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Modeling the impact of early antiretroviral therapy for adults coinfected with HIV and hepatitis B or C in South Africa

Martin, Natasha K.a,b; Devine, Angelac; Eaton, Jeffrey W.d; Miners, Alecc; Hallett, Timothy B.d; Foster, Graham R.e; Dore, Gregory J.f; Easterbrook, Philippa J.g; Legood, Rosac; Vickerman, Petera,b

doi: 10.1097/QAD.0000000000000084
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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.

Author Information

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.

Correspondence to Natasha K. Martin, School of Social and Community Medicine, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. Tel: +44 (0) 117 3314570; e-mail:

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© 2014 Lippincott Williams & Wilkins, Inc.