Survival and risk factors associated with mortality in people living with HIV from 2005 to 2018 in Nanjing, China

Non-linear association between CD4+ T-cell counts and mortality risk in people living with HIV: evidence from a 10-year cohort study

Background

The study aimed to investigate the dose-response association between CD4+ T-cell counts and mortality risk in people living with HIV (PLHIV).

Methods

Data on PLHIV who had a high prevalence of acquired immunodeficiency syndrome (AIDS) were retrospectively collected from the routine treatment database in Henan Province, China, covering the period from October 2003 to October 2021. We randomly selected 1,000 PLHIV from age groups 30, 40, 50, and 60 years who met the inclusion criteria as study participants. The Kaplan-Meier analysis, the Cox proportional hazards regression model, and the restricted cubic spline (RCS) model were employed to analyze the association between CD4+ T-cell counts and mortality risk in PLHIV.

Results

A total of 4,000 participants were enrolled in the study, with a follow-up period of 28,158 person-years. During this period, there were 941 (23.5%) deaths, resulting in a mortality rate of 3.34 per 100 person-years. The mean duration of follow-up was 6.77 ± 3.45 years, and the cumulative survival rate was 76.5%. The Cox proportional hazards regression model revealed that as the CD4+ T-cell count increased, the hazard ratio (HR) decreased. The results of the RCS model demonstrated a non-linear association between CD4+ T-cell counts and mortality risk in PLHIV, with cutoff values for each age group being 382, 332, 334, and 215 cells/μL. The non-linear curve indicated that the HR decreased as the CD4+ T-cell counts increased. However, once the CD4+ T-cell counts reached their respective cutoff values, the curve showing the reduction in mortality risk began to flatten.

Conclusion

There was a non-linear association between CD4+ T-cell counts and mortality risk in PLHIV. Although the cutoff values vary across age groups, they consistently remain close to 350 cells/μL. Therefore, considering a threshold of CD4+ T-cell count <350 cells/μL across various age groups is crucial as a strategic approach to mitigate mortality rates among PLHIV.

Effect of antiretroviral therapy on the mortality of HIV-1 infection long-term non-progressors: a cohort study

BACKGROUND

The study aims to investigate the demographic characteristics, the variations in their immune status, and mortality risk among HIV-1 infection long-term non-progressors (LTNP).

METHODS

Eligible LTNP and typical progressors (TP) were recruited in Guangxi by December 2018. Participants were followed up until December 2022, monitoring ART status, CD4+ T cell counts, and survival/death outcomes. Multivariate logistic, Cox regression, and Kaplan-Meier method were employed to scrutinize associated factors and mortality risk of LTNP.

RESULTS

A total of 212 LTNP and 390 TP were included. LTNP cohort predominantly comprised males (84.43%), those diagnosed with HIV at age ≤ 40 years (93.87%), and those infected through injection drug use (59.91%). The mortality rate of LTNP were lower than TP (12.74% vs. 27.18%). TP had a higher mortality risk compared to LTNP (adjusted hazard ratio [aHR] = 4.051, 95% CI: 2.284-7.186, P < 0.001). The mortality risk was also elevated in the ART-naïve group versus the ART-experienced ones (aHR = 3.943, 95%CI: 2.658-5.850, P < 0.001). Notably, the CD4/CD8 ratio in the LTNP group did not fully recover (< 1.0) despite ART. However, LTNP with ART-experienced had a significantly lower mortality risk compared to ART-naïve LTNP group (Log-rank: P = 0.003).

CONCLUSIONS

ART effectively restores and maintains normal CD4+ T cell levels among LTNP, thereby decreasing mortality risk. Nonetheless, the CD4/CD8 ratio in LTNP exhibits incompletely recovered post-ART. These findings provide a scientific foundation for promoting ART in LTNP population.

