Decreased HIV Transmission after a Policy of Providing Free Access to Highly Active Antiretroviral Therapy in Taiwan

Academia Sinica, T’ai-pei, Taipei, Taiwan
The Journal of Infectious Diseases (Impact Factor: 6). 10/2004; 190(5):879-85. DOI: 10.1086/422601
Source: PubMed


Taiwan established a nationwide surveillance system for human immunodeficiency virus (HIV) infection in 1989 and adopted a policy to provide all HIV-infected citizens with free access to highly active antiretroviral therapy (HAART) beginning in April 1997. This provided an opportunity to determine the effect of the widespread use of HAART on the evolution of the HIV epidemic.
We analyzed national HIV surveillance data. The HIV transmission rate was estimated by use of an exponential model of HIV epidemic evolution, with statistical projection over the interval between infection and detection to fit the surveillance data.
By the end of 2002, the cumulative number of HIV-infected citizens in Taiwan had reached 4390 (0.019% of the total population). After free access to HAART was established, the estimated HIV transmission rate decreased by 53% (0.391 vs. 0.184 new cases/prevalent case-year [95% confidence interval, 31%-65%]). There was no statistically significant change in the incidence of syphilis, in the general population or among HIV-positive patients, during the same period.
Providing free HAART to all HIV-infected citizens was associated with a 53% decrease in the HIV transmission rate and contributed to the control of the HIV epidemic in Taiwan.

