Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada from 1984 to 2003

The changing landscape of both causes and locations of death in a regional HIV population 2010-2021

BACKGROUND

Although HIV-related deaths among people with HIV have dramatically decreased, deaths from other medical conditions and non-medical events have increased. The location of death among people with HIV remains underreported.

OBJECTIVES

We reviewed the deaths, causes of death, and reported location of death (i.e. within or outside of medical settings) of all people with HIV with the Southern Alberta Cohort, Calgary, Canada, between 1 January 2010 and 1 January 2022.

METHODS

This was a retrospective longitudinal cohort study reviewing all deaths within a comprehensive geographically defined HIV cohort over 11 years.

RESULTS

Deaths from HIV-related causes decreased from 52% of all deaths in 2010 to 14% in 2021. In 2021, non-HIV medical deaths increased from 38% to 44%, and non-medical deaths (e.g. violence, suicide, drug overdose) increased from 0.5% to 39%. Of non-medical deaths, 67% resulted from substance use/overdose. Overall, deaths in any medical setting decreased from 91% in 2010 to 39% in 2021; 61% of all deaths occurred in a medical setting (e.g. hospital/emergency department or supported/long-term/hospice care), 27% in a residence, and 9% in the community.

CONCLUSION

The shifting causes of death (i.e. fewer HIV-related deaths, more overdose deaths) and location of death (i.e. fewer in medical settings, more at home/in the community) requires close monitoring so future resources can be matched to predicted patient needs.

Longitudinal trends in causes of death among adults with HIV on antiretroviral therapy in Europe and North America from 1996 to 2020: a collaboration of cohort studies

BACKGROUND

Mortality rates among people with HIV have fallen since 1996 following the widespread availability of effective antiretroviral therapy (ART). Patterns of cause-specific mortality are evolving as the population with HIV ages. We aimed to investigate longitudinal trends in cause-specific mortality among people with HIV starting ART in Europe and North America.

METHODS

In this collaborative observational cohort study, we used data from 17 European and North American HIV cohorts contributing data to the Antiretroviral Therapy Cohort Collaboration. We included data for people with HIV who started ART between 1996 and 2020 at the age of 16 years or older. Causes of death were classified into a single cause by both a clinician and an algorithm if International Classification of Diseases, Ninth Revision or Tenth Revision data were available, or independently by two clinicians. Disagreements were resolved through panel discussion. We used Poisson models to compare cause-specific mortality rates during the calendar periods 1996-99, 2000-03, 2004-07, 2008-11, 2012-15, and 2016-20, adjusted for time-updated age, CD4 count, and whether the individual was ART-naive at the start of each period.

FINDINGS

Among 189 301 people with HIV included in this study, 16 832 (8·9%) deaths were recorded during 1 519 200 person-years of follow-up. 13 180 (78·3%) deaths were classified by cause: the most common causes were AIDS (4203 deaths; 25·0%), non-AIDS non-hepatitis malignancy (2311; 13·7%), and cardiovascular or heart-related (1403; 8·3%) mortality. The proportion of deaths due to AIDS declined from 49% during 1996-99 to 16% during 2016-20. Rates of all-cause mortality per 1000 person-years decreased from 16·8 deaths (95% CI 15·4-18·4) during 1996-99 to 7·9 deaths (7·6-8·2) during 2016-20. Rates of all-cause mortality declined with time: the average adjusted mortality rate ratio per calendar period was 0·85 (95% CI 0·84-0·86). Rates of cause-specific mortality also declined: the most pronounced reduction was for AIDS-related mortality (0·81; 0·79-0·83). There were also reductions in rates of cardiovascular-related (0·83, 0·79-0·87), liver-related (0·88, 0·84-0·93), non-AIDS infection-related (0·91, 0·86-0·96), non-AIDS-non-hepatocellular carcinoma malignancy-related (0·94, 0·90-0·97), and suicide or accident-related mortality (0·89, 0·82-0·95). Mortality rates among people who acquired HIV through injecting drug use increased in women (1·07, 1·00-1·14) and decreased slightly in men (0·96, 0·93-0·99).

INTERPRETATION

Reductions of most major causes of death, particularly AIDS-related deaths among people with HIV on ART, were not seen for all subgroups. Interventions targeted at high-risk groups, substance use, and comorbidities might further increase life expectancy in people with HIV towards that in the general population.

FUNDING

US National Institute on Alcohol Abuse and Alcoholism.

Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging

BACKGROUND

People living with HIV (PLHIV) on effective antiretroviral therapy are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases. In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether epigenetic aging (i.e., the residual between regressing epigenetic age on chronological age) was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated epigenetic aging focusing on the Horvath, Hannum, PhenoAge and GrimAge epigenetic clocks, and a pace of biological aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini.

RESULTS

Age at HIV diagnosis was associated with Hannum epigenetic age acceleration (EAA) (β-coefficient [95% Confidence Interval]; 0.53 [0.05, 1.00], p = 0.03) and longer duration since HIV diagnosis was associated with slower Hannum EAA (- 0.53 [- 1.00, - 0.05], p = 0.03). The average daily dietary intake of fruits and vegetables was associated with DunedinPACE (0.12 [0.03, 0.22], p = 0.01). The associations of Hannum EAA with the age at HIV diagnosis and duration of time since HIV diagnosis were attenuated when the average daily intake of fruits and vegetables or physical activity were included in our models. Diet and self-perceived quality of life measures modified the relationship between CD4+ T cell counts at participant enrollment and Hannum EAA.

CONCLUSIONS

Epigenetic age is more advanced in OPLHIV in Eswatini in those diagnosed with HIV at an older age and slowed in those who have lived for a longer time with diagnosed HIV. Lifestyle and quality of life factors may differentially affect epigenetic aging in OPLHIV. To our knowledge, this is the first study to assess epigenetic aging in OPLHIV in Eswatini and one of the few in sub-Saharan Africa.

Estimation of Improvements in Mortality in Spectrum Among Adults With HIV Receiving Antiretroviral Therapy in High-Income Countries

INTRODUCTION

Mortality rates for people living with HIV (PLHIV) on antiretroviral therapy (ART) in high-income countries continue to decline. We compared mortality rates among PLHIV on ART in Europe for 2016-2020 with Spectrum's estimates.

METHODS

The AIDS Impact Module in Spectrum is a compartmental HIV epidemic model coupled with a demographic population projection model. We used national Spectrum projections developed for the 2022 HIV estimates round to calculate mortality rates among PLHIV on ART, adjusting to the age/country distribution of PLHIV starting ART from 1996 to 2020 in the Antiretroviral Therapy Cohort Collaboration (ART-CC)'s European cohorts.

RESULTS

In the ART-CC, 11,504 of 162,835 PLHIV died. Between 1996-1999 and 2016-2020, AIDS-related mortality in the ART-CC decreased from 8.8 (95% CI: 7.6 to 10.1) to 1.0 (0.9-1.2) and from 5.9 (4.4-8.1) to 1.1 (0.9-1.4) deaths per 1000 person-years among men and women, respectively. Non-AIDS-related mortality decreased from 9.1 (7.9-10.5) to 6.1 (5.8-6.5) and from 7.0 (5.2-9.3) to 4.8 (4.3-5.2) deaths per 1000 person-years among men and women, respectively. Adjusted all-cause mortality rates in Spectrum among men were near ART-CC estimates for 2016-2020 (Spectrum: 7.02-7.47 deaths per 1000 person-years) but approximately 20% lower in women (Spectrum: 4.66-4.70). Adjusted excess mortality rates in Spectrum were 2.5-fold higher in women and 3.1-3.4-fold higher in men in comparison to the ART-CC's AIDS-specific mortality rates.

DISCUSSION

Spectrum's all-cause mortality estimates among PLHIV are consistent with age/country-controlled mortality observed in ART-CC, with some underestimation of mortality among women. Comparing results suggest that 60%-70% of excess deaths among PLHIV on ART in Spectrum are from non-AIDS causes.

Epigenetic aging in older people living with HIV in Eswatini: a pilot study of HIV and lifestyle factors and epigenetic aging

Background

People living with HIV (PLHIV) on effective antiretroviral therapy (ART) are living near-normal lives. Although they are less susceptible to AIDS-related complications, they remain highly vulnerable to non-communicable diseases (NCD). In this exploratory study of older PLHIV (OPLHIV) in Eswatini, we investigated whether biological aging (i.e., the difference between epigenetic age and chronological age, termed 'epigenetic age acceleration [EAA]') was associated with HIV-related parameters, and whether lifestyle factors modified these relationships. We calculated EAA focusing on the second-generation epigenetic clocks, PhenoAge and GrimAge, and a pace of aging biomarker (DunedinPACE) among 44 OPLHIV in Eswatini.

Results

Among participants, the PhenoAge clock showed older epigenetic age (68 years old [63, 77]) but a younger GrimAge epigenetic age (median=56 years old [interquartile range=50, 61]) compared to the chronological age (59 years old [54, 66]). Participants diagnosed with HIV at an older age showed slower DunedinPACE (β-coefficient [95% Confidence Interval]; -0.02 [-0.04, -0.01], p=0.002) and longer duration since HIV diagnosis was associated with faster DunedinPACE (0.02 [0.01, 0.04], p=0.002). The average daily dietary intake of fruits and vegetables was associated with faster DunedinPACE (0.12 [0.03, 0.22], p=0.01) and modified the relationship between HIV status variables (number of years living with HIV since diagnosis, age at HIV diagnosis, CD4+ T cell counts) and PhenoAge EAA, and DunedinPACE.

