Patient Monitoring Before Starting HIV Treatment Would Improve Survival

Main Category: HIV / AIDS
Article Date: 11 Mar 2008 - 3:00 PDT

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HIV treatment in Africa could lengthen and save many more lives if programs monitored infected individuals more closely and identified those needing treatment earlier, according to a study published in PLoS Medicine.

More than one million people in Africa are receiving life-sustaining treatment for HIV, reflecting a dramatic increase over only a few years ago. The US alone has contributed tens of billions of dollars to promoting AIDS treatment and prevention in developing countries. Are these efforts realizing the optimal effect of treatment, in terms of prolonging lives?

The answer appears to be no, in part because programs fail to treat people in time for them to realize the full benefit of treatment, according to research by Timothy Hallett and colleagues at Imperial College London and the Biomedical Research and Training Institute, Harare, Zimbabwe.

The roll-out of antiretroviral treatment (ART) in developing countries has concentrated so far on finding HIV-positive people who currently need treatment. In developing countries, these are often individuals who have AIDS-related symptoms such as recurrent severe infections. But healthy people are also being diagnosed as HIV positive during voluntary testing and at antenatal clinics. How should these HIV-positive but symptom-free individuals be managed?

To answer this question, the researchers developed a mathematical model, based on known information about the course of HIV infection in Africa, to simulate disease progression in a hypothetical group of 1,000 HIV-infected adults from the time of infection, through diagnosis and clinical monitoring, and into treatment. Testing several possible scenarios for how HIV- infected individuals should be monitored and who should start treatment, they used the model to calculate how many people would receive HIV medications, and how long they would live, given each set of rules.

The computer model predicted that if programs offer ART only after patients have AIDS-related symptoms, only a quarter of people with HIV will start treatment before they die, and people who are treated will live an average of 6 years longer than they would have lived without treatment. But if people are recruited to treatment programs when they are healthy and are frequently monitored using CD4 T cell counts to decide when to start medication, three-quarters of them will be treated, and on average 15 years of life will be saved per person treated.

The model also found that strategies which measure CD4 cells regularly in people who have not yet started treatment will save more life-years, because medications are more likely to be started before the immune system is irreversibly damaged. More frequent monitoring was predicted to save more years of life per year of medications prescribed, suggesting that the additional medication costs of starting treatment earlier would be justified.

The impact of monitoring HIV-infected patients prior to treatment in resource-poor settings: Insights from mathematical modelling.
Hallett TB, Gregson S, Dube S, Garnett GP (2008)
PLoS Med 5(3): e53.
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