Transmission Network and Phylogenetic Analysis Highlight the Role of Suburban Population in HIV-1 Transmission Among Older Adults in Nanjing, Jiangsu Province, China

Describing the transmission characteristics among older adults is essential for designing tailored interventions. An epidemiological investigation combined with phylogenetic analysis was conducted to reveal potential transmission linkages among older adults in Nanjing. Between 2018 and 2022, 188 pol sequences were successfully amplified. Multiple genotypes were identified, including CRF07_BC (55.3%), CRF01_AE (30.3%), CRF08_BC (8.0%), B (3.2%), CRF55_01B (1.1%), CRF67_01B (0.5%), CRF68_01B (0.5%), and unique recombinant forms (URF) (1.1%). Transmission network analysis identified 120 genetically linked patients forming 23 clusters, ranging from 2 to 26 individuals. Multivariable logistic regression analysis showed that compared with farmers and heterosexuals, patients with other occupations (OR = 0.404, 95% CI: 0.173-0.945) and MSM (OR = 0.193, 95% CI: 0.050-0.738) were less likely to have high linkage. Subjects who lived in suburban areas were more likely to have high linkage (OR = 10.932, 95% CI: 3.335-35.830). The Sankey diagram suggested that patients living in suburban areas primarily transmitted the disease within the local district (χ2 = 24.192, p < 0.001). Among the 188 pol sequences, the prevalence of pretreatment drug resistance was 8%. In suburban areas with a rising HIV-1 epidemic, improving early detection and timely treatment is critical. More tailored interventions for this subgroup are urgently needed.

Challenges in managing HIV and non-communicable diseases and health workers' perception regarding integrated management of non-communicable diseases during routine HIV care in South Central Uganda: A qualitative study

BACKGROUND

Non-communicable diseases are highly prevalent among adults living with HIV, emphasizing the need for comprehensive healthcare strategies. However, a dearth of knowledge exists regarding the health systems challenges in managing HIV and non-communicable diseases and the perception of health workers regarding the integrated management of non-communicable diseases during routine HIV care in rural Ugandan settings. This study aims to bridge this knowledge gap by exploring the health system challenges in managing HIV and non-communicable diseases and health workers' perception regarding the integration of non-communicable diseases in routine HIV care in South Central Uganda.

METHODS

In this qualitative study, we collected data from 20 purposively selected key informants from Kalisizo Hospital and Rakai Hospital in South Central Uganda. Data were collected from 15th December 2020 and 14th January 2021. Data were analyzed using a thematic content approach with the help of NVivo 11.

RESULTS

Of the 20 health workers, 13 were females. In terms of work duration, 9 had worked with people living with HIV for 11-15 years and 9 were nurses. The challenges in managing HIV and non-communicable diseases included difficulty managing adverse events, heavy workload, inadequate communication from specialists to lower cadre health workers, limited financial and human resources, unsupportive clinical guidelines that do not incorporate non-communicable disease management in HIV care and treatment, and inadequate knowledge and skills required to manage non-communicable diseases appropriately. Health workers suggested integrating non-communicable disease management into routine HIV care and suggested the need for training before this integration.

CONCLUSION

The integration of non-communicable disease management into routine HIV care presents a promising avenue for easing the burden on health workers handling these conditions. However, achieving successful integration requires not only the training of health workers but also ensuring the availability of sufficient human and financial resources.

Implementation of “Test and Treat” Strategy: Analysis of Deaths of People Living with HIV from 2017 to 2022 in Baise City, China

