Shifting sands: changing regional and gender-specific patterns of HIV/AIDS mortality in Canada, 1987 to 2008

Trispecific antibody targeting HIV-1 and T cells activates and eliminates latently-infected cells in HIV/SHIV infections

Agents that can simultaneously activate latent HIV, increase immune activation and enhance the killing of latently-infected cells represent promising approaches for HIV cure. Here, we develop and evaluate a trispecific antibody (Ab), N6/αCD3-αCD28, that targets three independent proteins: (1) the HIV envelope via the broadly reactive CD4-binding site Ab, N6; (2) the T cell antigen CD3; and (3) the co-stimulatory molecule CD28. We find that the trispecific significantly increases antigen-specific T-cell activation and cytokine release in both CD4+ and CD8+ T cells. Co-culturing CD4+ with autologous CD8+ T cells from ART-suppressed HIV+ donors with N6/αCD3-αCD28, results in activation of latently-infected cells and their elimination by activated CD8+ T cells. This trispecific antibody mediates CD4+ and CD8+ T-cell activation in non-human primates and is well tolerated in vivo. This HIV-directed antibody therefore merits further development as a potential intervention for the eradication of latent HIV infection.

Trends and causes of mortality in a population-based cohort of HIV-infected adults in Spain: comparison with the general population

Combination antiretroviral therapy reduces mortality of HIV-infected persons. In Spain, where this therapy is widely available, we aim to evaluate mortality trends and causes of death in HIV-infected adults, and to estimate the excess mortality compared to the general population. From 1999 to 2018 mortality by causes was analyzed in a population-based cohort of adults aged 25 to 74 years diagnosed with HIV infection in Spain. Observed deaths and expected deaths according mortality in the general population of the same sex and age were compared using standardized mortality ratios (SMRs). HIV-infected people increased from 839 in 1999–2003 to 1059 in 2014–2018, median age increased from 37 to 47 years, the annual mortality rate decreased from 33.5 to 20.7 per 1000 person-years and the proportion of HIV-related deaths declined from 64% to 35%. HIV-related mortality declined from 21.4 to 7.3 (p < 0.001), while non-HIV-related mortality remained stable: 12.1 and 13.4 per 1000, respectively. Mortality decreased principally in persons diagnosed with AIDS-defining events. In the last decade, 2009–2018, mortality was still 8.1 times higher among HIV-infected people than in the general population, and even after excluding HIV-related deaths, remained 4.8 times higher. Excess mortality was observed in non-AIDS cancer (SMR = 3.7), cardiovascular disease (SMR = 4.2), respiratory diseases (SMR = 7.9), liver diseases (SMR = 8.8), drug abuse (SMR = 47), suicide (SMR = 5.3) and other external causes (SMR = 6). In conclusion, HIV-related mortality continued to decline, while non-HIV-related mortality remained stable. HIV-infected people maintained important excess mortality. Prevention of HIV infections in the population and promotion of healthy life styles in HIV-infected people must be a priority.

Prevalence and Predictors of Depression Among People Living With HIV/AIDS: A National Study

BACKGROUND

Depression is prevalent among people living with HIV/AIDS (PLWHA), but there are few longitudinal studies investigating the prevalence of depression among HIV respondents in Taiwan.

OBJECTIVES

This study examined the trend in the prevalence of depression and its main predictors among PLWHA in Taiwan.

METHODS

This study analyzed the 2-million random-sample data set of the Taiwanese longitudinal health research database using data from 2000 to 2011and applied the Internal Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes for the detection of HIV infection and depression. Chi-square tests and logistic regression analyses were conducted to determine predictive factors for depression.

RESULTS

A total of 769 PLWHA who met the criterion of HIV infection were extracted from the database. Of these respondents, 20.03% had a diagnosis of depression after their HIV-positive diagnosis. The annual prevalence of depression among the study respondents increased significantly from 1.95% in 2000 to 6.93% in 2011 according to time trend analysis (χ = 6.428, df =11, p = .03). Multivariate, logistic regression analysis indicated a history of drug abuse was the main predictor of a diagnosis of depression.

DISCUSSION

The increasing trend in the prevalence of depression revealed an urgent need for the development of care programs for PLWHA with depression. Such programs should take into consideration a history of drug abuse as a strong risk factor for the development of depression.

The changes and the predictors of suicide ideation and suicide attempt among HIV-positive patients at 6-12 months post diagnosis: A longitudinal study

AIMS

This study examined the changes and the predictors of suicide ideation/suicide attempt and the moderating effects of psychosocial factors on the suicide ideation/suicide attempts among human immunodeficiency virus (HIV)-positive patients at 6-12 months post-diagnosis.

BACKGROUND

Suicide behaviours are prevalent among newly diagnosed HIV-positive patients, but the changes in suicide behaviours after diagnosis and the role of psychosocial factors in these behaviours are not well studied.