Conclusions

Biological age is accelerated in OPLHIV in Eswatini, with those living with HIV for a longer duration at risk for faster biological aging. Lifestyle factors, especially healthier diets, may attenuate biological aging in OPLHIV. To our knowledge, this is the first study to assess biological aging in Eswatini and one of the few in sub-Saharan Africa.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Growing old with antiretroviral therapy or elderly people in antiretroviral therapy: two different profiles of comorbidity?

Background

In persons living with HIV (PLWH), the burden of non-communicable chronic diseases increased over time, because of aging associated with chronic inflammation, systemic immune activation, and long-term exposure to the combination antiretroviral therapy (ART).

Methods

To explore the association of chronological age, age at first ART, and exposure to ART with non-communicable chronic diseases, we performed a cross-sectional analysis to evaluate the prevalence of comorbidities in patients enrolled in the SCOLTA Project, stratified by groups of chronological age (50–59 and 60–69 years) and by years of antiretroviral treatment (ART, ≤ 3 or > 3 years).

Results

In 1394 subjects (23.8% women), mean age at enrollment was 57.4 (SD 6.5) years, and at first ART 45.3 (SD 10.7). Men were older than women both at enrollment (57.6 vs 56.8, p = 0.06) and at first ART (45.8 vs 43.6, p = 0.0009). ART duration was longer in women (13.1 vs 11.7 years, p = 0.01). The age- and sex-adjusted rate ratios (aRRs, and 95% confidence interval, CI) showed that longer ART exposure was associated with dyslipidemia (aRR 1.35, 95% CI 1.20–1.52), hypertension (aRR 1.52, 95% CI 1.22–1.89), liver disease (aRR 1.78, 95% CI 1.32–2.41), osteopenia/osteoporosis (aRR 2.88, 95% CI 1.65–5.03) and multimorbidity (aRR 1.36, 95% CI 1.21–1.54). These findings were confirmed in strata of age, adjusting for sex.

Conclusions

Our data suggest that longer ART exposure was associated with increased risk of dyslipidemia, hypertension, and osteopenia/osteoporosis, hence the presence of multimorbidity, possibly due to the exposition to more toxic antiretrovirals. We observed different comorbidities, according to ART exposure and age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07739-y.

Sex stratification of the trends and risk of mortality among individuals living with HIV under different transmission categories

We retrospectively examined 33,142 persons living with HIV (PLWH) in Taiwan from a nationwide database to assess sex-stratified trends and risk of all-cause mortality under different transmission categories from 1984 to 2016. Overall, 61.25% were men who have sex with men (MSM), 14.37% were men who have sex with women (MSW), 18.32% were male persons who inject drugs (M-PWID), 3.30% were women who have sex with men (WSM), and 2.74% were female PWID (F-PWID). All-cause mortality (per 100 person-years) among heterosexual people and PWID was higher in men (4.04 and 3.39, respectively) than in women (2.93 and 2.18, respectively). In each sex-stratified transmission category, the all-cause mortality reduced substantially from 1984–1996 to 2012–2016, but evolved distinctly from 2007–2011 to 2012–2016. Since 2007–2011, the decline in all-cause mortality has slowed notably in the groups with sexually transmitted HIV, but has increased in PWID, surpassing even that among groups with sexually transmitted HIV in 2012–2016. PLWH with sexually transmitted HIV had lower risks of all-cause mortality than PWID, regardless of sex. Sex and transmission category did not interact significantly on all-cause mortality. Understanding the reasons for the distinct evolving trends of all-cause mortality in each transmission category serves as a reference for developing strategies to reduce mortality in PLWH in Taiwan further.

Assessing the underreporting of deaths among people living with HIV in Rio de Janeiro, Brazil, from 2014 to 2019

We assessed the proportions and causes of the underreporting of deaths among people living with HIV (PLHIV) in Rio de Janeiro, Brazil, from 2014 to 2019. Demographic variables, mention of tuberculosis (TB), and CD4 cell counts closest to death were used to compare those who had HIV/AIDS mentioned on their death certificate (HMDC) to those who did not. Out of 10,698 deaths, 2,863 (26.8%) had no HMDC, from which 412 (14.4%) had external underlying cause. After excluding deaths from external causes, we found that 24% still had no HMDC. Age ≥ 40 years (OR = 1.75; 95%CI: 1.52-2.01), non-white race/ethnicity (OR = 1.16; 95%CI: 1.02-1.31), the male gender (OR = 1.25; 95%CI: 1.11-1.42), higher CD4 cell counts closest to death (OR = 1.14; 95%CI: 1.12-1.16), absence of TB (OR = 4.86; 95%CI: 3.76-6.29) and not dying within a hospital (OR = 2.61; 95%CI: 2.31-2.95) were associated with increased probabilities of not having HMDC. The proportion of deaths with no HMDC increased from 18.7% to 35.1% between 2014 and 2019. The high proportion of underreported deaths in Rio de Janeiro indicates that HIV/AIDS mortality coefficients in the state may be underestimated. With the changing patterns of mortality of PLHIV, physicians are advised to consider the broader clinical spectrum of HIV infection, and surveillance officers should improve death monitoring.

A Systematic Review of Risk Factors for Suicide Among Persons Living with HIV (1996-2020)

Persons living with HIV (PWH) are at elevated risk for suicide. We conducted a systematic literature review following PRISMA-P guidelines to examine risk factors associated with suicide as a cause of morbidity among PWH. We searched six electronic databases using search terms (suicide, suicide attempt, self-harm, self-injurious behavior, HIV, AIDS, PWH). We focused on factors that were specific to HIV infection (CD4 count, HIV-1 RNA, and antiretroviral therapy [ART]). The initial search yielded N = 2657 studies. Eligible studies included suicide as an outcome, quantitative study design, and publication in peer-reviewed journals from 1996 through 2020. Fourteen studies met inclusion criteria. PWH share risk factors for suicide found in the general population: psychiatric illness, previous suicide attempt, drug and alcohol misuse. PWH also have HIV-specific risk factors for suicide. HIV diagnosis in the past two years and transmission related to injection drug use were associated with increased risk; HIV-1 RNA, ART, and AIDS-defining illness were not.

Healthcare utilization among persons living with HIV in Manitoba, Canada, prior to HIV diagnosis: A case-control analysis

BACKGROUND

Understanding care patterns of persons living with HIV prior to diagnosis can inform prevention opportunities, earlier diagnosis, and engagement strategies. We examined healthcare utilization among HIV-positive individuals and compared them to HIV-negative controls.

METHODS

Data were from a retrospective cohort from Manitoba, Canada. Participants included individuals living with HIV presenting to care between 2007 and 2011, and HIV-negative controls, matched (1:5) by age, sex, and region. Data from population-based administrative databases included physician visits, hospitalizations, drug dispensation, and chlamydia and gonorrhea testing. Diagnoses associated with physician visits were classified according to International Classification of Diseases chapters. Conditional logistic regression models were used to compare cases/controls, with adjusted odds ratios (AORs) and their 95% confidence intervals (95% CI) reported.

RESULTS

A total of 193 cases and 965 controls were included. Physician visits and hospitalizations were higher for cases, compared to controls. In the 2 years prior to case date, cases were more likely to be diagnosed with "blood disorders" (AOR: 4.2, 95% CI: 2.0-9.0), be treated for mood disorders (AOR: 2.4, 95% CI: 1.6-3.4), and to have 1+ visits to a hospital (AOR: 2.2, 95% CI: 1.4-3.6).

CONCLUSION

Opportunities exist for prevention, screening, and earlier diagnosis. There is a need for better integration of healthcare services with public health.

Short-term mortality from HIV-infected persons diagnosed from 2012 to 2016: Impact of late diagnosis of HIV infection

We investigated the temporal trends of short-term mortality (death within 1 year of diagnosis) and cause-specific deaths in human immunodeficiency virus (HIV)-infected persons by stage of HIV infection at diagnosis. We also assessed the impact of late diagnosis (LD) on short-term mortality.Epidemiological records of HIV-infected Singapore residents from the National HIV Registry were linked to death records from the Registry of Births and Deaths for observational analyses. Newly-diagnosed HIV cases with available cluster of differentiation 4 count at time of diagnosis in a 5-year period from 2012 to 2016 were included in the study. Hazard ratios (HRs) and 95% confidence interval (CI) of LD for all deaths excluding suicides and self-inflicted or accidental injuries, and HIV/ acquired immunodeficiency syndrome (AIDS)-related deaths occurring within 1 year post-diagnosis were calculated using Cox proportional hazards regression models with adjustment for age at HIV/AIDS diagnosis. Population attributable risk proportions (PARPs) were then calculated using the adjusted HRs.Of the 1990 newly-diagnosed HIV cases included in the study, 7.2% had died by end of 2017, giving an overall mortality rate of 2.16 per 100 person-years (PY) (95% CI 1.82-2.54). The mortality rate was 3.81 per 100 PY (95% CI 3.15-4.56) in HIV cases with LD, compared with 0.71 (95% CI 0.46-1.05) in non-LD (nLD) cases. Short-term mortality was significantly higher in LD (9.1%) than nLD cases (1.1%). Of the 143 deaths reported between 2012 and 2017, 58.0% were HIV/AIDS-related (nLD 28.0% vs LD 64.4%). HIV/AIDS-related causes represented 70.4% of all deaths which occurred during the first year of diagnosis (nLD 36.4% vs LD 74.7%). The PARP of short-term mortality due to LD was 77.8% for all deaths by natural causes, and 87.8% for HIV/AIDS-related deaths.The mortality rate of HIV-infected persons with LD was higher than nLD, especially within 1 year of diagnosis, and HIV/AIDS-related causes constituted majority of these deaths. To reduce short-term mortality, persons at high risk of late-stage HIV infection should be targeted in outreach efforts to promote health screening and remove barriers to HIV testing and treatment.

