Andrew Hill, Liverpool University, UK Anton Pozniak, Chelsea and Westminster Hospital, London

1. Higher antiretroviral treatment coverage is associated with lower HIV infection rates: analysis of 51 low and middle-income countries Andrew Hill, Liverpool University, UK Anton Pozniak, Chelsea and Westminster Hospital, London Alice Raymond, Imperial College, London Katherine Heath, Imperial College, London Nathan Ford, World Health Organisation, Geneva World AIDS Conference, July 2014, Melbourne, Australia [LBPE29]

2. Background Antiretroviral treatment lowers the risk of HIV transmission in sero-discordant couples (HPTN 052 trial) Mathematical modelling studies suggest that HIV transmission could be significantly reduced if more than 80% of HIV infected people are treated with antiretrovirals Research question Do countries who treat more people with antiretrovirals have lower rates of new HIV infections, and lower rates of HIV-related death? Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

3. Methods UNAIDS database. For each country, standardised estimates for 2012: Total with HIV-infection Receiving antiretroviral treatment New HIV infections HIV-related deaths 36 African countries were included, plus 15 non-African low and middle-income countries with at least 50,000 HIV-infected individuals. Data from 7 high-income countries were extracted from published references, but were not included in the correlations of ART coverage versus incidence Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

4. Methods Weighted least squares and linear regression methods were used to investigate the association between: % Treated: percentage of all people with HIV who received ART in 2012 % Incidence: percentage increase in total HIV infections in 2012 % Deaths: percentage of people with HIV who died from HIV in 2012 This analysis looks at ART coverage of the whole population, not just from people eligible for treatment Linear and non-linear regression models Multivariate analysis: African / non-African, GDP per capita, PEPFAR inclusion Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

5. Countries with over 45% HIV-infected people on antiretroviral treatment _____________________________________________________ Country Infected Treated % _____________________________________________________ Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

6. The percentage of all HIV-infected people on antiretroviral treatment, by country UK: 67% USA: 33% Thailand: 54% Brazil: 53% Argentina: 52% Botswana: 62% Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

7. Countries with <20% HIV-infected people on antiretroviral treatment _____________________________________________________ Country Infected Treated % Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

8. Countries with less than 15% of HIV-infected people on antiretroviral treatment, by country Somalia: 5% Indonesia: 5% Madagascar: 0.6% Andrew Hill et al. World AIDS Conference 2014 [LBPE29]

9. Cascade of HIV care – UK 98400 Breakpoint in cascade: not diagnosed HIV positive 77610 69198 65928 57072 Reference: Public Health England 2013 Report p.22 - Brown AE et al., 2014

10. Cascade of HIV care – Georgia 6600 3432 2904 2508 1716 1320 Reference: UNAIDS database (2012) – Chkhartishvili et al., 2013

11. Cascade of HIV care – United States 1148200 940376 Breakpoint in cascade: diagnosed HIV positive but not treated 755516 424834 375461 290495 Reference: CDC Fact sheet December 2013 p.2 - Halls et al., 2013

12. Results • Weighted least squares regression analysis showed that countries with higher ARV coverage rates had - lower rates of new HIV infections (p<0.0001) - lower HIV-related death rates (p<0.0001) • These were both linear correlations – the non-linear models did not improve the strength of the associations. • In multivariate analyses, these correlations were independent from GDP per-capita, African / non-African regions and PEPFAR support

13. New HIV infections (percentage growth) versus ART coverage in 51 countries. Andrew Hill et al. World AIDS Conference 2014 [LBPE29] Figure 1. The percentage of all HIV-infected people taking antiretrovirals, by country

14. Death rates from HIV infectionversus ART coverage in 51 countries. Andrew Hill et al. World AIDS Conference 2014 [LBPE29] Figure 1. The percentage of all HIV-infected people taking antiretrovirals, by country

15. Results • According to these analyses, if all 51 low and middle income countries had had the same ART coverage as Botswana (62%), 1,243,647 of the 1,901,800 total HIV infections in 2012 (65%) could have been prevented. • Under the same conditions, 998,732 of the total 1,427,200 deaths from HIV in 2012 in these 51 countries (70%) could have been avoided.

16. Limitations • This is a cross-sectional analysis of a single year - 2012. However the analysis is being repeated using the new 2013 UNAIDS database, for validation • There are many other differences between countries which might explain these associations. Countries with better treatment coverage might also have better HIV prevention programmes for example. • There is variability around the association – some countries have high rates of new infections despite high ARV coverage (e.g. Uganda) or low infection rates despite lower ARV coverage (Niger). • High income countries have not yet been included

17. Conclusions Countries with higher ART coverage rates had significantly lower rates of new HIV infection and HIV-related death. According to this analysis, in 2012, if all 51 countries had antiretroviral coverage rates as high as Botswana (62%). - 65% of the new HIV infections (1.2/1.9 million) could have been prevented - 70% of the HIV-related deaths (1/1.4 million) could have been prevented The results provide a compelling argument for continuing to improve antiretroviral treatment coverage worldwide Andrew Hill et al. World AIDS Conference 2014 [LBPE29]