BOSTON — Antiretroviral therapy has dramatically reduced mortality from HIV in sub-Saharan Africa but mortality for HIV-positive adults remains 3 to 6 times greater than for HIV-negative adults.

Jeffrey W. Eaton, PhD, a research fellow in the School of Public Health at Imperial College London, presented results Wednesday at CROI 2016 that help to explain why mortality is so high for HIV-positive people even in areas where antiretroviral therapy is widely available, and use that knowledge to direct medical to maximize the benefits of antiretroviral therapy programs.

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“If current patterns of access to care persist, people who disengage from care are accounting for an increasingly larger proportion of HIV deaths,” said Dr Eaton. “That is likely a key focus area for continuing to reduce HIV mortality.”

A team of researchers reviewed empirical data and mathematical modelling estimates about mortality across stages of HIV care. Empirical estimates came from linked clinical and vital registration data from Western Cape, South Africa, and patient populations in Uganda, Malawi, and South Africa.

Mathematical models were calibrated to HIV epidemics and care and treatment utilization in Rwanda, Kenya, Malawi, and South Africa and estimated the distribution of HIV deaths occurring at each stage of care. The distribution of deaths was then projected over the next decade assuming continuation of current patterns of HIV care uptake and retention. Three models simulated the effects of changing guidelines to immediate antiretroviral therapy initiation for all patients linked to care.

Researchers estimate that patients on antiretroviral therapy for six months or more represent only 10% to 30% of HIV-related deaths in sub-Saharan Africa. Projections for 2025 suggest that HIV-positive patients who initiate care but never begin antiretroviral therapy could account for as many as 9% to 22% of HIV-related deaths in Rwanda, Malawi, Kenya and South Africa. Furthermore, patients in those countries who undergo less than six months of antiretroviral therapy will account for an increasing share of HIV-related deaths during that time.

WHO guidelines issued late last year call for immediate initiation of antiretroviral therapy for HIV-positive people regardless of CD4 cell count. Mathematical modelling showed that the guideline could reduce HIV-related deaths by 6% to 14% over the next decade.

“Immediate ART eliminates the pre-ART care and monitoring stage where retention has been poor,” Dr Eaton explained. “The benefit of streamlining the health system was likely to be responsible for the most reductions in HIV deaths at the population level. That really underscored the priority for interventions that help enable people to get on ART. That might be how the new guidelines have the biggest impact over the coming decade.”


1. Bendavid E. 117. HIV Mortality by Care Cascade Stage and Implications for Universal ART Eligibility. Presented at: CROI 2016. Feb. 22-25, 2016. Boston