Racial, ethnic, and gender disparities in hospitalizations among persons with HIV in the United States and Canada, 2005-2015

OBJECTIVE

To examine recent trends and differences in all-cause and cause-specific hospitalization rates by race, ethnicity, and gender among persons with HIV (PWH) in the United States and Canada.

DESIGN

HIV clinical cohort consortium.

METHODS

We followed PWH at least 18 years old in care 2005-2015 in six clinical cohorts. We used modified Clinical Classifications Software to categorize hospital discharge diagnoses. Incidence rate ratios (IRR) were estimated using Poisson regression with robust variances to compare racial and ethnic groups, stratified by gender, adjusted for cohort, calendar year, injection drug use history, and annually updated age, CD4+, and HIV viral load.

RESULTS

Among 27 085 patients (122 566 person-years), 80% were cisgender men, 1% transgender, 43% White, 33% Black, 17% Hispanic of any race, and 1% Indigenous. Unadjusted all-cause hospitalization rates were higher for Black [IRR 1.46, 95% confidence interval (CI) 1.32-1.61] and Indigenous (1.99, 1.44-2.74) versus White cisgender men, and for Indigenous versus White cisgender women (2.55, 1.68-3.89). Unadjusted AIDS-related hospitalization rates were also higher for Black, Hispanic, and Indigenous versus White cisgender men (all P < 0.05). Transgender patients had 1.50 times (1.05-2.14) and cisgender women 1.37 times (1.26-1.48) the unadjusted hospitalization rate of cisgender men. In adjusted analyses, among both cisgender men and women, Black patients had higher rates of cardiovascular and renal/genitourinary hospitalizations compared to Whites (all P < 0.05).

CONCLUSION

Black, Hispanic, Indigenous, women, and transgender PWH in the United States and Canada experienced substantially higher hospitalization rates than White patients and cisgender men, respectively. Disparities likely have several causes, including differences in virologic suppression and chronic conditions such as diabetes and renal disease.

The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada

Introduction

Universal provision of effective antiretroviral medication has been essential to reduce mortality, increase longevity, and reduce onward transmission of HIV. This study aims to illuminate persistent threats to the health and longevity of under-served PLWH in British Columbia (BC), Canada.

Methods

Between 2007 and 2010, 1000 PLWH across BC were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study and completed a cross-sectional survey on their HIV-care experiences and healthcare engagement. The sample generally reflects an under-served population of PLWH. A linkage to the provincial Vital Statistics registry is used in this analysis in order to examine overall mortality and cause-specific mortality trends; probability of death was modeled using logistic regression for participants with ongoing clinical monitoring (n = 910).

Results

By June 2017, 208 (20.8%) participants had died. The majority of deaths 57 (27.4%) were attributed to drug-related complications or overdoses, 39 (18.8%) were attributed to HIV-related complications, and 36 (17.3%) to non-AIDS-defining malignancies. We observed elevated odds of death among PLWH who smoked tobacco (aOR: 2.11, 95% CI: 1.38, 3.23), were older (aOR: 1.06 per one-year increase, 95% CI: 1.04, 1.08), indicated heavy alcohol consumption (aOR: 1.57, 95% CI: 1.11, 2.22), and reported unstable housing (aOR: 1.96, 95% CI: 1.37, 2.80); while higher CD4 cell count was protective (aOR: 0.87 per 100-unit increase, 95% CI: 0.79, 0.94) as was male gender), though non-significant (aOR: 0.73, 95% CI: 0.49, 1.07).

Conclusions

Overdose is - the leading cause of mortality among a cohort of under-served PLWH in BC, Canada. Public health efforts to end the HIV epidemic and support the health and well-being of PLWH are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs. Integrated low-barrier primary care is essential for supporting under-served PLWH, and safe drug supply is needed to support PLWH who use drugs.

Belatacept-based immunosuppressive regimen in HIV-positive kidney transplant recipients

Background

Kidney allograft survival in human immunodeficiency virus (HIV)-positive patients is lower than that in the general population. Belatacept increases long-term patient and allograft survival rates when compared with calcineurin inhibitors (CNIs). Its use in HIV-positive recipients remains poorly documented.

Methods

We retrospectively report a French cohort of HIV-positive kidney allograft recipients who were switched from CNI to belatacept, between June 2012 and December 2018. Patient and allograft survival rates, HIV immunovirological and clinical outcomes, acute rejection, opportunistic infections (OIs) and HLA donor-specific antibodies (DSAs) were analysed at 3 and 12 months, and at the end of follow-up (last clinical visit attended after transplantation). Results were compared with HIV-positive recipients group treated with CNI.

Results

Twelve patients were switched to belatacept 10 (2–25) months after transplantation. One year after belatacept therapy, patient and allograft survival rates scored 92% for both, two (17%) HIV virological rebounds occurred due to antiretroviral therapy non-compliance, and CD4⁺ and CD8⁺ T-cell counts remained stable over time. Serious adverse events included two (17%) acute steroid-resistant T-cell-mediated rejections and three (25%) OIs. Kidney allograft function significantly increased over the 12 post-switch months (P = 0.009), and DSAs remained stable at 12 months after treatment. The control group showed similar results in terms of patient and kidney allograft survival rates, DSA characteristics and proteinuria

Conclusions

Switch from CNI to belatacept can be considered safe and may increase long-term kidney allograft survival in HIV-positive kidney allograft recipients. These results need to be confirmed in a larger cohort.

Mortality trends and causes of death among HIV positive patients at Newlands Clinic in Harare, Zimbabwe

Background

We report trends in mortality patterns and causes among HIV positive patients, who initiated antiretroviral therapy (ART), at an urban clinic in Harare, Zimbabwe.

Methods

A retrospective cohort study was conducted in which routinely collected data for patients enrolled and followed up between February 2004 and December 2017 were assessed. Patients follow up was from the day of the treatment initiation until exit by death, transfer out or loss to follow up. Two doctors categorized causes of death (COD) as tuberculosis (TB), communicable AIDS, non-communicable diseases (NCDs), malignancies, others and unknown. We used competing risk survival analysis, first to estimate all-causes and cause-specific mortality rates over time, and then to assess risk factors of different causes of death.

Results

A total of 4 868 patients were followed up for 27 527 person years (PY). Among the 506 patients who died, COD was unknown for 76 patients (15%) and common COD were TB (n = 71, 14%), Malignancies (n = 54, 10.7%) Meningitis (n = 39, 7.7%) and NCDs (n = 60, 11.9%). 49.4% of the deaths were within the first year of starting ART. Median age at death was 36 years (IQR:19–46). There was a near threefold increase in proportion of deaths due to NCDs and malignancies over the period of follow up. Low baseline CD4 cell count and WHO stages 3 & 4 were significant risk factors for all-cause mortality.

Conclusions

TB remains the leading cause of death among HIV infected people. Deaths due to NCDs and malignancies increased over time. ART facilities need to incorporate management of NCDs including cancer as part of comprehensive care of PLHIV to reduce mortality.

Improvement in insulin sensitivity and serum leptin concentration after the switch from a ritonavir-boosted PI to raltegravir or dolutegravir in non-diabetic HIV-infected patients

OBJECTIVES

An observational, prospective, cohort study was performed to assess changes in insulin sensitivity and serum leptin level after a switch from a ritonavir-boosted PI (PI/r) to raltegravir or dolutegravir in HIV-infected adults on stable combination ART (cART).

METHODS

Non-diabetic HIV-infected patients receiving suppressive cART including tenofovir disoproxil fumarate/emtricitabine plus one PI/r, who underwent a switch from the PI/r to raltegravir (group A) or dolutegravir (group B), were enrolled in the study. Serum levels of insulin, leptin and the homeostasis model assessment of insulin resistance (HOMA) index were evaluated during a 12 month follow-up.

RESULTS

Overall, 86 patients were enrolled: 45 patients were included in group A and 41 were included in group B. The mean age was 45.7 years and 74 (86%) patients were male. After 12 months of follow-up, a significant reduction in the mean concentration of leptin and insulin was reported both in group A [-0.61 ng/mL (P < 0.001) and -2.5 mIU/L (P = 0.008), respectively] and in group B [-0.54 ng/mL (P = 0.005) and -2.1 mIU/L (P = 0.017), respectively], without a significant difference between the groups. A significant and comparable reduction in the mean HOMA index was reported both in group A [-0.55 (P = 0.004)] and in group B [-0.49 (P < 0.001)], as well as a significant decrease in lipid levels.

