Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group

Exploring the Important Attributes of Human Immunodeficiency Virus and Generating Decision Rules

Acquired Immunodeficiency Syndrome (AIDS) is the most severe phase of Human Immunodeficiency Virus (HIV) infection. Living with HIV results in a weakened immune system, with AIDS being the final stage of HIV and puzzling the world. The current medical environment remains unable to effectively cure AIDS, with treatment depending on long-term antiretroviral therapy (ART). To effectively treat and prevent HIV, it is important to elucidate the key factors of HIV propagation. This study proposes a rough set classifier based on adding recency (R) (i.e., the last physician visit), frequency (F) (i.e., the frequency of medical visits), and monetary (M) (i.e., medication adherence) attributes and integrated attribute selection methods to generate discriminatory rules and find the core attributes of HIV. The collected data consist of 1308 HIV infection records from Taiwan. From the experimental results, the frequency of CD4+ cells in the peripheral blood is able to determine patient medication, treatment willingness, and HIV infection stages, because HIV patients are less likely to be willing to receive long-term ART. Furthermore, drug abuse is found to be the greatest cause of HIV infection. These results show that the additional RFM attributes can improve classification accuracy, with the core attributes being M, R, plasma viral load (PVL) and age. Hence, we suggest that clinical physicians use these core attributes to understand the HIV infection stages.

Disseminated histoplasmosis in HIV-infected patients: determinants of relapse and mortality in a north-eastern area of Brazil

Many relapses and deaths resulting from disseminated histoplasmosis (DH) in acquired immunodeficiency syndrome (AIDS) patients have been observed in an endemic area in north-eastern Brazil. The objective of this study was to evaluate the risk factors associated with the clinical outcomes of DH/AIDS coinfection in patients from the state of Ceará, Brazil. A retrospective cohort of AIDS patients, after their hospital discharge due to first DH episode in the period 2002-2008, was followed until December 31, 2010, to investigate the factors associated with relapse and mortality. A total of 145 patients were evaluated in the study. Thirty patients (23.3%) relapsed and the overall mortality was 30.2%. The following variables were significantly (P < 0.05) associated with relapse and overall mortality (univariate analysis): non-adherence to highly active antiretroviral therapy (HAART), irregular use of an antifungal, non-recovery of the CD4+ count and having AIDS before DH; histoplasmosis relapse was also significantly associated with mortality. In the multivariate analysis, non-adherence to HAART was the independent risk factor that was associated with both relapse (Adj OR = 6.28) and overall mortality (Adj OR = 8.03); efavirenz usage was discovered to be significant only for the overall mortality rate (Adj OR = 4.50). Adherence to HAART was the most important variable that influenced the outcomes in this specific population.

Predictors of death in Malaysian HIV-infected patients on anti-retroviral therapy

OBJECTIVE

To determine the predictors of death in Malaysian HIV-infected patients undergoing antiretroviral therapy (ART).

METHODS

Data from 845 HIV-infected patients aged ≥ 20 years on ART in a large teaching hospital in Malaysia from 1989 to 2009 were analyzed using Kaplan-Meier and Cox regression analyses.

RESULTS

72.7% of the patients survived. Multivariate Cox regression showed that significant predictors of death were age ≥ 50 years (HR 1.76; 95% CI 1.18-2.64), secondary education (HR 3.57; 95% CI 1.12-11.37), tertiary education (HR 3.57; 95% CI 1.09-11.70), being unemployed (HR 1.49; 95% CI 1.07-2.09), AIDS on initial presentation (HR 5.75; 95% CI 3.29-10.07), single-drug ART (HR 1.84; 95% CI 1.27, 2.66), double-drug ART (HR 1.63; 95% CI 1.19-2.25) and inability to achieve viral load ≤ 50 copies/ml (HR 10.22; 95% CI 7.26-14.37).

CONCLUSION

Every effort needs to be made to ensure that all HIV patients have access to triple drug ART, to lower viral load to ≤ 50 copies/ml and to treat HIV patients before they progress to AIDS as these are significant modifiable predictors of death in Malaysian HIV patients.

Pre-ART levels of inflammation and coagulation markers are strong predictors of death in a South African cohort with advanced HIV disease

BACKGROUND

Levels of high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and D-dimer predict mortality in HIV patients on antiretroviral therapy (ART) with relatively preserved CD4+ T cell counts. We hypothesized that elevated pre-ART levels of these markers among patients with advanced HIV would be associated with an increased risk of death following the initiation of ART.

METHODS

Pre-ART plasma from patients with advanced HIV in South Africa was used to measure hsCRP, IL-6 and D-dimer. Using a nested case-control study design, the biomarkers were measured for 187 deaths and two controls matched on age, sex, clinical site, follow-up time and CD4+ cell counts. Odds ratios were estimated using conditional logistic regression. In addition, for a random sample of 100 patients, biomarkers were measured at baseline and 6 months following randomization to determine whether ART altered their levels.

RESULTS

Median baseline biomarkers levels for cases and controls, respectively, were 11.25 vs. 3.6 mg/L for hsCRP, 1.41 vs. 0.98 mg/L for D-dimer, and 9.02 vs. 4.20 pg/mL for IL-6 (all p<0.0001). Adjusted odds ratios for the highest versus lowest quartile of baseline biomarker levels were 3.5 (95% CI: 1.9-6.7) for hsCRP, 2.6 (95%CI 1.4-4.9) for D-dimer, and 3.8 (95% CI: 1.8-7.8) for IL-6. These associations were stronger for deaths that occurred more proximal to the biomarker measurements. Levels of D-dimer and IL-6, but not hsCRP, were significantly lower at month 6 after commencing ART compared to baseline (p<0.0001).

