Improved survival in HIV treatment programmes in Asia

Abstract

Background: Antiretroviral treatment (ART) for HIV-positive patients has expanded rapidly in Asia over the last 10 years. Our study aimed to describe the time trends and risk factors for overall survival in patients receiving first-line ART in Asia.

Methods: We included HIV-positive adult patients who initiated ART between 2003-2013 (n=16,546), from seven sites across six Asia-Pacific countries. Patient follow-up was to May 2014. We compared survival for each country and overall by time period of ART initiation using Kaplan-Meier curves. Factors associated with mortality were assessed using Cox regression, stratified by site. We also summarized first-line ART regimens, CD4⁺ T-cell count at ART initiation, and CD4⁺ T-cell and HIV viral load testing frequencies.

Results: There were 880 deaths observed over 54,532 person-years of follow-up, a crude rate of 1.61 (95% CI 1.51, 1.72) per 100 person-years. Survival significantly improved in more recent years of ART initiation. The survival probability at 4 years follow-up for those initiating ART in 2003-2005 was 92.1%, 2006-2009 was 94.3% and 2010-2013 was 94.5% (P<0.001). Factors associated with higher mortality risk included initiating ART in earlier time periods, older age, male sex, injecting drug use as HIV exposure and lower pre-ART CD4⁺ T-cell count. Concurrent with improved survival was increased tenofovir use, ART initiation at higher CD4⁺ T-cell counts and greater monitoring of CD4⁺ T-cells and HIV viral load.

Conclusions: Our results suggest that HIV-positive patients from Asia have improved survival in more recent years of ART initiation. This is likely a consequence of improvements in treatment, patient management and monitoring over time.

Figure 1

Survival estimates across all countries by time period of ART initiation.

Figure 2. First-line ART regimen by time period of ART initiation

(A) Proportion of patients by drug class. (B) Proportion of patients by NRTI drug or drug combination. Other NRTI drugs initiated included: Abacavir (0.1% overall time periods); Didanosine (0.7%); Stavudine (0.2%); Zazlcitabine (<0.1%); Zidovudine (0.1%); Emtricitabine (4.9%); Tenofovir (4.7%). (C) Proportion of patient by NNRTI drug. Not represented are Etravirine (<0.1%) and Rilpivirine (<0.1%). (D) Proportion of patients by PI Ddrug. Other PI drugs initiated included: Nelfinavir (2.1%); Ritonavir (0.4%); Saquinaavir (3.4%). NRTI = nucleoside reverse transcriptase inhibitor; NNRTI = nonnucleoside reverse transcriptase inhibitor; PI = protease inhibitor; 3TC/FTC = lamivudine/emtricitabine; d4T = stavudine; AZT = zidovudine; TDF = tenofovir; ABC = abacavir; EFV = efavirenze; NVP = nevirapine; LPV = lopinavir/ritonavir; ATV = atazanavir/ritonavir; IDV = indinavir; DRV = darunavir.

Figure 3. Summary of the CD4 cell count (cells/μL) at ART initiation, across all countries

(A) Median CD4 cell count (cells/μL) at ART initiation, by time period of ART initiation and with interquartile range shown. (B) Proportion of patients CD4 cell count (cells/μL) at ART initiation with absolute patient numbers below, by time period of ART initiation.

Figure 4. Rates per person-year (per py), with 95% confidence interval, of (A) CD4 testing and (B) HIV viral load (VL) testing, across all countries by time period of ART initiation