Starting HIV therapy leads to improvements in daily function and economic wellbeing

Continuous improvements up to five years after starting treatment

Antiretroviral therapy has continuous and sustained benefits for the quality of life and economic wellbeing of people living with HIV, South African research published in the online edition of AIDS shows. Approximately 900 people were followed for up to five years after starting HIV treatment. Although over 40% of people were lost to follow-up, the prevalence of symptoms declined significantly over the study and there was also a big drop in the number of people reporting difficulties performing day-to-day tasks or job-related activities. The proportion of people relying on a carer fell from 81% at baseline to just 1% midway through the research.

“The benefits of treatment for economic engagement are large and sustained and continue to increase steadily over at least the first 5 years of treatment,” comment the authors. “Patients who had jobs reported substantially less difficulty performing their jobs as the duration of ART lengthened. Reliance on external support also fell steadily.”

Access to antiretroviral therapy in South Africa and many other resource-limited countries is increasing rapidly. This has led to significant declines in rates of HIV-related illness and death.

Glossary

observational study

A study design in which patients receive routine clinical care and researchers record the outcome. Observational studies can provide useful information but are considered less reliable than experimental studies such as randomised controlled trials. Some examples of observational studies are cohort studies and case-control studies.

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

naïve

In HIV, an individual who is ‘treatment naïve’ has never taken anti-HIV treatment before.

Previous research has also shown that antiretroviral therapy has other benefits, improving quality of life and economic productivity. However, follow-up in these studies has typically lasted between 12 and 24 months, so it is not known if there are further improvements or if they are sustained.

Researchers therefore designed an observational study involving 879 adults of working age receiving HIV care at three sites in South Africa. The study participants were either antiretroviral naive (had never taken HIV treatment) or had been taking treatment for less than six months. They were interviewed at baseline about the presence of symptoms, their ability to perform day-to-day tasks, employment status, the impact of ill health on their work-related activities and their reliance on care. These interviews were repeated at regular intervals after the participants started antiretroviral therapy and follow-up lasted for up to 5.5 years.

Over three-quarters (78%) of participants were women, approximately half (47%) were aged between 30 and 39 years and the median CD4 cell count at baseline was 104 cells/mm3.

There was a high drop-out rate, with 47% of the original cohort leaving care by year five.

For those who remained in care, outcomes improved continuously and significantly over the five years of the study.

The probability of reporting pain in the previous week fell from 69% at baseline to 35% (p < 0.001) three years after starting therapy, falling to 17% after five years (p < 0.001).

Almost two-thirds of participants (62%) reported feeling fatigued in the previous week during their baseline interview. This had fallen to just 7% after five years of HIV treatment (p < 0.001).

A low CD4 cell count was associated with these symptoms.

Starting therapy also had a positive effect on daily functioning and the ability to perform job-related tasks.

The probability of being unable to perform normal daily activities fell from 47% in the three months prior to initiating therapy to 13% after three years of treatment (p < 0.001), and to just 5% after five years of follow-up.

Among the people who reported impairment, the number of days in the previous working week that they were unable to undertake normal tasks fell from approximately four days before starting treatment to a little under two days after five years of therapy (p = 0.03).

The probability of having a job increased from 32% at the start of the study to 44% by the end of follow-up (p < 0.0001).

Answers from people who were in employment showed that 56% reported difficulties performing job-related tasks at baseline. This had fallen to 7% after three years and fell to 6% by the end of follow-up.

Reliance on external support also fell substantially. Many people (81%) reported having a carer in the three months before they started therapy. After 2.5 years on treatment the proportion of people relying on a carer had fallen to 1%.

The investigators acknowledge that the high drop-out rate was a limitation of their study. Nevertheless they conclude: “for most patients, ART offers the possibility of a normal, healthy life over a number of years. Through its effect on productivity and employment, the benefits to individual patients will translate, in turn, into social and economic development gains for societies as a whole.”

References

Rosen S et al. Effect of antiretroviral therapy on patients’ economic well being: five-year follow-up. AIDS 27, online edition. DOI: 10.1097/QAD0000000000000053, 2013.