Incidence of opportunistic infections and the impact of antiretroviral therapy among HIV-infected adults in low- and middle-income countries: a systematic review and meta-analysis
Journal article published in Clinical Infectious Diseases
To understand regional burdens and inform delivery of health services, we conducted a systematic review and meta-analysis to evaluate the effect of antiretroviral therapy (ART) on incidence of key opportunistic infections (OIs) in human immunodeﬁciency virus (HIV)–infected adults in low- and middle-income countries (LMICs).
Eligible studies describing the cumulative incidence of OIs and proportion on ART from 1990 to November 2013 were identiﬁed using multiple databases. Summary incident risks for the ART-naive period, and during and after the ﬁrst year of ART, were calculated using random-effects meta-analyses. Summary estimates from ART subgroups were compared using meta-regression. The number of OI cases and associated costs averted if ART was initiated at a CD4 count ≥200 cells/µL were estimated using Joint United Nations Programme on HIV/AIDS (UNAIDS) country estimates and global average OI treatment cost per case.
We identiﬁed 7965 citations, and included 126 studies describing 491 608 HIV-infected persons. In ART-naive patients, summary risk was highest (>5%) for oral candidiasis, tuberculosis, herpes zoster, and bacterial pneumonia. The reduction in incidence was greatest for all OIs during the ﬁrst 12 months of ART (range, 57%–91%) except for tuberculosis, and was largest for oral candidiasis, Pneumocystis pneumonia, and toxoplasmosis. Earlier ART was estimated to have averted 857 828 cases in 2013 (95% conﬁdence in- terval [CI], 828 032–874 853), with cost savings of $46.7 million (95% CI, $43.8–$49.4 million).
There was a major reduction in risk for most OIs with ART use in LMICs, with the greatest effect seen in the ﬁrst year of treatment. ART has resulted in substantial cost savings from OIs averted.
- Incidence and prevalence of opportunistic and other infections and the impact of antiretroviral therapy among HIV-infected children in low- and middle-income countries