CONCLUSIONS

In HIV-positive subjects on suppressive cART, the switch from a PI/r to raltegravir or dolutegravir led to a significant and comparable reduction in both HOMA index and serum leptin level, reflecting a similar and significant improvement in insulin sensitivity.

An HIV-infected Patient with No Serious Adverse Events after Overdosing on Raltegravir

Patients with HIV infection represent a high-risk group for medication overdose because of the high frequency of complicating psychiatric disorders. Raltegravir is well-known for its low frequency of adverse effects. We herein report a 42-year-old Japanese man with HIV infection who was hospitalized 6 hours after overdosing with 24,000 mg of raltegravir in a suicide attempt. No serious adverse events occurred, although the plasma concentration of raltegravir at 18 hours after the overdose was 79,871.1 ng/mL. Raltegravir may be well-indicated for HIV patients at risk of overdosing.

Causes of death and mortality trends of all individuals reported with HIV/AIDS in Israel, 1985-2010

Background

Highly active antiretroviral therapy (HAART) has changed life-expectancy and mortality trends among people living with HIV/AIDS (PLWHA) since 1996. This retrospective cohort study aimed to assess the mortality epidemiology of PLWHA in Israel and analyze the causes of death.

Methods

This cohort study included all adult Israeli-citizens PLWHA between 1985 and 2010 and crossed matched with the Civil Registry to identify those who died. Death certificates were classified into AIDS or non-AIDS deaths related-causes. Standardized mortality-ratio (SMR) represented mortality excess.

Results

Of all 5140 PLWHA who were followed-up for 36 955 person-years, 1066 (20.7%) died. The ratio of AIDS-related deaths to non-AIDS related deaths reduced from 1.2:1 before 1996 to 0.6:1 after 1997, and case-fatality rates reduced from 12.0 to 0.9%, respectively (P < 0.001). SMR were 3.0 (95% CI: 2.3–3.5) for males and 3.9 (95% CI: 3.3–4.5) for females.

Fatality cases were more likely older Israeli-born males, co-infected with tuberculosis, reported before 1996 and acquired HIV by drug-injection or infected-blood products. Deaths of AIDS-related causes were common among Israeli-born gay men, while non-AIDS deaths were common among those reported after 1997 and drug users.

Conclusions

Death rates declined since HAART introduction. Yet, SMR remained high, and PLWHA infected by drug-use or blood-products have not enjoyed relative longevity.

Underreporting of AIDS deaths in Brazil: linkage of hospital records with death certificate data

This study investigated the underreporting of deaths due to Acquired Immunodeficiency Syndrome (AIDS) in Brazil, using the product of the linkage between the Mortality Information System (SIM) and the Hospital Information System (SIH) for the years 2008 to 2012. The hypothesis was that there were deaths recorded in the SIM that should have AIDS as the underlying cause of death, but that had been poorly classified. Many of the decedents had previous hospitalizations due to the illness. Underreported AIDS deaths were defined taking into account the coding rules of the International Classification of Diseases 10th Revision, in order to discriminate AIDS deaths from those due to other causes in people living with HIV / AIDS. In this period, 60,362 deceased had AIDS as the underlying cause, and we found another 2,671 (4.2%) as underreported causes. Underreported deaths increased the average AIDS mortality rate from 6.3/100,000 to 6.6/100,000. In conclusion, this study demonstrated that, through linkage in between SIH and SIM, it is possible to find underreporting of AIDS deaths in Brazil. These results serve as a warning for the need for actions that would promote a better certification of the causes of death among AIDS patients.

Clusterization of co-morbidities and multi-morbidities among persons living with HIV: a cross-sectional study

BACKGROUND

Among people living with HIV (PLWH), the prevalence of non-HIV related co-morbidities is increasing. Aim of the present study is to describe co-morbidity and multi-morbidity, their clustering mode and the potential disease-disease interactions in a cohort of Italian HIV patients.

METHODS

Cross-sectional analysis conducted by the Coordinamento Italiano per lo Studio di Allergia e Infezioni da HIV (CISAI) on adult subjects attending HIV-outpatient facilities. Non-HIV co-morbidities included: cardiovascular disease, diabetes mellitus, hypertension, oncologic diseases, osteoporosis, probable case of chronic obstructive pulmonary disease (COPD), hepatitis C virus (HCV) infection, psychiatric illness, kidney disease. Multi-morbidity was defined as the presence of two or more co-morbidities.

RESULTS

One thousand and eighty-seven patients were enrolled in the study (mean age 47.9 ± 10.8). One hundred-ninety patients (17.5%) had no co-morbidity, whereas 285 (26.2%) had one condition and 612 (56.3%) were multi-morbid. The most recurrent associations were: 1) dyslipidemia + hypertension (237, 21.8%); 2) dyslipidemia + COPD (188, 17.3%); 3) COPD + HCV-Ab+ (141, 12.9%). Multi-morbidity was associated with older age, higher body mass index, current and former smoking, CDC stage C and longer ART duration.

CONCLUSIONS

More than 50% of PLHW were multi-morbid and about 30% had three or more concurrent comorbidities. The identification of common patterns of comorbidities address the combined risks of multiple drug and disease-disease interactions.

Influence of Hepatitis C virus coinfection on immune reconstitution in HIV subjects

Despite successful HIV suppression by antiretroviral treatment (ART), immune activation may persist in HIV patients, contributing to an impaired immunological reconstitution and disease progression. Information regarding Hepatitis C virus (HCV) coinfection as a factor that accounts for immune activation in HIV subjects remains unclear. Furthermore, most studies have been carried out considering HIV/HCV patients as a whole, without taking into account the presence or absence of liver damage. Therefore, it is unknown if HCV and/or its liver-related disease could act as two independent factors contributing to the immune activation. In this study, we investigated the presence of immune activation in a cohort of 50 HIV/HCV patients by measuring cytokine levels, CD4⁺ T-cell counts and CD4/CD8 ratios. Six patient groups were defined according to HIV viral load, HCV status, and liver disease to assess the impact of each of these factors on immune activation and reconstitution in HIV/HCV patients. Only subjects with controlled HIV infection and cleared HCV displayed immunological parameters within normal ranges. The mere presence of HCV contributes to immune activation leading to an inappropriate immunological reconstitution. This state exacerbates in the presence of HCV-associated liver disease. Our results suggest that ART is not enough to suppress immune activation in the context of HIV/HCV coinfection, since both HCV and its liver-related disease would contribute to the immune activation. Given that immune activation worsens immunological reconstitution and clinical status, these results support the priority of HCV treatment in HIV/HCV patients and suggest the monitoring of their liver status.

Outcomes in human immunodeficiency virus-infected recipients of heart transplants

BACKGROUND

With the advent of combined antiretroviral therapy (cART), growing evidence has shown human immunodeficiency virus (HIV) may no longer be an absolute contraindication for solid organ transplantation. This study compares outcomes of heart transplantations between HIV-positive and HIV-negative recipients using SRTR transplant registry data.

METHODS

Patient survival, overall graft survival and death-censored graft survival were compared between HIV-positive and HIV-negative recipients. Multivariate Cox regression and Cox regression with a disease risk score (DRS) methodology were used to estimate the adjusted hazard ratios among heart transplant recipients (HTRs).

RESULTS

In total, 35 HTRs with HIV+ status were identified. No significant differences were found in patient survival (88% vs 77%; P = 0.1493), overall graft survival (85% vs 76%; P = 0.2758), and death-censored graft survival (91% vs 91%; P = 0.9871) between HIV-positive and HIV-negative HTRs in 5-year follow-up. No significant differences were found after adjusting for confounders.

CONCLUSIONS

This study supports the use of heart transplant procedures in selected HIV-positive patients. This study suggests that HIV-positive status is not a contraindication for life-saving heart transplant as there were no differences in graft, patient survival.

Mortality in Hospitalised HIV/AIDS Patients in a Tertiary Centre in Sub-Saharan Africa: Trends Between 2007 and 2015, Causes and Associated Factors

Background:

With easy accessibility to combination Antiretroviral Therapy (cART), mortality amongst hospitalized HIV/AIDS patients needs to be described.

Objective:

We aimed at determining the trends, causes and factors associated with in-hospital mortality amongst HIV/AIDS patients in the Douala General Hospital.

Methods:

We retrospectively reviewed hospitalisation records of HIV/AIDS patients hospitalized in the medical wards of the DGH from 2007 to 2015. Four cause-of-death categories were defined: 1. Communicable conditions and AIDS-defining malignancies, 2. Chronic non-communicable conditions and non-AIDS defining malignancies’, 3. Other non-communicable conditions and 4. Unknown conditions. Logistic regression was used to determine factors associated mortality.

Results:

We analyzed 891 eligible files. The mean age was 43 (standard deviation (SD): 10) years and median length of hospital stay was 9 (interquatile range (IQR)4 - 15) days. The overall all-cause mortality was 23.5% (95% CI: 20.8% - 26.4%). The category - communicable conditions and AIDS defining malignancies represented 79.9%, of deaths and this remained constant for each year during the study period. Tuberculosis was the most common specific cause of death (23.9%). Patients who had two (OR=2.35, 95%CI: 1.35 - 4.06) and more than two (OR=4.23, 95%CI: 1.62 – 11.12) opportunistic infections, a haemoglobin level less than 10g/l (OR=2.38, 95%CI: 1.58 - 3.59) had increased odds of dying.

