How complete is AIDS surveillance in Europe? An eagle eye comparison with mortality data

HIV case reporting in the countries of North Africa and the Middle East

The aim of the paper is to provide an overview of HIV case reporting data for the year 2011 from the countries of the World Health Organization Eastern Mediterranean Region (WHO EMR).

Fourteen countries provided data for the year 2011 and reported a total of 4263 HIV cases of which 66.8% were men. The highest number of reported HIV cases in men per 100,000 population was in Oman (5.8), Somalia (5.5) and Iran (3.3), while in women in Somalia (7.6), Oman (3.9) and Morocco (2.4).

In the majority of the countries, the most common reported mode of transmission was heterosexual. This could be due to under-reporting of male-to-male transmission and more frequent testing of men than women.

Is back-projection methodology still relevant for estimating HIV incidence from national surveillance data?

Accurate estimates of HIV incidence are crucial to understand the extent of transmission of the infection, evaluate intervention strategies and effectively plan new public health control measures. HIV/AIDS surveillance systems in numerous industrialised countries record the number of known new HIV and/or AIDS diagnoses, which are often used as a surrogate marker for HIV incidence. HIV/AIDS diagnosis data have been used to reconstruct historical HIV incidence trends using modified back-projection methods. Estimates of HIV incidence are most robust when reliable data on the number of incident infections, a subset of all diagnoses, is widely available, and surveillance systems should prioritise the collection of these data. Back-projection alone provides reliable estimates of HIV incidence in the past, but is not useful when estimating current or future HIV incidence. However, back-projection methodology should be used in conjunction with other corroborative methods to estimate current HIV incidence, and methods to combine the various techniques should be investigated.

Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program

BACKGROUND

In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry.

METHODS

The retrospective analyses included deaths among participants registered in an observational cohort who initiated highly-active antiretroviral therapy (HAART) between August 1, 1996 and June 30, 2006. Deaths were routinely reported manually by physicians and through annual electronic record linkages with a population-based vital event registry. Multivariate logistic regression was carried out to assess independent predictors of death reporting by manual methods.

RESULTS

Of the 3,116 individuals included in the analyses, 622 (20.0%) died during follow-up. Manual reporting by physicians only identified 377 (60.6%), while electronic linkages captured 598 (96.1%) of all deaths. Multivariate analysis indicated that deaths among individuals with lower CD4 cell count, higher HIV plasma viral load, a history of injection drug use, and under the care of an HIV-experienced physicians were more likely to be reported manually. Furthermore, non-accidental deaths were more likely to be reported manually, and manual reporting of deaths increased over time.

CONCLUSIONS

Relying only on manual reports to ascertain deaths significantly underestimates the total number of deaths in the population. This can generate important biases when evaluating the impact of therapeutic interventions in the populational setting.

[Aspects of rehabilitation in HIV and AIDS]

Medical treatment of HIV infection has changed dramatically since 1997. The uncontrollable threat became a chronic disease. On the other hand, many HIV-infected people suffer from high psychological distress and multiple physical complaints. Interaction in HIV prevention could transform into psychological counseling. Counselors should initiate rehabilitation measures and occupational reintegration by utilizing all legal possibilities for handicapped people. Patients and physicians, psychologists and social workers as well as self-help groups should initiate successful reintegration into the workforce and daily life; this could positively influence compliance behavior.

Gender differences in progression to AIDS and death from HIV seroconversion in a cohort of injecting drug users from 1986 to 2001

BACKGROUND

Although the consensus is that gender does not influence HIV progression, its relevance may depend on the setting.

AIM

To study gender differences in HIV progression to AIDS and death from 1986 to 2001 in a cohort of injecting drug user (IDU) seroconverters in Spain.

METHODS

Risk of AIDS and death in persons infected for the same length of time were compared through Kaplan-Meier, allowing for late entry, and Cox regression adjusting for gender, age, and calendar period (before 1992, 1992-1995, 1996-1998, 1999-2001) fitted as time dependent covariates.

RESULTS

Of 929 IDU, 24.7% were women. Median seroconversion year was 1993.3 for men and women. 44% of women and 34% of men received antiretroviral therapy. Risk of AIDS was lower in women in univariate (hazard ratio (HR) 0.72; 95%CI:0.51 to 1.01) and multivariate analyses (HR 0.73 95%CI:0.52 to 1.03). A 46% reduction in risk of AIDS for period 1999-2001 compared with 1992-1995 was seen in both men and women (HR: 0.56 (95%CI:0.36 to 0.87). As for mortality, women's risk of death was lower univariately (HR 0.67 95%CI:0.45 to 0.99) although compared with 1992-95, men experienced a 34% reduction in mortality during 1999-2001 (HR 0.66 95%CI:0.40 to 1.01), which was not statistically significant in women.