Background: Acquired immune deficiency syndrome (AIDS) remains a significant public health concern in China. Treatment coverage has been expanded by revising the antiretroviral therapy (ART) for people living with HIV (PLWH). Several years after implementing the new “Test and Treat” strategy, it is essential to evaluate its impact on people living with HIV since its implementation. Objectives: This study was conducted to comprehensively analyze the deaths of PLWH from 2017 to 2022 in Baise City, China. Methods: A retrospective cohort study was conducted to comprehensively analyze the deaths of PLWH in Baise from 2017 to the first half of 2022. The data was acquired from the AIDS Information System (AIDSIS). The all-cause and AIDS-related mortality rates were calculated for PLWH, along with the proportion of specific death causes. Interrupted time series analysis was utilized to examine changes in all-cause mortality pre- and post-implementation of the new strategy. Kaplan-Meier curves were drawn to compare the mortality risk within 1 year of diagnosis between treated and untreated patients, as well as between late discoverers and non-late discoverers. Related factors of death were also analyzed using the Cox proportional hazards regression model. Results: During the observation period, among a total of 8,922 PLWH cases, 1,265 people died, resulting in an all-cause mortality rate of 4.19 per 100 person-years. Acquired immune deficiency syndrome -related deaths numbered 438, accounting for 34.62% of the total deaths, with a mortality rate of 1.45 per 100 person-years. There were 730 non-AIDS-related deaths, representing 57.71%, with a mortality rate of 2.42 per 100 person-years. The overall mortality rate from all causes within 1 year after diagnosis was 5.58 per 100 person-years. No significant difference was identified in the all-cause mortality rate between the periods before and after the implementation of the new strategy. Untreated PLWH and late discoverers exhibited a high risk of death within 1 year of diagnosis. Most deaths were caused by common chronic diseases, while AIDS-related mortality was mainly due to opportunistic infections. Factors such as gender, age at diagnosis, occupation, educational background, ethnic group, infection route, history of ART, and baseline CD4 level were associated with the risk of all-cause mortality and AIDS-related mortality. Conclusions: After the implementation of the “Test and Treat” strategy, no significant difference in mortality among PLWH was recorded in Baise City, China. We recommend that the health department strengthen the testing of PLWH and improve treatment options. Additionally, we suggest encouraging the maintenance of long-term ART treatment and taking measures to prevent and control tuberculosis and common chronic diseases in individuals who are HIV positive.

Molecular transmission network analysis of newly diagnosed HIV-1 infections in Nanjing from 2019 to 2021

OBJECTIVE

The objective of this study was to conduct a comprehensive analysis of the molecular transmission networks and transmitted drug resistance (TDR) patterns among individuals newly diagnosed with HIV-1 in Nanjing.

METHODS

Plasma samples were collected from newly diagnosed HIV patients in Nanjing between 2019 and 2021. The HIV pol gene was amplified, and the resulting sequences were utilized for determining TDR, identifying viral subtypes, and constructing molecular transmission network. Logistic regression analyses were employed to investigate the epidemiological characteristics associated with molecular transmission clusters.

RESULTS

A total of 1161 HIV pol sequences were successfully extracted from newly diagnosed individuals, each accompanied by reliable epidemiologic information. The analysis revealed the presence of multiple HIV-1 subtypes, with CRF 07_BC (40.57%) and CRF01_AE (38.42%) being the most prevalent. Additionally, six other subtypes and unique recombinant forms (URFs) were identified. The prevalence of TDR among the newly diagnosed cases was 7.84% during the study period. Employing a genetic distance threshold of 1.50%, the construction of the molecular transmission network resulted in the identification of 137 clusters, encompassing 613 nodes, which accounted for approximately 52.80% of the cases. Multivariate analysis indicated that individuals within these clusters were more likely to be aged ≥ 60, unemployed, baseline CD4 cell count ≥ 200 cells/mm3, and infected with the CRF119_0107 (P < 0.05). Furthermore, the analysis of larger clusters revealed that individuals aged ≥ 60, peasants, those without TDR, and individuals infected with the CRF119_0107 were more likely to be part of these clusters.

CONCLUSIONS

This study revealed the high risk of local HIV transmission and high TDR prevalence in Nanjing, especially the rapid spread of CRF119_0107. It is crucial to implement targeted interventions for the molecular transmission clusters identified in this study to effectively control the HIV epidemic.