Conclusion:

In-hospital mortality is high amongst HIV/AIDS patients at the Douala general hospital. The category - communicable conditions and AIDS defining malignancies - is still the main underlying cause of death. We hope that our findings will help to develop interventions aimed at reducing in-hospital mortality.

Early Treatment of Primary HIV Infection Is Associated with Decreased Mortality

The aim of this study was to understand factors associated with increased mortality in a cohort of primary HIV infection (PHI) in New South Wales (NSW) over three decades. Six hundred and two patients with PHI were enrolled from 1984 to 2009. Probabilistic data linkage was performed to NSW Registry of births deaths and marriages and Australian Bureau of Statistics mortality database. Mortality was measured by crude death rate. Pre highly active antiretroviral therapy (pre-HAART) era was defined as before January 1, 1997. A Cox proportional hazard model was used to identify factors associated with death. One hundred and thirty-eight deaths occurred during 6,223 person years (PY) follow-up. Overall crude death rate was 2.2 per 100 PY (95% confidence interval [CI], 1.9-2.6), 3.6 (95% CI, 3.1-4.3)in pre-HAART era and 0.20 (95% CI, 0.08-0.47) in post-HAART era. AIDS was the most frequent cause of death (52%, 72/138), all occurring in the pre-HAART era. Of non-AIDS deaths, the leading known cause was non-AIDS cancer 8% (11/138) followed by suicide 4% (6/138). On multivariate analysis, estimated date of infection in pre-HAART era and time to commencement of ART greater than 1 year post diagnosis were more likely to be associated with death (p < .05). Mortality in PHI has decreased significantly in the post-HAART era. Non-AIDS deaths due to malignancy and suicide are emerging as leading causes in this population in the post-HAART era. Time to starting ART greater than 1 year was associated with increased mortality.

Correlation between PAI-1, leptin and ferritin with HOMA in HIV/AIDS patients

BACKGROUND

Data about correlation of interleukins (IL-1 α, IL-1 β, IFN γ, IL-2, IL-4, IL-6, IL-8, IL-10), adipocytokines (leptin, adiponectin, monocyte chemoattractant protein-1 (MCP-1), resistin, plasminogen activator inhibitor-1 (PAI-1), tumor necrosis factor alpha (TNFα), ferritin, C reactive protein (CRP) and vascular endothelial growth factor (VEGF) with homeostasis model assessment (HOMA) in HIV/AIDS patients are still limited. Therefore the aim of this study was to evaluate the possible correlations of serum levels of PAI-1, leptin and ferritin with HOMA in HIV/AIDS patients treated with combined antiretroviral therapy (cART).

METHODS

This cross-sectional study included 64 HIV/AIDS patients, all Caucasians, receiving cART at the HIV/AIDS Centre, Belgrade, Serbia. PAI-1, leptin, ferritin and insulin levels were measured using the Metabolic Syndrome Array I (Randox Laboratories Ltd., London, UK), while adiponectin and resistin levels were measured using Metabolic Syndrome Array II (Randox Laboratories Ltd., London, UK), interleukins (IL-1 α, IL-1 β, IFN γ, IL-2, IL-4, IL-6, IL-8, IL-10), MCP-1, TNF-α as well as VEGF was measured using Cytokine Array I (Randox Laboratories Ltd., London, UK). Insulin resistance was determined using the homeostasis model assessment index (HOMA). Multicollinearity of independent variables in multivariate model was analyzed using Variance Inflation Factor.

RESULTS

Correlation analysis revealed significant correlations between HOMA and waist circumference, body mass index, patients' age, number of cART combinations and triglycerides (p = 0.001, p = 0.001, p = 0.050, p = 0.044, p = 0.002, respectively). HOMA negatively correlated with levels of high density lipoprotein (HDL) (Rho = -0.282; p = 0.025). PAI-1 (Rho = 0.334; p= 0.007) and leptin (Rho = 0.492; p = 0.001) together with ferritin (Rho = 0.396, p = 0.001) positively and significantly correlated with HOMA. Levels of IL-1 α, IL-1 β, IFN γ, IL-2, IL-4, IL-6, IL-8, IL-10, adiponectin, MCP-1, resistin, TNF-α, CRP and VEGF did not significantly correlate with HOMA. Further, multiple logistic regression showed that there is a statistically significant correlation between PAI, leptin and ferritin with HOMA levels (p = 0.042; p < 0.001, p = 0.009).

CONCLUSIONS

We showed significant correlation between PAI-1, leptin and ferritin, independently of each other with HOMA, in HIV/AIDS patients on cART.

A first-line antiretroviral therapy-resistant HIV patient with rhinoentomophthoromycosis

The Conidiobolus coronatus-related rhinoentomophthoromycosis in immunocompetent and immunocompromised (HIV negative) individuals has been treated successfully with antifungal drugs. However, C. coronatus infections in first-line antiretroviral therapy (ART)-resistant (HIV infected) individuals particularly with rhinoentomophthoromycosis have not been reported previously. Here, we describe a case of itraconazole non-responding rhinoentomophthoromycosis in an HIV-infected patient with first-line antiretroviral (ART) drug resistance which was successfully managed through systematic diagnostic and therapeutic approaches in dermatologic setting. A 32-year-old HIV-1-infected man presented with painless swelling, nasal redness and respiratory difficulty. The patient was receiving first-line ART and had a history of traumatic injury before the onset of nasopharyngeal manifestations. The patient's previous history included oral candidiasis and pulmonary tuberculosis.

HIV treatment as prevention among people who inject drugs - a re-evaluation of the evidence

Background

Population-level associations between community measures of HIV viral load and HIV incidence have been interpreted as evidence for HIV anti-retroviral treatment (ART) as prevention among people who inject drugs (PWID). However, investigation of concurrent HCV and HIV incidence trends allows examination of alternative explanations for the fall in HIV incidence. We estimate the contribution of ART and reductions in injecting risk for reducing HIV incidence in Vancouver between 1996 and 2007.

Methods

A deterministic model of HIV and HCV transmission among PWID was calibrated to the baseline (1996) HIV and HCV epidemic among PWID in Vancouver. While incorporating parameter uncertainty, the model projected what levels of ART protection and decreases in injecting risk could reproduce the observed reduction in HIV and HCV incidence for 1996-2007, and so what impact would have been achieved with just ART or just reductions in injecting risk.

Results

Model predictions suggest the estimated reduction (84%) in HCV incidence for 1996-2007 required a 59% (2.5-97.5 percentile range 49-76%) reduction in injecting risk, which accounted for nine-tenths of the observed decrease in HIV incidence; the remainder was achieved with a moderate ART efficacy for reducing sexual HIV infectivity (70%, 51-89%) and an uncertain ART efficacy for reducing injection-related HIV infectivity (44%, 0-96%). Despite this uncertainty, projections suggest that the decrease in injecting risk reduced HIV incidence by 76% (63-85%) and ART further reduced HIV incidence by 8% (2-19%), or on its own by 3% (-34-37%).

Conclusions

Observed declines in HIV incidence in Vancouver between 1996 and 2007 should be seen as a success for intensive harm reduction, whereas ART probably played a small role.

Association between the use of protease inhibitors in highly active antiretroviral therapy and incidence of diabetes mellitus and/or metabolic syndrome in HIV-infected patients: A systematic review and meta-analysis

This systematic review and meta-analysis tries to determine whether there is an association between the use of protease inhibitors (PIs) and the incidence of diabetes mellitus (DM) and/or metabolic syndrome (MS) in HIV-infected patients. A systematic literature search was performed using MEDLINE/PubMed, CENTRAL, LILACS, and EMBASE. Included articles were observational studies published on or prior to November 2015 that met specific inclusion criteria. Pooled relative risks (RRs) and hazard ratios (HRs) were calculated. Nine articles met the inclusion criteria, describing 13,742 HIV patients. Use of PIs was associated with the development of MS (RR: 2.11; 95% CI 1.28-3.48; p-value 0.003). No association between the use of PIs and development of DM was found: the HR for the incidence of DM among patients using PIs was 1.23 (95% CI 0.66-2.30; p-value: 0.51) and the RR was 1.25 (95% CI 0.99-1.58; p-value 0.06). Use of PIs in HIV-infected patients is associated with an increased risk of MS. No evidence of an increased risk of DM was found. However, because MS is a precursor to DM, it is possible that studies with a longer follow-up duration are needed in order to detect an association between PI use and onset of DM.

The Impact of Weight Gain During HIV Treatment on Risk of Pre-diabetes, Diabetes Mellitus, Cardiovascular Disease, and Mortality

Since the introduction of combined antiretroviral therapy (cART) and more effective treatments for AIDS, there has been a dramatic shift from the weight loss and wasting that characterised HIV/AIDS (and still does in countries where cART is not readily available or is initiated late) to healthy weight, or even overweight and obesity at rates mirroring those seen in the general population. These trends are attributable to several factors, including the "return to health" weight gain with reversal of the catabolic effects of HIV-infection following cART-initiation, strategies for earlier cART-initiation in the course of HIV-infection which have prevented many people living with HIV-infection from developing wasting, in addition to exposure to the modern obesogenic environment. Older cART regimens were associated with increased risk of body fat partitioning disorders (lipodystrophy) and cardiometabolic complications including atherothrombotic cardiovascular disease (CVD) and diabetes mellitus. Whilst cART now avoids those medications implicated in causing lipodystrophy, long-term cardiometabolic data on more modern cART regimens are lacking. Longitudinal studies show increased rates of incident CVD and diabetes mellitus with weight gain in treated HIV-infection. Abdominal fat gain, weight gain, and rising body mass index (BMI) in the short-term during HIV treatment was found to increase incident diabetes risk. Rising BMI was associated with increased risk of incident CVD, however the relationship varied depending on pre-cART BMI category. In contrast, a protective association with mortality is evident, predominantly in the underweight and in resource-poor settings, where weight gain reflects access to cART and virological suppression. The question of how to best evaluate, manage (and perhaps constrain) weight gain during HIV treatment is of clinical relevance, especially in the current climate of increasingly widespread cART use, rising overweight, and obesity prevalence and growing metabolic and cardiovascular disease burden in people living with HIV-infection. Large prospective studies to further characterise the relationship between weight gain during HIV treatment and risk of diabetes, CVD and mortality are required.