CONCLUSIONS

HIV progression was lower in female IDU before and after 1997 and their uptake of antiretroviral therapy was higher than male IDU. The inability to detect a reduction in mortality for women during 1999-2001 is probably attributable to lack of power. Differences in severity of addiction, drug using patterns, and competing causes of death may explain these findings.

Classic Kaposi's sarcoma in Italy, 1985-1998

To evaluate incidence rates (IRs) of classic Kaposi's sarcoma (CKS) in Italy after the spread of AIDS, we distinguished CKS from AIDS-related KS (AKS) using an 'ad hoc' record linkage procedure between 15 Cancer Registries (CRs) (21% of the Italian population) and the national AIDS Registry. Between 1985 and 1998, 874 cases of CKS and 634 cases of AKS were diagnosed in the study areas. CKS accounted for 16 and 27% of KS cases below 55 years of age in men and women, respectively, but for 91 and 100% of those above age 55. The IRs for CKS were 1.0/ in men and 0.4/100,000 in women, but they varied between 0.3 in Umbria and 4.7 in Sassari in men, and between 0.1 in Parma and 1.7 in Sassari in women. IRs of CKS in both genders were stable between 1985-1987 and 1993-1998. In Northern and Central CRs the IR (adjusted for age and gender) for CKS was 0.5 in individuals born in the same area, but 1.6 in individuals born in Southern Italy or in the Islands (rate ratio = 3.2) suggesting that KS-associated herpesvirus, the cause of KS, is acquired early in life.

Progression of HIV infection and mortality by hepatitis C infection in patients with haemophilia over 20 years

Hepatitis C virus (HCV) infection is an important cause of mortality in human immune deficiency virus (HIV)-positive haemophiliacs. This study describes progression to AIDS, death from HCV end-stage liver disease (ESLD) and all-cause mortality over 20 years. All HIV-positive haemophiliacs in La Paz University Hospital were included in this cohort. HIV seroconversion was estimated using mathematical techniques for interval-censored data from 1979 to 1985. Poisson regression was used to estimate rates of AIDS, death from ESLD and all causes in different periods: before 1988, 1988-89, 1990-91, 1992-93, 1994-95, 1996-97 and 1998-2001 using competing risk models. Among 383 cohort members, global AIDS incidence was 9.7 per 100 person-years, peaking in 1992-93 and dropping by 87% in 1998-2001 compared with before 1988 [incidence rate ratio (IRR) 0.13; 95% CI: 0.03-0.53]. Overall mortality was 7.5 per 100 person-years, was highest from 1992 to 1997, and fell by 66% in 1998-2001 compared with before 1988 (IRR 0.34; 95% CI: 0.14-0.81). Eighteen (5%) persons died of ESLD which represented 19% of deaths before 1988, 4% during 1988-89, 1990-91 and 1992-93, 2% in 1994-95, 10% in 1996-97 and 33% in 1998-2001. Overall death rate from ESLD was 0.5 cases per 100 person-years with no statistically significant trend observed over time. Important reductions in HIV disease progression to AIDS and death have been observed from 1998 to 2001, and can be attributed to highly active antiretroviral therapy. Although no increase in the rate of HCV-related deaths can be demonstrated, HCV accounts for an increasing proportion of deaths in the recent years.

Incidence of AIDS-Defining Cancers After AIDS Diagnosis Among People with AIDS in Italy, 1986–1998

A record linkage was carried out between the Italian National Registry of AIDS and 19 cancer registries. The aim was to evaluate the 1986 through 1998 trends in incidence rate (IR) of AIDS-defining cancers (ADCs) among persons with AIDS (PWA) in Italy overall and according to various characteristics. A steady decrease in IRs was found for Kaposi sarcoma (KS) in men between 1986-1992 (2.5 per 100 person-years [py]) and 1997-1998 (1.0 per 100 py). Conversely, the first decrease in IRs of KS in women (from 0.9 to 0.6 per 100 py) and of non-Hodgkin lymphoma in both genders (from 1.7 to 0.7 per 100 py) was seen between 1993-1996 and 1997-1998, thus pointing to a favorable impact of highly active antiretroviral therapies. The decline was consistent across different age and HIV transmission groups, but it was more marked in PWA with a CD4 count >50 cells/microL than in PWA with more severe immune suppression. As a proportion of AIDS cases, invasive cervical cancer increased from 1.5% in 1993-1996 to 2.4% in 1997-1998, but IRs after AIDS could not be evaluated. On account of the marked decline of KS in men in 1997-1998, the overall burden of ADCs in Italy became similar in both genders.