DESIGN

This study used a prospective longitudinal design.

METHODS

A total of 113 participants diagnosed as HIV-positive for 6-12 months were recruited from the outpatient department. Data were collected from June 2015 - October 2016. They were asked to complete Beck's Scale for Suicide Ideation, the Beck Depression Inventory-II, the Body Image Scale, the Meaning in Life Questionnaire and the Multidimensional Scale of Perceived Social Support at baseline, the third month and the sixth month.

RESULTS

The results showed the high occurrence rates for suicide ideation ranging from 27.2%, 21.6%, and 25.8% and suicide attempt ranging from 14.7%, 8.6%, and 13.3% at the baseline, the third month and the sixth month, respectively. The education level, social support from family and depressive symptoms were the predictors of suicide ideation. The history of depression disorders, depressive symptoms and social support from friends significantly predicted suicide attempt. Meaning in life-presence moderated the relationship between depressive symptoms and suicide ideation.

CONCLUSIONS

After diagnosed for 6-12 months, HIV-positive patients remain the high-risk group for suicide ideation and attempt. Suicide intervention targeting the risk and protective factors are required for HIV-positive patients.

Changes in mortality rates and causes of death in a population-based cohort of persons living with and without HIV from 1996 to 2012

Background

Non-HIV/AIDS-related diseases are gaining prominence as important causes of morbidity and mortality among people living with HIV. The purpose of this study was to characterize and compare changes over time in mortality rates and causes of death among a population-based cohort of persons living with and without HIV in British Columbia (BC), Canada.

Methods

We analysed data from the Comparative Outcomes And Service Utilization Trends (COAST) study; a retrospective population-based study created via linkage between the BC Centre for Excellence in HIV/AIDS and Population Data BC, and containing data for HIV-infected individuals and the general population of BC, respectively. Our analysis included all known HIV-infected adults (≥ 20 years) in BC and a random 10% sample of uninfected BC adults followed from 1996 to 2012. Deaths were identified through Population Data BC – which contains information on all registered deaths in BC (BC Vital Statistics Agency dataset) and classified into cause of death categories using International Classification of Diseases (ICD) 9/10 codes. Age-standardized mortality rates (ASMR) and mortality rate ratios were calculated. Trend test were performed.

Results

3401 (25%), and 47,647 (9%) individuals died during the 5,620,150 person-years of follow-up among 13,729 HIV-infected and 510,313 uninfected individuals, respectively. All-cause and cause-specific mortality rates were consistently higher among HIV-infected compared to HIV-negative individuals, except for neurological disorders. All-cause ASMR decreased from 126.75 (95% CI: 84.92-168.57) per 1000 population in 1996 to 21.29 (95% CI: 17.79-24.79) in 2011-2012 (83% decline; p < 0.001 for trend), compared to a change from 7.97 (95% CI: 7.61-8.33) to 6.87 (95% CI: 6.70-7.04) among uninfected individuals (14% decline; p < 0.001). Mortality rates from HIV/AIDS-related causes decreased by 94% from 103.85 per 1000 population in 1996 to 6.72 by the 2011–2012 era (p < 0.001). Significant ASMR reductions were also observed for hepatic/liver disease and drug abuse/overdose deaths. ASMRs for neurological disorders increased significantly over time. Non-AIDS-defining cancers are currently the leading non-HIV/AIDS-related cause of death in both HIV-infected and uninfected individuals.

Conclusions

Despite the significant mortality rate reductions observed among HIV-infected individuals from 1996 to 2012, they still have excess mortality risk compared to uninfected individuals. Additional efforts are needed to promote effective risk factor management and appropriate screening measures among people living with HIV.

Reductions in all-cause and cause-specific mortality among HIV-infected individuals receiving antiretroviral therapy in British Columbia, Canada: 2001-2012

OBJECTIVES

Since 2006, the British Columbia HIV/AIDS Drug Treatment Program (DTP) has expanded enrolment and dramatically increased its number of participants. We examined the effect this expansion has had on the underlying cause of death in HIV-infected individuals.

METHODS

We analysed data from participants aged 18 years and older in the DTP to measure 2-year mortality rates and causes of death from 2001 to 2012. We conducted tests of trend for all-cause and cause-specific mortality, and compared demographics and characteristics of individuals. Cox proportional hazard models were used to determine the risk of death.

RESULTS

A total of 8185 participants received antiretroviral therapy (ART) during the study period. Mortality declined from 3.88 per 100 person-years (PY) in 2001-2002 to 2.15 per 100 PY in 2011-2012 (P = 0.02). There were significant decreases in HIV-related deaths (2.34 to 0.56 per 100 PY; P = 0.02) and deaths attributable to chronic liver disease (0.20 to 0.09 per 100 PY; P = 0.01), cardiovascular disease (0.24 to 0.05 per 100 PY; P = 0.03) and suicides (0.47 to 0 per 100 PY; P = 0.003). Multivariate models, adjusted for age, gender, history of injecting drug use, AIDS diagnoses and baseline CD4 cell counts, demonstrated that initiation of ART in all time periods after 2001-2002 was independently associated with reduced mortality (P < 0.001).

