Expert consensus statement on the science of HIV in the context of criminal law.

CAPRISA, 2018.Abstract available in pdf

Outcomes for people living with HIV treated through the Thai National AIDS Program: 2008 – 2014

The past two decades have seen increasing number of patients with HIV accessing treatment in resource limited settings. This has resulted in a better prognosis and increased life expectancy of HIV-infected individuals. This thesis aims to 1) quantify the estimated life expectancy of HIV-infected patients among different income regions, and 2) investigate programmatic and patient outcomes of patients treated under the Universal coverage program (UC) in Thailand.Meta-analytic techniques were used to assess life expectancy across high and low/middle-income countries. This thesis also assesses outcomes of the UC between 2008 and 2014, when the database was linked with National Death Registry. Life expectancy was estimated using the abridged-life table method. Survival analysis techniques were used to estimate lost to follow-up and mortality rates in adults, and attrition and treatment outcomes in children who started first-line antiretroviral therapy (ART). Life expectancy after starting ART differs markedly between high and low/middle-income regions. The life expectancy between sex is similar in high-income countries, but in low/middle income countries women had better life-expectancy than men. This pattern of better life expectancy in women was also found in the Thai UC system. In addition, life expectancy of Thai HIV-infected people has improved over time, and with increasing CD4 cell count at ART initiation. Loss to follow-up was higher prior to ART compared to after starting ART, but the rates were modest compared to cohorts in sub-Saharan Africa. Patients who are young and healthy had the highest risk of LTFU, especially adolescents. Children aged <12 years starting first-line ART were more likely to achieve immunological recovery compared to children ≥12 years, many of whom switched to second-line ART within 6 months after detectable viral load failure.Scaling-up of ART has substantially increased the life expectancy of patients starting ART between different income regions globally, and more specifically within the Thai UC system. These results demonstrate that the Thai UC, with integrated provision of treatment and care services for people living with HIV, is effective in terms of programmatic and patient outcomes, and could provide a model for service and care delivery in other resource-limited countries

Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis

Objectives: Life expectancy is an important indicator informing decision making in policies relating to HIV-infected people. Studies estimating life expectancy after starting combination antiretroviral therapy (cART) have noted differences between income regions. The objective of our study was to perform a meta-analysis to assess life expectancy of HIV-positive people after starting cART, and to quantify differences between low/middle- and high-income countries. Methods: Eight cohort studies estimating life expectancy in HIV-positive people initiating cART aged ≥ 14 years using the abridged life table method were identified. Random effects meta-analysis was used to pool estimated outcomes, overall and by income region. Heterogeneity between studies was assessed with the I2 statistic. We estimated additional years of life expected after starting cART at ages 20 and 35 years. Results: Overall life expectancy in high-income countries was an additional 43.3 years [95% confidence interval (CI) 42.5–44.2 years] and 32.2 years (95% CI 30.9–33.5 years) at ages 20 and 35 years, respectively, and 28.3 (95% CI 23.3–33.3) and 25.6 (95% CI 22.1–29.2) additional years, respectively, in low/middle-income countries. In low/middle-income countries, life expectancy after starting cART at age 20 years was an additional 22.9 years (95% CI 18.4–27.5 years) for men and 33.0 years (95% CI 30.4–35.6 years) for women, but was similar in the two sexes in high-income countries. In all income regions, life expectancy after starting cART increased over calendar time. Conclusions: Our results suggest that the life expectancy of HIV-positive people after starting cART has improved over time. Monitoring life expectancy into the future is important to assess how changes to cART guidelines will affect patient long-term outcomes

Long‐term outcomes of rapid antiretroviral NNRTI‐based initiation among Thai youth living with HIV: a national registry database study

Introduction The Thai National AIDS programme (NAP) treatment guidelines have recommended rapid antiretroviral therapy (ART) initiation, regardless of CD4 count since 2014. We assessed treatment outcomes among youth living with HIV (YLHIV), initiating first‐line ART and assessed the association between virological failure (VF) and timing of ART initiation. Methods We retrospectively reviewed data for YLHIV aged 15–24 years, initiating non‐nucleoside reverse transcriptase inhibitor‐based ART from 2014 to 2019, through the NAP database. We classified the timing of ART into three groups based on duration from HIV‐positive diagnosis or system registration to ART initiation: (1) 3 months (delayed ART). VF was defined as viral load (VL) ≥ 1000 copies/ml after at least 6 months of first‐line ART. Factors associated with VF were analysed using generalized estimating equations. Results Of 19,825 YLHIV who started ART, 78% were male. Median (interquartile range, IQR) age was 21 (20–23) years and CD4 count was 338 (187–498) cells/mm3. After registration, 12,216 (62%) started rapid ART, 4272 (22%) intermediate ART and 3337 (17%) delayed ART. The proportion of YLHIV starting ART <30 days significantly increased from 43% to 57% from 2014–2016 to 2017–2019 (p < 0.001). The median duration of first‐line therapy was 2 (IQR 1–3) years and 89% started with efavirenz‐based regimens. Attrition outcomes showed that 325 (2%) died (0.73 [95% CI 0.65–0.81] per 100 person‐years [PY]) and 1762 (9%) were loss to follow‐up (3.96 [95% CI 3.78–4.15] per 100 PY). Of 17,512 (88%) who had VL checked from 6 to 12 months after starting treatment, 80% achieved VL <200 copies/ml. Overall, 2512 experienced VF 5.87 (95% CI 5.65–6.11) per 100 PY). In a multivariate model, the adjusted incidence rate ratio for VF was 1.47 (95% CI 1.33–1.63, p < 0.001) in the delayed ART group and 1.14 (95% CI 1.03–1.25, p< 0.001) in the intermediate ART group, compared to YLHIV in the rapid ART group. Conclusions Rapid ART initiation after diagnosis was associated with significantly reduced risks of VF and death in YLHIV, supporting the implementation of rapid ART for optimizing health outcomes

Life expectancy after initiation of combination antiretroviral therapy in Thailand

Background: Access to combination antiretroviral therapy (cART) has decreased mortality in HIV-positive people. We aimed to estimate the expected additional years of life in HIV-positive Thai people after starting cART through the National AIDS Program (NAP), administered by the Thai National Health Security Office (NHSO). Methods: The NHSO database collects characteristics of all Thai HIV-infected patients through the National AIDS Program, including linkage with the National Death Registry for vital status. This study included patients aged >= 15 years at cART initiation between 2008 and 2014. The abridged life table method was used to construct life tables stratified by sex and baseline CD4(+) T-cell count. Life expectancy was defined as the additional years of life from age at starting cART. Results: 201,688 eligible patients were included in analyses, contributing 618,837 person-years of followup. Median CD4(+) T-cell count was 109 cells/mm(3) and median age 37 years. The overall life expectancy after cART initiation at age 20 was 25.4 (95% CI, 25.3, 25.6) years and 20.6 (95% CI, 20.5, 20.7) at age 35 years. Life expectancy at baseline CD4(+) T-cell count >= 350 cells/mm(3) was 51.9 (95% CI, 51.0, 52.9) years for age 20 years and 43.2 (95% CI, 42.4, 44.1) years for age 35 years, close to life expectancy in the general Thai population. Conclusions: Increasing life expectancy with higher baseline CD4(+) T-cell counts supports the guideline recommendations to start cART irrespective of CD4(+) T-cell count. These results are beneficial to forecast the treatment cost and develop health policies for people living with HIV in Thailand and Asi