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Impact of Antiretroviral Therapy on TB

disease in Resource Limited Settings


Dr. N. Kumarasamy
Chief Medical Officer
YRGCARE Medical Centre
Chief-Chennai Antiviral Research and Treatment (CART) Clinical Research Site/NIH
Voluntary Health Services
Chennai, India

Spectrum of OI (n= 6815) YRGCARE cohort: Jun1996- Aug 2004


Kumarasamy et al. IJMR 2005.

Co-factors relating to progression of


patients with HIV disease
Kumarasamy et al., CID Jan 2003
Co-factors

OR

95% CI

P-value

HIV associated
illness
Pulmonary TB
PCP
Cryptococcal
Toxoplasmosis

3.52
4.47
6.98
2.57

1.96-6.32
2.67-7.51
4.1-11.97
1.27-5.2

<0.001
<0.001
<0.001
0.01

7.84

1.61-38.22

0.01

Co-infection
HCV

HPTN 052
1,750 heterosexual serodiscordant couples in resourceconstrained countries randomized to receive ART early
(CD4 350-550 cells/L) or defer until CD4 < 250 cells/L
Event Rates

Early ART

Deferred ART

HR

P-value

Transmission Rate
per 100 pt-years
(95% CI)

0.3
(0.1-0.6)

2.2
(1.6-3.1)

0.11
(0.04-0.32)

< 0.001

Clinical Event Rate


per 100 pt-years
(95% CI)

2.4
(1.7-3.3)

4.0
(3.5-5.0)

0.59
(0.40-0.88)

<0.001

Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC,Kumarasamy N et al, NEJM, 2011

In South Africa, early ART was cost-saving over a 5-year period.


In both South Africa and India, early ART was projected to be
very cost-effective over a lifetime.
With individual, public health, and economic benefits, there is a
compelling case for early ART for serodiscordant couples in
resource-limited settings.

Summary of Changes in
Recommendations in WHO 2013 ART
Guidelines-When to Start in Adults

AIDS-related deaths to be averted due


to the new treatment guidelines

Mean CD4 count at ART initiation is below 200


in LMIC

Mean CD count (cells/L)

Low-income

2002

2009

Lower middleincome

2002

Source: Egger M. CROI 2012

2009

Upper middleincome

2002

Year of starting
ART

2009

High-income

2002

2009

Estimates from random-effects


model adjusted for age, sex and
year of starting ART, 2002-2009

IeDEA JAIDS 2014


11

Source: UNAIDS.

Simulation model of HIV testing and treatment


- Prevalence and Incidence in different groups
- Cost of testing

Conclusion: Voluntary HIV screening among National


population every 5 yrs offers substantial clinical benefit
and cost effective. Annual screening is cost effective
among high risk population and in high prevalent districts

Sequencing Therapy in in Resource Limited


Setting

2 NRTIs(TDF+3TC/FTC) + 1 NNRTI (EFV)


2 NRTIs(AZT+3TC) + 1 PI/RTV(ATVr or LPVr)
1 PI/RTV(DRVr) + Integrase / CCR5
inhibitor/ 2nd Gen NNRTI (ETV)

Conclusions
Global progress on scale-up of ART has been extraordinary- 15
millions on ART.
Decrease in morbidity and mortality
Declining incidence of HIV
Sustainability of ARVs-This will require forward-looking
policies, more effective and innovative approaches, together
with further investments
Prevention of transmission of resistance strains
Prevention and management of NCDs
ARVs for treatment and prevention are a powerful tool towards
ending the HIV epidemic