In 2002, the Antiretroviral Therapy Cohort Collaboration (ART-CC) - a Bristol-led initiative involving 19 cohort studies from across Europe and North America - investigated rates of AIDS and death in more than 12,000 HIV positive patients treated in high income countries.

Evidence-based treatment

Patient records were assessed from the time at which they were given antiretroviral medication, which is designed to suppress the HIV virus and stop or reverse the damage it causes to the body’s immune system.

The most important prognostic factor was found to be the number of CD4 cells (white blood cells) circulating in patients’ blood.

In 2006 ART-CC, together with a collaboration of cohorts in low income countries, published the first comparison of mortality of patients starting antiretroviral treatment between low and high-income countries. This identified high mortality soon after starting treatment among patients treated in low income countries.

Prior to the ART-CC’s research, the most opportune time for patients to begin antiretroviral treatment remained unclear. In 2009, ART-CC provided evidence that 350 cells/mm³ should be the minimum CD4 count below which antiretroviral treatment be started.

The collaboration demonstrated that improvements in HIV treatment for people in high income countries reduced mortality rates by nearly 40% and added an average 13 extra years to patients’ life expectancy.

Worldwide health impact

The ART-CC’s work informed changes during 2009-11 to guidelines issued by the World Health Organisation (WHO), as well as British, European and US health bodies, to recommend starting antiretroviral treatment earlier.

Dr Margaret May, who led the studies, subsequently worked with the UK Collaborative HIV Cohort (UK CHIC) study to raise public awareness about the benefits of earlier treatment.

A subsequent report issued by the Health Protection Agency (now Public Health England) in 2012 showed that between 2010 and 2011, AIDS diagnosis in the UK decreased by 30 per cent and mortality by 18 per cent, thanks to recommendations for earlier treatment having been incorporated into nationwide policy.

Amendments to the minimum threshold for treatment also impacted on HIV patients in Africa, where between 2009 and 2011, UNAIDS found that AIDS-related deaths fell by 32 per cent.

“Advances in treatment have transformed HIV from being a fatal disease, which was the reality for patients before the advent of combination antiretroviral treatment, into a long-term chronic condition.” Professor Jonathan Sterne, School of Social and Community Medicine

Better outcomes

The ART-CC’s research helped improve the quality of life for people living with HIV, based on analysis of life expectancy provided for the insurance industry. Since 2009, insurance companies including Swiss Re, Hanover Re and AERAS extended their offer from ten years cover to up to 25 years, improving the ability of people with HIV to obtain mortgages and business loans.

Efforts to disseminate these findings by advocacy groups such as HIV i-Base and the European AIDS Treatment Group meant that the number of UK insurers providing services to HIV positive people increased from 33 per cent to 66 per cent between 2010 and 2012.