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    • "[12]–[21] The concept of scaling up highly active antiretroviral therapy (HAART), commonly referred to as TasP, has gained substantial momentum, as its efficacy and effectiveness have become increasingly apparent. [8], [9], [22]–[24] However, the real-world population-level effectiveness and sustainability of this strategy remains to be adequately characterized. "
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    ABSTRACT: There has been renewed call for the global expansion of highly active antiretroviral therapy (HAART) under the framework of HIV treatment as prevention (TasP). However, population-level sustainability of this strategy has not been characterized. We used population-level longitudinal data from province-wide registries including plasma viral load, CD4 count, drug resistance, HAART use, HIV diagnoses, AIDS incidence, and HIV-related mortality. We fitted two Poisson regression models over the study period, to relate estimated HIV incidence and the number of individuals on HAART and the percentage of virologically suppressed individuals. HAART coverage, median pre-HAART CD4 count, and HAART adherence increased over time and were associated with increasing virological suppression and decreasing drug resistance. AIDS incidence decreased from 6.9 to 1.4 per 100,000 population (80% decrease, p = 0.0330) and HIV-related mortality decreased from 6.5 to 1.3 per 100,000 population (80% decrease, p = 0.0115). New HIV diagnoses declined from 702 to 238 cases (66% decrease; p = 0.0004) with a consequent estimated decline in HIV incident cases from 632 to 368 cases per year (42% decrease; p = 0.0003). Finally, our models suggested that for each increase of 100 individuals on HAART, the estimated HIV incidence decreased 1.2% and for every 1% increase in the number of individuals suppressed on HAART, the estimated HIV incidence also decreased by 1%. Our results show that HAART expansion between 1996 and 2012 in BC was associated with a sustained and profound population-level decrease in morbidity, mortality and HIV transmission. Our findings support the long-term effectiveness and sustainability of HIV treatment as prevention within an adequately resourced environment with no financial barriers to diagnosis, medical care or antiretroviral drugs. The 2013 Consolidated World Health Organization Antiretroviral Therapy Guidelines offer a unique opportunity to further evaluate TasP in other settings, particularly within generalized epidemics, and resource-limited setting, as advocated by UNAIDS.
    PLoS ONE 02/2014; 9(2):e87872. DOI:10.1371/journal.pone.0087872 · 3.23 Impact Factor
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    • "In this study, we established that the viral load of the mothers reduced by 36% following HAART treatment, suggesting a higher probability of reduced vertical transmission of HIV that may have an impact on the overall levels of MTC. A study in Taiwan, provided a compelling evidence about the effect of HAART on HIV transmission [34]. The study showed a 53% reduction in new positive HIV tests after the introduction of free access to HAART. "
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    ABSTRACT: Ensuring that no baby is born with HIV is an essential step towards achieving an AIDS-free generation. To achieve this, strategies that decouple links between childbirth and HIV transmission are necessary. Traditional forms of prevention of mother-to-child transmission of HIV (PMTCT), has been recommended. Recognizing the importance and challenges of combination of methods to achieve rapid PMTCT, the World Health Organization (WHO) recommended option B Highly Active Antiretroviral Therapy (HAART) for all HIV-positive pregnant women. This study aimed to evaluate the effectiveness of the HAART in PMTCT. A cohort of HIV-infected pregnant women in Kenya were obtained from the DREAM Center, Nairobi. The study participants underwent adherence counselling and Option B of HAART [Nevirapine(NVP) + Lamivudine + Zidovudine] at the fourth week of gestation followed by an intravenous NVP administration intrapartum and postpartum NVP syrup to the respective infants for six weeks. Absolute pre-HAART and post-HAART CD4 counts and viral loads counts were determined. Comparison of the CD4 counts and viral loads before and after administration of HAART were done using Wilcoxon's Matched Pairs Signed-Ranks Test. The mean absolute CD4 cell counts in mothers after administration of HAART was significantly higher (Z = 15.664, p < 0.001) than before the administration of HAART). Also the viral load of the mothers significantly (Z = 11.324, p < 0.001) reduced following HAART treatment. Following the HAART administration in mothers, up to 90% of children were confirmed to be HIV negative. Administration of HAART to mothers and children demonstrated an effective mechanism of PMTCT. However, other aspects of HAART such as adherence, costs, mothers behaviour during HAART, and the child feeding programme during the therapy should further be evaluated and ascertained how they can affect the overall efficacy of option B HAART in PMTCT.
    BMC Research Notes 01/2014; 7(1):52. DOI:10.1186/1756-0500-7-52
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    • "The universal uptake and effective use of antiretroviral therapy (ART) among injection drug users constitutes a key strategy to reduce AIDS-related deaths and HIV incidence (Joint United Nations Programme on HIV/ AIDS [UNAIDS], 2010). ART use has shown to predictably suppress plasma HIV RNA to undetectable levels, reducing HIV-related morbidity, mortality, serodiscordant transmission (Abdool Karim et al., 2010; Cohen et al., 2011; Grant et al., 2010), and HIV incidence (Das et al., 2010; Fang et al., 2004; Montaner et al., 2006). However, illicit drug users face multiple, individual , and socio-structural barriers to achieving optimal HIV outcomes (Krüsi, Wood, Montaner, & Kerr, 2010; Wood, Kerr, Tyndall, & Montaner, 2008). "
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    ABSTRACT: Food insecurity may be a barrier to achieving optimal HIV treatment-related outcomes among illicit drug users. This study therefore, aimed to assess the impact of severe food insecurity, or hunger, on plasma HIV RNA suppression among illicit drug users receiving antiretroviral therapy (ART). A cross-sectional Multivariate logistic regression model was used to assess the potential relationship between hunger and plasma HIV RNA suppression. A sample of n = 406 adults was derived from a community-recruited open prospective cohort of HIV-positive illicit drug users, in Vancouver, British Columbia (BC), Canada. A total of 235 (63.7%) reported "being hungry and unable to afford enough food," and 241 (59.4%) had plasma HIV RNA < 50 copies/ml. In unadjusted analyses, self-reported hunger was associated with lower odds of plasma HIV RNA suppression (Odds Ratio = 0.59, 95% confidence interval [CI]: 0.39-0.90, p = 0.015). In multivariate analyses, this association was no longer significant after controlling for socio-demographic, behavioral, and clinical characteristics, including 95% adherence (Adjusted Odds Ratio [AOR] = 0.65, 95% CI: 0.37-1.10, p = 0.105). Multivariate models stratified by 95% adherence found that the direction and magnitude of this association was not significantly altered by the adherence level. Hunger was common among illicit drug users in this setting. Although, there was an association between hunger and lower likelihood of plasma HIV RNA suppression, this did not persist in adjusted analyses. Further research is warranted to understand the social-structural, policy, and physical factors shaping the HIV outcomes of illicit drug users.
    AIDS Care 09/2013; 26(4). DOI:10.1080/09540121.2013.832724 · 1.60 Impact Factor
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