Risk of cancer in persons with AIDS in Italy, 1985-1998

A record linkage was carried out between the Italian Registry of AIDS and 19 Cancer Registries (CRs), which covered 23% of the Italian population, to estimate the overall cancer burden among persons with HIV or AIDS (PWHA) in Italy, according to various characteristics. Observed and expected numbers of cancer and standardised incidence ratios (SIRs) were assessed until 1998 in 12 104 PWHA aged 15-69 years, for a total of 60 421 person-years. Significantly increased SIRs were observed for Kaposi's sarcoma (KS, 1749-fold higher than the general population), non-Hodgkin's lymphomas (NHL, 352), and invasive cervical cancer (22). SIR was significantly elevated also for cancer of the anus (34), lung cancer (2.4), brain tumours (4.4), Hodgkin's disease (16), and leukaemias (5.3). The majority of lung and brain cancers were not histologically confirmed, and the possibility of misclassification with KS or NHL cannot be ruled out. The SIR for all non-AIDS-defining cancers was 2.2 in men and 2.5 in women. Intravenous drug users showed significantly more elevated SIRs for lung cancer (9.4), and brain tumours (6.7) than other transmission categories (SIR=1.4 and 2.3, respectively). This study confirmed increased SIRs for haemolymphopoietic neoplasms other than NHL in PWHA, although many-fold smaller than for NHL. An association with human papillomavirus-related cancers was also confirmed.

Effectiveness of highly active antiretroviral therapy in Spanish cohorts of HIV seroconverters: differences by transmission category

OBJECTIVE

To evaluate the population effectiveness of highly active antiretroviral therapy (HAART) in HIV progression and determine the heterogeneity of the effect of HAART in GEMES (Spanish multicenter study of seroconverters).

DESIGN

Multicenter cohort study.

METHODS

Data from 1091 persons with well-documented HIV seroconversion dates from 1980s to January 2000 were analysed. Risk of AIDS and death in subjects with same duration of HIV infection were compared in different calendar periods; before 1992, 1992-1995 (reference), 1996-1997, 1998 and 1999 with Kaplan-Meier methods and Cox proportional hazards models, allowing for late entry, fitting calendar period as time-dependent covariate and adjusting for transmission category, age and gender.

RESULTS

Statistically significant reductions in the risk of AIDS were first observed in 1998 [hazard ratio (HR), 0.59; 95% confidence interval (CI), 0.35-1.01] becoming more pronounced in 1999 (HR, 0.45; 95% CI, 0.24-0.84). Reduction in the risk of death was seen in 1997, though only reached borderline significance in 1999 (HR, 0.53; 95% CI, 0.26-1.07). Progression to AIDS and death was slower in women (HR, 0.68; 95% CI, 0.46-0.99 and HR, 0.53; 95% CI, 0.33-0.87, respectively). Compared with men who have sex with men (MSM), intravenous drug users (IDU) had lower reductions in the risk of AIDS and death.

CONCLUSIONS

Reductions in incidence of AIDS and death in GEMES are seen after 1998 and 1999, respectively, compared with 1992-1995, being more pronounced in MSM compared with IDU, the commonest category in Spain.

Epidemiology of non-Hodgkin lymphomas and other haemolymphopoietic neoplasms in people with AIDS

HIV-infected individuals have a high risk of developing non-Hodgkin lymphoma (NHL). In Europe, the prevalence of AIDS with a concurrent NHL diagnosis increased from 3.6% to 5.4% between 1994 and 2000. In population-based record linkages between cancer registries and AIDS registries in the USA, Italy, and Australia, the relative risks of NHL in people with AIDS ranged between 15 for low-grade and T-cell NHL and 400 for high-grade NHL. The corresponding relative risk of Hodgkin's disease was about 10, whereas the risks for multiple myeloma and leukaemias were in the range 2 to 5. Since the introduction of highly active antiretroviral therapy in the more developed countries (1996), most studies have suggested a decline in the incidence of some types of NHL, most notably the primary brain form. In studies from Africa, the risk of HIV-associated NHL is about ten times less than that in the more developed countries, but underascertainment and earlier death from other AIDS-related illnesses may explain the relative lack of HIV-associated lymphomas.