CONCLUSIONS

We observed declines in HIV-related mortality and certain non-HIV-related causes of death among participants in the BC DTP from 2001 to 2012. These findings suggest that there may be broader benefits to the increasingly liberal HIV treatment guidelines, including reductions in death caused by cardiovascular disease and chronic liver disease.

Life expectancy of HIV-positive individuals on combination antiretroviral therapy in Canada

Background

We sought to evaluate life expectancy and mortality of HIV-positive individuals initiating combination antiretroviral therapy (ART) across Canada, and to consider the potential error introduced by participant loss to follow-up (LTFU).

Methods

Our study used data from the Canadian Observational Cohort (CANOC) collaboration, including HIV-positive individuals aged ≥18 years who initiated ART on or after January 1, 2000. The CANOC collaboration collates data from eight sites in British Columbia, Ontario, and Quebec. We computed abridged life-tables and remaining life expectancies at age 20 and compared outcomes by calendar period and patient characteristics at treatment initiation. To correct for potential underreporting of mortality due to participant LTFU, we conservatively estimated 30 % mortality among participants lost to follow-up.

Results

9997 individuals contributed 49,589 person-years and 830 deaths for a crude mortality rate of 16.7 [standard error (SE) 0.6] per 1000 person-years. When assigning death to 30 % of participants lost to follow-up, we estimated 1170 deaths and a mortality rate of 23.6 [SE 0.7] per 1000 person-years. The crude overall life expectancy at age 20 was 45.2 [SE 0.7] and 37.5 [SE 0.6] years after adjusting for LTFU. In the LTFU-adjusted analysis, lower life expectancy at age 20 was observed for women compared to men (32.4 [SE 1.1] vs. 39.2 [SE 0.7] years), for participants with injection drug use (IDU) history compared to those without IDU history (23.9 [SE 1.0] vs. 52.3 [SE 0.8] years), for participants reporting Aboriginal ancestry compared to those with no Aboriginal ancestry (17.7 [SE 1.5] vs. 51.2 [SE 1.0] years), and for participants with CD4 count <350 cells/μL compared to CD4 count ≥350 cells/μL at treatment initiation (36.3 [SE 0.7] vs. 43.5 [SE 1.3] years). Life expectancy at age 20 in the calendar period 2000–2003 was lower than in periods 2004–2007 and 2008–2012 in the LTFU-adjusted analyses (30.8 [SE 0.9] vs. 38.6 [SE 1.0] and 54.2 [SE 1.4]).

Conclusions

Life expectancy and mortality for HIV-positive individuals receiving ART differ by calendar period and patient characteristics at treatment initiation. Failure to consider LTFU may result in underestimation of mortality rates and overestimation of life expectancy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-0969-x) contains supplementary material, which is available to authorized users.

Gender differences in clinical outcomes among HIV-positive individuals on antiretroviral therapy in Canada: a multisite cohort study

BACKGROUND

Cohort data examining differences by gender in clinical responses to combination antiretroviral therapy (ART) remain inconsistent and have yet to be explored in a multi-province Canadian setting. This study investigates gender differences by injection drug use (IDU) history in virologic responses to ART and mortality.

METHODS

Data from the Canadian Observational Cohort (CANOC) collaboration, a multisite cohort study of HIV-positive individuals initiating ART after January 1, 2000, were included. This analysis was restricted to participants with a follow-up HIV-RNA plasma viral load measure and known IDU history. Weibull hazard regression evaluated time to virologic suppression (2 consecutive measures <50 copies/mL), rebound (>1000 copies/mL after suppression), and all-cause mortality. Sensitivity analyses explored the impact of presumed ART use in pregnancy on virologic outcomes.

RESULTS

At baseline, women (1120 of 5442 participants) were younger (median 36 vs. 41 years) and more frequently reported IDU history (43.5% vs. 28.8%) (both p<0.001). Irrespective of IDU history, in adjusted multivariable analyses women were significantly less likely to virologically suppress after ART initiation and were at increased risk of viral load rebound. In adjusted time to death analysis, no differences by gender were noted. After adjusting for presumed ART use in pregnancy, observed gender differences in time to virologic suppression for non-IDU, and time to virologic rebound for IDU, became insignificant.

CONCLUSIONS

HIV-positive women in CANOC are at heightened risk for poor clinical outcomes. Further understanding of the intersections between gender and other factors augmenting risk is needed to maximize the benefits of ART.