to ART, 2.5 million became newly infected, and 1.7 million died of HIV-related disease

Clinical trials provide the evidence critical for patient empowerment

In this issue of the Journal, Delva et al. discuss in a Viewpoint our Perspective article published in the New England Journal of Medicine in which we argue for the urgent need for a clinical trial on when to initiate antiretroviral therapy (ART) in HIV-infected patients in sub-Saharan Africa. The authors posit that there is currently sufficient evidence to make informed decisions regarding this issue and consequently individual patients’ autonomy should be the key factor in determining the timing for ART initiation

When to Start ART in Africa — An Urgent Research Priority

The history of the HIV–AIDS epidemic was profoundly altered by the introduction of antiretroviral therapy (ART). More than 8 million people in low-income and middle-income countries have received lifesaving ART over the past decade, yet in 2011 an estimated 34 million people were living with HIV infection, 6.8 million were eligible for treatment but lacked access to ART, 2.5 million became newly infected, and 1.7 million died of HIV-related disease

Reflections on 30 Years of AIDS

TOC summary: Although the end of the epidemic is not yet in sight, the remarkable response has improved health around the world

Detectable HIV Viral Load in Kenya: Data from a Population-Based Survey.

IntroductionAt the individual level, there is clear evidence that Human Immunodeficiency Virus (HIV) transmission can be substantially reduced by lowering viral load. However there are few data describing population-level HIV viremia especially in high-burden settings with substantial under-diagnosis of HIV infection. The 2nd Kenya AIDS Indicator Survey (KAIS 2012) provided a unique opportunity to evaluate the impact of antiretroviral therapy (ART) coverage on viremia and to examine the risks for failure to suppress viral replication. We report population-level HIV viral load suppression using data from KAIS 2012.MethodsBetween October 2012 to February 2013, KAIS 2012 surveyed household members, administered questionnaires and drew serum samples to test for HIV and, for those found to be infected with HIV, plasma viral load (PVL) was measured. Our principal outcome was unsuppressed HIV viremia, defined as a PVL ≥ 550 copies/mL. The exposure variables included current treatment with ART, prior history of an HIV diagnosis, and engagement in HIV care. All point estimates were adjusted to account for the KAIS 2012 cluster sampling design and survey non-response.ResultsOverall, 61·2% (95% CI: 56·4-66·1) of HIV-infected Kenyans aged 15-64 years had not achieved virological suppression. The base10 median (interquartile range [IQR]) and mean (95% CI) VL was 4,633 copies/mL (0-51,596) and 81,750 copies/mL (59,366-104,134), respectively. Among 266 persons taking ART, 26.1% (95% CI: 20.0-32.1) had detectable viremia. Non-ART use, younger age, and lack of awareness of HIV status were independently associated with significantly higher odds of detectable viral load. In multivariate analysis for the sub-sample of patients on ART, detectable viremia was independently associated with younger age and sub-optimal adherence to ART.DiscussionThis report adds to the limited data of nationally-representative surveys to report population- level virological suppression. We established heterogeneity across the ten administrative and HIV programmatic regions on levels of detectable viral load. Timely initiation of ART and retention in care are crucial for the elimination of transmission of HIV through sex, needle and syringe use or from mother to child. Further refinement of geospatial mapping of populations with highest risk of transmission is necessary

Stable incidence rates of tuberculosis (TB) among human immunodeficiency virus (HIV)-negative South African gold miners during a decade of epidemic HIV-associated TB.

During the last decade, annual tuberculosis (TB) case-notification rates increased 4-fold, to >4000 cases/100000 person-years, in the study workforce, among whom prevalence of human immunodeficiency virus (HIV) was 30% in 2000. Three separate cohort studies, totalling 6454 HIV-negative participants, were combined and analyzed for time trends. Observed incidence of TB varied between 962 (1991-1994) and 1589 (1999-2000) cases/100000 person-years (P=.17, test for trend). There was, however, a progressive increase in age, and, for each period, older age was associated with increased incidence rates of TB (P<.001). Having adjusted for age differences, there was no significant association between incidence of TB and calendar period (P=.81, test for trend). Relative to 1991-1994, multivariate-adjusted incidence-rate ratios were 0.94, for 1995-1997, 0.96, for 1998-1999, and 1.05, for 1999-2000. Preventing a secondary epidemic of TB among HIV-negative individuals may be achievable with conventional means, even in settings with a high burden of HIV-associated TB

When to start ART in Africa.

To the Editor: In their Perspective article, De Cock and El-Sadr (March 7 issue)1 highlight the need for data on when to start antiretroviral therapy (ART) for HIV-infected people in Africa who have CD4+ counts above 350 cells per cubic millimeter. However, their proposed solution — a new randomized, controlled trial in Africa — is flawed