Factors influencing HIV progression in a seroconverter cohort in Madrid from 1985 to 1999

OBJECTIVE

To study HIV progression from seroconversion over a 15 year period and measure the population effectiveness of highly active antiretroviral therapy (HAART).

METHODS

A cohort study of people with well documented dates of seroconversion. Cumulative risk of AIDS and death were calculated by extended Kaplan-Meier allowing for late entry. Cox proportional hazards models were used to study variables associated with HIV progression. To assess the impact of HAART, calendar time was divided in three periods; before 1992, 1992-6, and 1997-9.

RESULTS

From January 1985 to May 2000, 226 seroconverters were identified. The median seroconversion interval was 11 months, median seroconversion date was March 1993. 202 (89%) were men, 76% of whom were homo/bisexual. A 66% reduction in progression to AIDS was observed in 1997-9 compared to 1992-96 (HR 0.34 95% CI: 0.16 to 0.70). People with primary education appeared to have faster progression to AIDS compared to those with university studies (HR 2.69 95%CI: 1.17 to 6.16). An 82% reduction in mortality from HIV seroconversion was observed in 1997-9 (HR 0.18 95% CI: 0.05 to 0.68) compared to 1992-6. Progression to death for people with primary education was twice as fast as for those with university education (p 0.0007). People without confirmation of an HIV negative test had faster progression (HR 4.47 95% CI: 1.18 to 16.92).

CONCLUSIONS

The reduction in progression to AIDS and death from seroconversion from 1992-6 to 1997-9 in Madrid is likely to be attributable to HAART. HIV progression was faster in subjects with primary education; better educational level may be associated with better adherence to medication.

Invasive cervical cancer as an AIDS-defining illness in Europe

OBJECTIVE(S)

To evaluate the frequency and correlates of invasive cervical cancer (ICC) as an AIDS-defining illness (ADI) in Europe.

DESIGN

Statistical analysis of data from: national AIDS surveillance systems of 15 European countries with >or= 50 female AIDS cases; and from population-based cancer registries of the same nations.

METHODS

AIDS cases notified between 1993 (when ICC was included among ADI) and 1999 in women aged 20-49 years were taken into consideration. The association between the presence of ICC as an ADI and potential determinants was assessed by calculation of odds ratios (OR) and 95% confidence intervals (CI). Country-specific incidence rates of ICC in women aged 20-49 years were correlated with selected AIDS-associated variables by means of the Pearson correlation coefficient (r).

RESULTS

The OR of having ICC as an ADI increased with age and was significantly elevated in southern (3.1) and central (2.5) compared with northern Europe. It was also increased among injecting drug users (IDU; 1.5). The proportion of ICC as ADI was inversely correlated with incidence rates of ICC in the general female population, but directly correlated with the proportion of IDU among female AIDS cases.

CONCLUSIONS

The frequency of ICC as an ADI in Europe was independent from the background risk of ICC in the general population. It was higher where IDU predominated among female AIDS cases and where population-based ICC screening programs were less effective.

[Estimating the completeness of AIDS reporting in Spain]

OBJECTIVE

To evaluate AIDS case reporting in the Spanish regions as compared with the AIDS deaths registered in mortality statistics, in order to identify possible deviations indicative of underreporting.

METHODS

We carried out an ecological analysis taking each region as a unit. We compared incidence and mortality obtained from the AIDS reporting system with the HIV/AIDS deaths obtained from the mortality statistics of the Spanish Institute for Statistics. The 1986-1998 period was analysed globally, then the analysis was repeated for the 1995-1998 period.

RESULTS

In the 1986-1998 period there was a good correlation (r = 0.93) between the AIDS incidence rates and HIV/AIDS mortality rates obtained from death statistics. Some regions presented an AIDS incidence lower than expected according to their mortality rate when it was compared with the national average, with Asturias (27%), Comunidad Valenciana (26%), Andalucia (20%), Ceuta (18%) and Cantabria (13%) standing out. Taking as a reference the five regions with the highest completeness, the underreporting in Spain was of 13%. In the 1995-1998 period these deviations increased moderately. In the 1986-1998 period, 18.9% less deaths were notified to the AIDS reporting system in comparison with death statistics, showing a great variability between regions.

CONCLUSIONS

In Spain the reporting level of AIDS cases is acceptable for the aims of surveillance, although in some regions measures to improve it should be taken. The notification of deaths to the AIDS reporting system presents great deficiencies.