The albumin-bilirubin grade uncovers the prognostic relationship between hepatic reserve and immune dysfunction in HIV-associated hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of liver-related mortality in people living with HIV, where co-infection with hepatotropic viruses accelerates the course of chronic liver disease.

AIM

To evaluate whether the albumin-bilirubin (ALBI) grade, a more accurate marker of liver dysfunction in HCC, might identify patients with progressive liver dysfunction in the context of HIV/hepatitis co-infection.

METHODS

Using uni- and multi-variable analyses, we studied the albumin-bilirubin grade as a predictor of overall survival (OS) in a large, multi-center cohort of patients with HIV-associated HCC recruited from 44 centres in 9 countries within the Liver Cancer in HIV study group. Patients who underwent liver transplantation were excluded.

RESULTS

A total of 387 patients, predominantly HCV co-infected (78%) with balanced representation of all Barcelona Clinic Liver Cancer (BCLC) stages (A = 33%, B = 18%, C = 37%, D = 12%) were recruited. At HCC diagnosis, 84% had been on anti-retrovirals for a median duration of 8.8 years. The albumin-bilirubin grade identified significant differences in median survival of 97 months for grade 1 (95% CI 13-180 months), 17 months for grade 2 (95% CI 11-22 months) and 6 months for grade 3 (95% CI 4-9 months, P < .001). A more advanced albumin-bilirubin grade correlated with lower CD4 counts (464/373/288 cells/mm³ for grades 1/2/3) and higher HIV viraemia (3.337/8.701/61.845 copies/mL for grades 1/2/3, P < .001).

CONCLUSIONS

In this large, multi-center retrospective study, the albumin-bilirubin grade highlights the interplay between liver reserve and immune dysfunction as prognostic determinants in HIV-associated HCC.

Periodontal and other oral manifestations of immunodeficiency diseases

The list of immunodeficiency diseases grows each year as novel disorders are discovered, classified, and sometimes reclassified due to our ever-increasing knowledge of immune system function. Although the number of patients with secondary immunodeficiencies (SIDs) greatly exceeds those with primary immunodeficiencies (PIDs), the prevalence of both appears to be on the rise probably because of scientific breakthroughs that facilitate earlier and more accurate diagnosis. Primary immunodeficiencies in adults are not as rare as once thought. Globally, the main causes of secondary immunodeficiency are HIV infection and nutritional insufficiencies. Persons with acquired immune disorders such as AIDS caused by the human immunodeficiency virus (HIV) are now living long and fulfilling lives as a result of highly active antiretroviral therapy (HAART). Irrespective of whether the patient's immune-deficient state is a consequence of a genetic defect or is secondary in nature, dental and medical practitioners must be aware of the constant potential for infections and/or expressions of autoimmunity in these individuals. The purpose of this review was to study the most common conditions resulting from primary and secondary immunodeficiency states, how they are classified, and the detrimental manifestations of these disorders on the periodontal and oral tissues.

In-Patient Mortality among PLHIV: A 7-Year Hospital-Based Retrospective Study in Coastal South India

BACKGROUND

With the wide usage of highly active antiretroviral therapy, the morbidity and mortality due to HIV have declined gradually. The aim of our study was to determine the cause of mortality among HIV-infected patients and the factors causing early death.

METHODS

Using medical records of 73 inpatients who are dead, data were collected and analyzed using SPSS version 19 (IBM SPSS Statistics). Chi-square test was performed to determine the factors contributing to early death. A P value <.05 was considered significant.

RESULTS

Among 73 deaths, 50 (68.5%) were AIDS related and 23 (31.5%) were non-AIDS related. The most common opportunistic infection causing death was Pneumocystis carinii pneumonia. Early deaths were strongly attributed to low CD4 counts at admission (<100 cells), antiretroviral therapy-naive status, late presentation, and fewer admissions ( P value <.05).

CONCLUSION

Although AIDS-defining illness remains the main cause of death in HIV, there is significant number of deaths due to non-HIV-related causes.

Causes of death and factors associated with early mortality of HIV-infected adults admitted to Korle-Bu Teaching Hospital

INTRODUCTION

This study sought to identify common causes of death as well as the factors associated with the high inpatient mortality rate of HIV-infected patients at the Korle-Bu Teaching Hospital (KBTH).

METHODS

The retrospective study reviewed the medical records of 547 HIV-infected adults aged 18 years or older admitted to the KBTH between the months of January 2012 and October 2013. Using standardized abstraction forms, clinical and demographic data of eligible patients was collected. Data was summarized using descriptive statistics. Demographic and clinical characteristics of patients who died within 7 days (early) and after (late) admission were compared using Rank Sum tests or Chi-square tests.

RESULTS

Of 547 eligible patients during the period, 222 (40.6%) died during hospitalization, with 124 (55.9%) of them dying within a week of admission. Of the 222 patients who died, 190 (85.6%) were previously known HIV-positive. Yet, 141 (63.5%) of the 222 patients who died had no prior highly active antiretroviral therapy (HAART). The most common admitting diagnoses were anemia (34.2%), cerebral toxoplasmosis (29.3%), and pneumonia (25.7%); the most common causes of death were tuberculosis (34.7%), anemia (30.2%) and cerebral toxoplasmosis (27.5%). Tuberculosis was the only factor significantly associated with early death (P<0.05).

CONCLUSION

The inpatient mortality rate among HIV-infected adults admitted to the KBTH is high. A majority of the patients were not receiving HAART despite known HIV diagnosis. Earlier initiation of HAART may lower the risk of opportunistic infections and HIV mortality rates. Additionally, a high index of suspicion and initiation of empiric treatment for TB may reduce early deaths.

Impact of opioid substitution therapy on the HIV prevention benefit of antiretroviral therapy for people who inject drugs

OBJECTIVE

A recent meta-analysis suggested that opioid substitution therapy (OST) increased uptake of antiretroviral treatment (ART) and HIV viral suppression. We modelled whether OST could improve the HIV prevention benefit achieved by ART among people who inject drugs (PWID).

METHODS

We modelled how introducing OST could improve the coverage of ART across a PWID population for different baseline ART coverage levels. Using existing data on how yearly HIV-transmission risk is related to HIV plasma viral load, changes in the level of viral suppression across the population were used to project the relative reduction in yearly HIV-transmission risk achieved by ART, with or without OST, compared with if there was no ART - defined here as the prevention effectiveness of ART.

RESULTS

Owing to OST use increasing the chance of being on ART and achieving viral suppression if on ART, the prevention effectiveness of ART for PWID on OST (compared with PWID not on OST) increases by 44, 31, or 20% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively. Improvements in the population-level prevention effectiveness of ART are also achieved across all PWID, compared with if OST was not introduced. For instance, if OST is introduced at 40% coverage, the population-level prevention effectiveness of ART could increase by 27, 20, or 13% for a low (20%), moderate (40%), or high (60%) baseline ART coverage, respectively.

CONCLUSION

OST could improve the HIV prevention benefit of ART; supporting strategies that aim to concurrently scale-up OST with ART.

Morphological changes in the digestive system of 322 necropsies of patients with acquired immune deficiency syndrome: comparison of findings pre- and post-HAART (Highly Active Antiretroviral Therapy)

Involvement of the digestive system in AIDS pathologies or injuries is frequent. Aiming at comparing the frequency, the importance that these lesions have for death and the survival time in patients using or not using HAART, we studied 322 necropsies classified as follows: Group A - without antiretroviral drugs (185 cases); B - one or two antiretroviral drugs or HAART for less than six months (83 cases); C - HAART for six months or longer (54 cases). In the overall analysis of the digestive system, changes were present in 73.6% of cases. The most frequent was Candida infection (22.7%), followed by cytomegalovirus (19.2%), Histoplasma capsulatum (6.5%), mycobacteria (5.6%), and Toxoplasma gondii (4.3%). T. gondii infection was more frequent in group A compared with group C, and cytomegalovirus (CMV) was more frequent in group A compared with groups B and C (p < 0.05); 2.2% of the deaths were due to gastrointestinal bleeding. Regarding the segments, only in the large intestine, and only cytomegalovirus, were more frequent in group A compared with group C. We conclude that digestive system infections are still frequent, even with the use of HAART. However, the average survival time in group C was more than three times greater than the one in group A and nearly double that of group B, demonstrating the clear benefit of this therapy.