HIV Services Uptake Among People Living with HIV in Jiangsu Province, China: A Cross-Sectional Study

Healthcare disparities are common among people living with HIV (PLWH) in China and likely impact access to HIV services. This study aimed to assess the current status of access to HIV services among PLWH and explore the correlates of service uptake using baseline data from a prospective cohort study among PLWH in Jiangsu Province. Guided by Andersen's behavioral model, univariable and multivariable logistic regressions were conducted to identify factors associated with access to HIV services. Out of 8989 eligible PLWH included in this study, 46.4% perceived difficulty in seeing a healthcare professional for HIV treatment services in 2021-2022. PLWH aged 18-34 years (adjusted odds ratio [AOR] = 1.69, 95% CI 1.32-2.15), 35-39 years (AOR = 1.33, 95% CI 1.08-1.65), identified as a bisexual/other (AOR = 1.14, 95% CI 1.01-1.29), had a college and above education (AOR = 1.32, 95% CI 1.07-1.63), and perceived moderate (AOR = 1.70, 95% CI 1.51-1.91) and severe (AOR = 2.20, 95% CI 1.94-2.49) levels of HIV stigma were more likely to perceive difficulty in seeing healthcare professionals for HIV treatment in 2021-2022. Living in northern Jiangsu was also associated with increased odds of perceiving difficulty in seeing healthcare professionals for HIV treatment (AOR = 1.12, 95% CI 1.00-1.26). These findings underscore the need for innovative solutions to eliminate the practical barriers to HIV services utilization among PLWH who are bisexual, well-educated, and effective HIV-related stigma reduction interventions.

Survival analysis of PLWHA undergoing combined antiretroviral therapy: exploring long-term prognosis and influencing factors

Introduction

The survival time of human immunodeficiency virus (HIV)-infected individuals or patients with acquired immunodeficiency syndrome (AIDS) is influenced by multiple factors. Studying survival and influential factors after antiretroviral therapy (ART) contributes to improving treatment protocols, management strategies, and prognosis for people living with HIV/AIDS (PLWHA).

Methods

This retrospective cohort study collected case data and follow-up records of PLWHA who received ART in Dazu District, Chongqing City, between 2007 and 2022. Cumulative survival rates were calculated using life tables. Survival curves were plotted using the Kaplan-Meier method. Uni-variable and multivariable Cox proportional hazards models analyzed factors influencing survival.

Results

The study included 5,237 PLWHA receiving ART. Within the first year of ART initiation, 146 AIDS-related deaths occurred, accounting for 29.49% (146/495) of total deaths. Cumulative survival rates at 1, 5, 10, and 15 years were 0.97, 0.90, 0.85, and 0.79, respectively. During the observation period, male patients who received ART had a 1.89 times higher risk of death compared to females (aHR, 1.89; 95%; CI, 1.50-2.37). Patients aged ≥60 years had a 3.44-fold higher risk of death than those aged <30 years (aHR, 3.44; 95% CI, 1.22-9.67). Injection drug users (aHR, 4.95; 95% CI, 2.00-12.24) had a higher risk of death than those with heterosexual (aHR, 1.60; 95% CI, 0.69-3.72) and homosexual transmission. Patients with a baseline CD4+ T lymphocyte count <200 cells/μL (aHR, 8.02; 95% CI, 4.74-13.57) and between 200 and 349 cells/μL (aHR, 2.14; 95% CI, 1.26-3.64) had a higher risk of death than those with ≥350 cells/μL. Patients with ART initiation at WHO clinical stage IV had a 2.48-fold higher risk of death than those at stage I (aHR, 2.48; 95% CI, 1.17-5.23).

Conclusion

The first year following ART initiation is critical in HIV/AIDS treatment, emphasizing the need for intensified follow-up and monitoring to facilitate successful immune system reconstruction. Older age, male sex, injection drug use, baseline CD4+ T lymphocyte count <200 cells/μL, and WHO clinical stage IV are associated with an increased risk of death. Tailored treatment and management strategies should be implemented for patient populations at higher risk of mortality and with a poorer prognosis.