Trends in CD4 cell count response to first-line antiretroviral treatment in HIV-positive patients from Asia, 2003-2013: TREAT Asia HIV Observational Database Low Intensity Transfer

Antiretroviral treatment (ART) guidelines have changed over the past decade, recommending earlier initiation and more tolerable regimens. The study objective was to examine the CD4 response to ART, depending on the year of ART initiation, in HIV-positive patients in the Asia-Pacific. We included HIV-positive adult patients who initiated ART between 2003 and 2013 in our regional cohort from eight urban referral centres in seven countries within Asia. We used mixed-effects linear regression models to evaluate differences in CD4 response by year of ART initiation during 36 months of follow-up, adjusted a priori for other covariates. Overall, 16,962 patients were included. Patients initiating in 2006-9 and 2010-13 had an estimated mean CD4 cell count increase of 8 and 15 cells/µl, respectively, at any given time during the 36-month follow-up, compared to those in 2003-5. The median CD4 cell count at ART initiation also increased from 96 cells/µl in 2003-5 to 173 cells/µl in 2010-13. Our results suggest that the CD4 response to ART is modestly higher for those initiating ART in more recent years. Moreover, fewer patients are presenting with lower absolute CD4 cell counts over time. This is likely to reduce their risk of opportunistic infections and future non-AIDS defining cancers.

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.

Rates and predictors of injury in a population-based cohort of people living with HIV

OBJECTIVES

Injuries are responsible for 10% of the global burden of disease; however, the epidemiology of injury among people living with HIV (PLHIV) has not been well elucidated. This study seeks to characterize rates and predictors of injury among PLHIV compared to the general population in British Columbia (BC), Canada.

DESIGN

A population-based dataset was created via linkage between the BC Centre for Excellence in HIV/AIDS and PopulationDataBC.

METHODS

PLHIV aged 20 years and older were compared to a random 10% sample of the adult general population. The International Classification of Diseases 9 and 10 codes were used to classify unintentional and intentional injuries based on the external cause of the injury from 1996 to 2013. Generalized estimating equation (GEE) Poisson regression models were fit to estimate the effect of HIV status on rates of unintentional and intentional injury, and to identify correlates of injury among PLHIV.

RESULTS

The crude incidence rate of unintentional injury was 18.56/1000 person-years [95% confidence interval (CI) 17.77-19.39] among PLHIV and 8.51/1000 person-years (95% CI 8.42-8.59) in the general population. Among PLHIV, 13.45% of deaths were due to injury, compared to 5.52% of deaths in the general population. In adjusted models, PLHIV were more likely to report unintentional (incidence rate ratio 1.42, 95% CI 1.32-1.52) and intentional injury (incidence rate ratio 1.93, 95% CI 1.70-2.18) compared to the general population.

CONCLUSIONS

We identified elevated rates of intentional and unintentional injury among PLHIV. Injuries are largely preventable; as such, targeted efforts are needed to decrease the burden of injury-related disability and death among PLHIV.

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

BACKGROUND

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).

METHODS

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.

RESULTS

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 interval [CI], 828 032-874 853), with cost savings of $46.7 million (95% CI, $43.8-$49.4 million).

CONCLUSIONS

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.

An Estimation of Mortality Risks among People Living with HIV in Karnataka State, India: Learnings from an Intensive HIV/AIDS Care and Support Programme

Background

In Indian context, limited attempts have been made to estimate the mortality risks among people living with HIV (PLHIV). We estimated the rates of mortality among PLHIV covered under an integrated HIV-prevention cum care and support programme implemented in Karnataka state, India, and attempted to identify the key programme components associated with the higher likelihood of their survival.

Methods

Retrospective programme data of 55,801 PLHIV registered with the Samastha programme implemented in Karnataka state during 2006–11 was used. Kaplan-Meier survival methods were used to estimate the ten years expected survival probabilities and Cox-proportional hazard model was used to examine the factors associated with risk of mortality among PLHIV. We also calculated mortality rates (per 1000 person-year) across selected demographic and clinical parameters.

Results

Of the total PLHIV registered with the programme, about nine percent died within the 5-years of programme period with an overall death rate of 38 per 1000 person-years. The mortality rate was higher among males, aged 18 and above, among illiterates, and those residing in rural areas. While the presence of co-infections such as Tuberculosis leads to higher mortality rate, adherence to ART was significantly associated with reduction in overall death rate. Cox proportional hazard model revealed that increase in CD4 cell counts and exposure to intensive care and support programme for at least two years can bring significant reduction in risk of death among PLHIV [(hazard ratio: 0.234; CI: 0.211–0.260) & (hazard ratio: 0.062; CI: 0.054–0.071), respectively] even after adjusting the effect of other socio-demographic, economic and health related confounders.

Conclusion

Study confirms that while residing in rural areas and presence of co-infection significantly increases the mortality risk among PLHIV, adherence to ART and improvement in CD4 counts led to significant reduction in their mortality risk. Longer exposure to the intervention contributed significantly to reduce mortality among PLHIV.

Prevalence of metabolic syndrome among HIV-infected patients in Ghana: A cross-sectional study

BACKGROUND

Prevalence of metabolic syndrome (MetS) in HIV-infected patients is very limited in the Ghanaian setting and may vary across the globe by the different study populations and criteria used.

AIM

We investigated the prevalence of MetS among HIV-infected patients receiving highly active antiretroviral therapy (HAART) at the St. Dominic Hospital, Akwatia, Ghana.

PATIENTS AND METHODS

This cross-sectional study recruited 433 HIV-infected patients (294 on HAART and 139 HAART-naïve) from the period of February 2013 to December 2013. Information on the demographic, clinical, anthropometric characteristics were obtained and lipid profile for each patient was assessed. MetS was assessed based on the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), World Health Organization (WHO) and International Diabetes Federation (IDF) criteria.

RESULTS

The prevalence of MetS was 24.5% according to WHO criteria, 48.3% by NCEP-ATP III criteria, and 42.3% by IDF criteria. In general, participants on HAART were significantly associated with higher prevalence of MetS compared to those without HAART (P < 0.05) irrespective of the criteria used. Prevalence of clustering components of MetS was significantly higher among those on HAART when risk scores of 2 and above were used compared with those not on HAART (P < 0.05).

CONCLUSION

HAART recipient developed MetS as indicated by dyslipidemia, high blood pressure, and abnormal body fat. It is incumbent on health giver to incorporate MetS assessment as a part of treatment and management plan in patients receiving HAART.

Temporal trends in death causes in adults attending an urban HIV clinic in Uganda: a retrospective chart review

OBJECTIVE

To study temporal trends of mortality in HIV-infected adults who attended an HIV clinic in Kampala, Uganda, between 2002 and 2012.

DESIGN

Descriptive retrospective study.

METHODS

Two doctors independently reviewed the clinic database that contained information derived from the clinic files and assigned one or more causes of death to each patient >18 years of age with a known date of death. Four cause-of-death categories were defined: 'communicable conditions and AIDS-defining malignancies', 'chronic non-communicable conditions', 'other non-communicable conditions' and 'unknown'. Trends in cause-of-death categories over time were evaluated using multinomial logistic regression with year of death as an independent continuous variable.

RESULTS

1028 deaths were included; 38% of these individuals were on antiretroviral therapy (ART). The estimated mortality rate dropped from 21.86 deaths/100 person years of follow-up (PYFU) in 2002 to 1.75/100 PYFU in 2012. There was a significant change in causes of death over time (p<0.01). Between 2002 and 2012, the proportion of deaths due to 'communicable conditions and AIDS-defining malignancies' decreased from 84% (95% CI 74% to 90%) to 64% (95% CI 53% to 74%) and the proportion of deaths due to 'chronic non-communicable conditions', 'other non-communicable conditions' and a combination of 'communicable and non-communicable conditions' increased. Tuberculosis (TB) was the main cause of death (34%). Death from TB decreased over time, from 43% (95% CI 32% to 53%) in 2002 to a steady proportion of approximately 25% from 2006 onwards (p<0.01).

CONCLUSIONS

Mortality rate decreased over time. The proportion of deaths from communicable conditions and AIDS-defining malignancies decreased and from non-communicable diseases, both chronic and non-chronic, increased. Nevertheless, communicable conditions and AIDS-defining malignancies continued to cause the majority of deaths, with TB as the main cause. Ongoing monitoring of cause of death is warranted and strategies to decrease mortality from TB and other common opportunistic infections are essential.

HIV and/or AIDS-related deaths and modifiable risk factors: A descriptive study of medical admissions at Oshakati Intermediate Hospital in Northern Namibia

BACKGROUND

High rates of HIV infection have decreased life expectancy in many African countries. Regardless of worldwide efforts to escalate treatment, care and prevention strategies, the number of deaths due to AIDS-related disorders is still high. Local healthcare workers suspect that there are modifiable factors in the care of HIV and/or AIDS patients which can be identified and improved.

AIM

To describe the HIV and/or AIDS-related causes of adult mortality and identify modifiable factors amongst patients admitted to Oshakati Intermediate Hospital, northern Namibia.

METHODS

Data was extracted retrospectively and coded using the modified CoDe protocol for AIDS. Modifiable factors relating to the patient, health system or clinical care were identified using a standardised data collection tool.

RESULTS

A total of 177 HIV and/or AIDS patients were identified, 94 (53.1%) were male and 120 (68%) had a CD4 count of less than 200 cells/mL. The common HIV-related causes of death were tuberculosis (25.9%), renal failure (15.8%), Pneumocystis jirovecii pneumonia (11.3%), cryptococcal meningitis (9%), HIV wasting syndrome (7.9%) and AIDS-defining malignancy (7.9%). The analysis revealed 281 modifiable factors; patient-related factors were the most common (153 [54.4%]), followed by health system factors (97 [34.5%]) and healthcare personnel factors (31 [11%]).

CONCLUSION

Our findings have highlighted the challenges in overall HIV and/or AIDS inpatient care and surrounding primary care facilities. The identification of specific modifiable factors can be used to reduce mortality by providing training as well as rational monitoring, planning and resource allocation.

Sex and Racial/Ethnic Differences in Premature Mortality Due to HIV: Florida, 2000-2009

OBJECTIVE

This study aimed to characterize premature mortality among people diagnosed with HIV infection from 2000 to 2009 in Florida, by sex and race/ethnicity, to estimate differences in premature mortality that could be prevented by linkage to HIV care and treatment.

METHODS

Florida surveillance data for HIV diagnoses (excluding concurrent AIDS diagnoses) were linked with vital records data to ascertain deaths through 2011. Years of potential life lost (YPLL) were obtained from the expected number of remaining years of life at a given age from the U.S. sex-specific period life tables.

RESULTS

Among 41,565 people diagnosed with HIV infection during the study period, 5,249 died, and 2,563 (48.8%) deaths were due to HIV/AIDS. Age-standardized YPLL (aYPLL) due to HIV/AIDS per 1,000 person-years was significantly higher for females than males (372.6, 95% confidence interval [CI] 349.8, 396.2 vs. 295.2, 95% CI 278.4, 312.5); for non-Hispanic black (NHB) females than non-Hispanic white (NHW) and Hispanic females (388.2, 95% CI 360.7, 416.9; 294.3, 95% CI 239.8, 354.9; and 295.0, 95% CI 242.9, 352.5, respectively); and for NHB males compared with NHW and Hispanic males (378.7, 95% CI 353.7, 404.7; 210.6, 95% CI 174.3, 250.8; and 240.9, 95% CI 204.8, 280.2, respectively). In multilevel modeling controlling for individual factors, NHB race was associated with YPLL due to HIV/AIDS for women (p=0.04) and men (p<0.001).

CONCLUSION

Among people diagnosed with HIV infection, females and NHB people had a disproportionately high premature mortality from HIV/AIDS, suggesting the need for enhanced efforts to improve linkage to and retention in care and medication adherence for these groups.

Obesity Among HIV-Infected Adults Receiving Medical Care in the United States: Data From the Cross-Sectional Medical Monitoring Project and National Health and Nutrition Examination Survey

Our objective was to compare obesity prevalence among human immunodeficiency virus (HIV)-infected adults receiving care and the U.S. general population and identify obesity correlates among HIV-infected men and women.Cross-sectional data was collected in 2009 to 2010 from 2 nationally representative surveys: Medical Monitoring Project (MMP) and National Health and Nutrition Examination Survey (NHANES).Weighted prevalence estimates of obesity, defined as body mass index ≥30.0 kg/m, were compared using prevalence ratios (PR, 95% confidence interval [CI]). Correlates of obesity in HIV-infected adults were examined using multivariable logistic regression.Demographic characteristics of the 4006 HIV-infected adults in MMP differed from the 5657 adults from the general U.S. population in NHANES, including more men (73.2% in MMP versus 49.4% in NHANES, respectively), black or African Americans (41.5% versus 11.6%), persons with annual incomes <$20,000 (64.5% versus 21.9%), and homosexuals or bisexuals (50.9% versus 3.9%). HIV-infected men were less likely to be obese (PR 0.5, CI 0.5-0.6) and HIV-infected women were more likely to be obese (PR1.2, CI 1.1-1.3) compared with men and women in the general population, respectively. Among HIV-infected women, younger age was associated with obesity (<40 versus >60 years). Among HIV-infected men, correlates of obesity included black or African American race/ethnicity, annual income >$20,000 and <$50,000, heterosexual orientation, and geometric mean CD4+ T-lymphocyte cell count >200 cells/μL.Obesity is common, affecting 2 in 5 HIV-infected women and 1 in 5 HIV-infected men. Correlates of obesity differ for HIV-infected men and women; therefore, different strategies may be needed for the prevention and treatment.

Retention in HIV Care and Predictors of Attrition from Care among HIV-Infected Adults Receiving Combination Anti-Retroviral Therapy in Addis Ababa

Background

Patient retention in chronic HIV care is a major challenge following the rapid expansion of combination antiretroviral therapy (cART) in Ethiopia.

Objective

To describe the proportion of patients who are retained in HIV care and characterize predictors of attrition among HIV-infected adults receiving cART in Addis Ababa.

Method

A retrospective analysis was conducted among 836 treatment naïve patients, who started cART between May 2009 and April 2012. Patients were randomly selected from ten health-care facilities, and their current status in HIV care was determined based on routinely available data in the medical records. Patients lost to follow-up (LTFU) were traced by telephone. Kaplan-Meier technique was used to estimate survival probabilities of retention and Cox proportional hazards regression was performed to identify the predictors of attrition.

Results

Based on individual patient data from the medical records, nearly 80% (95%CI: 76.7, 82.1) of the patients were retained in care in the first 3 and half years of antiretroviral therapy. After successfully tracing more than half of the LTFU patients, the updated one year retention in care estimate became 86% (95% CI: 83.41%, 88.17%). In the multivariate Cox regression analyses, severe immune deficiency at enrolment in care/or at cART initiation and ‘bed-ridden’ or ‘ambulatory’ functional status at the start of cART predicted attrition.

Conclusion

Retention in HIV care in Addis Ababa is comparable with or even better than previous findings from other resource-limited as well as EU/USA settings. However, measures to detect and enroll patients in HIV care as early as possible are still necessary.

Acute kidney injury in patients with human immunodeficiency virus infection

Acute kidney injury (AKI) is an important cause of hospitalization and morbidity in human immunodeficiency virus (HIV)-positive patients. However, the data on AKI in such patients is limited. The aim of the present study was to analyze the incidence, causes and outcome of AKI in HIV-positive patients from our antiretroviral therapy centre. All HIV-positive patients were evaluated for evidence of clinical AKI. AKI was noted in 138/3540 (3.9%) patients. Of 138 AKI patients, 96 (69.6%) had acquired immuno deficiency syndrome and 42 (30.4%) were HIV seropositive. Majority of AKI patients belonged to AKI network (AKIN) Stage II (42%) or III (48.5%) at presentation. Prerenal, intrinsic and postrenal AKI were noted in 53.6%, 44.2% and 2.2% of cases, respectively. Hypovolemia (44.2%) and sepsis (14.5%) contributed to AKI in vast majority of cases. AKI was multifactorial (volume depletion, sepsis and drugs) in 39% of patients. Acute tubular necrosis (ATN) was the most common intrinsic lesion. Acute interstitial nephritis and diffuse endocapillary proliferative glomerulonephritis were noted in five and two cases, respectively. In-hospital mortality was 24.64%. Lower CD4 count, decreased serum albumin level and Stage 4 WHO disease were associated with higher mortality. At 3 months or more follow-up complete recovery of renal function, chronic kidney disease Stage 3-5 and progression to end stage renal disease were noted in 58.69%, 14.5% and 2.2% of cases, respectively. Thus, prerenal factors and ischemic ATN were the most common cause of AKI in HIV-infected patients. Recovery of renal function was seen in 59% of cases, but AKI had high in-hospital mortality.

Possible Biomarkers for the Early Detection of HIV-associated Heart Diseases: A Proteomics and Bioinformatics Prediction

The frequency of cardiovascular disorders is increasing in HIV-infected individuals despite a significant reduction in the viral load by antiretroviral therapies (ART). Since the CD4 + T-cells are responsible for the viral load as well as immunological responses, we hypothesized that chronic HIV-infection of T-cells produces novel proteins/enzymes that cause cardiac dysfunctions. To identify specific factors that might cause cardiac disorders without the influence of numerous cofactors produced by other pathogenic microorganisms that co-inhabit most HIV-infected individuals, we analyzed genome-wide proteomes of a CD4 + T-cell line at different stages of HIV replication and cell growth over > 6 months. Subtractive analyses of several hundred differentially regulated proteins from HIV-infected and uninfected counterpart cells and comparisons with proteins expressed from the same cells after treating with the antiviral drug Zidovudine/AZT and inhibiting virus replication, identified a well-coordinated network of 12 soluble/diffusible proteins in HIV-infected cells. Functional categorization, bioinformatics and statistical analyses of each protein predicted that the expression of cardiac-specific Ca2 + kinase together with multiple Ca2 + release channels causes a sustained overload of Ca2 + in the heart which induces fetal/cardiac myosin heavy chains (MYH6 and MYH7) and a myosin light-chain kinase. Each of these proteins has been shown to cause cardiac stress, arrhythmia, hypertrophic signaling, cardiomyopathy and heart failure (p = 8 × 10^− 11). Translational studies using the newly discovered proteins produced by HIV infection alone would provide additional biomarkers that could be added to the conventional markers for an early diagnosis and/or development of specific therapeutic interventions for heart diseases in HIV-infected individuals.