CONCLUSIONS

Among patients with advanced HIV disease, elevated pre-ART levels of hsCRP, IL-6 and D-dimer are strongly associated with early mortality after commencing ART. Elevated levels of inflammatory and coagulation biomarkers may identify patients who may benefit from aggressive clinical monitoring after commencing ART. Further investigation of strategies to reduce biomarkers of inflammation and coagulation in patients with advanced HIV disease is warranted.

TRIAL REGISTRATION

Parent study: ClinicalTrials.gov NCT00342355.

The impact of Kaposi sarcoma and non-Hodgkin lymphoma on mortality of people with AIDS in the highly active antiretroviral therapies era

BACKGROUND

Kaposi sarcoma (KS) and non-Hodgkin lymphoma (NHL) have strongly diminished in the HAART era, but their impact on life expectancy of people with AIDS (PWA) needs to be monitored. We aimed at quantifying the burden of KS and NHL on mortality of PWA in the HAART period in Italy.

METHODS

Death certificates of 3209 PWA diagnosed in 1999-2006 who died as of December 2006 were reviewed to identify those deaths in which KS or NHL was the underlying cause. Standardized mortality ratios (SMR) were computed.

RESULTS

KS or NHL appeared in 4.3% and 14.6% death certificates, respectively; they were the underlying cause of death in 3.1% and 13.4% of cases. SMR were 8698-fold higher for KS and 349-fold higher for NHL, and tended to decline over the study period.

CONCLUSION

KS and NHL caused about 16% of deaths of PWA in the HAART era, with 100-fold higher risks of death compared to the Italian general population also in recent years. Clinicians and public health officials should be aware of the persisting negative impact of these cancers on life expectancy of PWA.

Demographic characteristics and survival with AIDS: health disparities in Chicago, 1993-2001

OBJECTIVES

We examined correlations between survival and race/ethnicity, age, and gender among persons who died from AIDS-related causes.

METHODS

We estimated survival among 11 022 persons at 12, 36, and 60 months after diagnosis with AIDS in 1993 through 2001 and reported through 2003 to the Chicago Department of Public Health. We estimated hazard ratios (HRs) by demographic and risk characteristics.

RESULTS

All demographic groups had higher 5-year survival rates after the introduction of highly active retroviral therapy (1996-2001) than before (1993-1995). The HR for non-Hispanic Blacks to Whites was 1.18 in 1993 to 1995 and 1.51 (P < .01) in 1996 to 2001. The HR for persons 50 years or older to those younger than 30 years was 1.63 in 1993-1995 and 2.28 (P < .01) in 1996-2001. The female-to-male HR was 0.90 in 1993-1995 and 1.20 (P < .02) in 1996-2001.

CONCLUSIONS

The risk of death was higher for non-Hispanic Blacks and Hispanics than for non-Hispanic Whites. Interventions are needed to increase early access to care for disadvantaged groups.

County-level socioeconomic status and survival after HIV diagnosis, United States

PURPOSE

To estimate relative survival (RS) after human immunodeficiency virus (HIV) diagnosis, by race/ethnicity and county-level socioeconomic status (SES).

METHODS

We estimated 5-year RS by age, race/ethnicity, transmission category, sex, diagnosis year, CD4 count, and by county-level SES variables from the U.S. Census. Data, from the national HIV/AIDS Reporting System, were for HIV-infected persons ages > or =13 years (diagnosis during 1996-2003 and follow-up through 2005). We calculated RS proportions by using a maximum likelihood algorithm and modeled the relative risk of excess death (RR) using generalized linear models, with poverty as a random effect.

RESULTS

For men, RS was worse in counties with larger proportions of people living below the 2000 U.S. poverty level (87.7% for poverty of > or =20% vs. 90.1% for poverty of <5.0%) and where unemployment was greater (87.8% where unemployment > 7.1% vs. 90.5% where unemployment < 4.0%). The effects of county-level SES on RS of women were similar. In multilevel multivariate models, RR for men and women within 5 years after an HIV diagnosis was significantly worse in counties where 10.0-19.9% (compared with <5.0%) lived below the poverty level (RR = 1.3 [95% CI 1.2-1.5] and RR = 1.8 [95% CI 1.4-2.2], respectively).

CONCLUSIONS

RS was worse in lower SES areas. To help address the impact of county-level SES, resources for HIV testing, care, and proven economic interventions should be directed to areas with concentrations of economically disadvantaged people.

Long-term survival of HIV-infected patients treated with highly active antiretroviral therapy in Serbia and Montenegro

BACKGROUND

Highly active antiretroviral therapy (HAART) has dramatically changed the prognosis of HIV disease, even in terminally ill patients. Although these patients may survive many years after the diagnosis of AIDS if treated with HAART, some still die during treatment.

METHODS

A retrospective study in a cohort of 481 HIV-infected patients treated with HAART between January 1998 and December 2005 was conducted to compare subgroups of long-term survivors (LTSs) and patients who died during treatment.

RESULTS

A total of 48 patients survived for more than 72 months (mean 83.8+/-standard deviation 5.6 months). Thirty patients died during treatment (mean 35.3+/-25.0 months), of whom nine died from non-AIDS-related causes, 18 died from AIDS-related causes, and three died as a result of HAART toxicity. Although LTSs were significantly (P=0.015) younger at HAART initiation, age below 40 years was not a predictor of long-term survival. The subgroups did not differ in the proportion of clinical AIDS cases at HAART initiation, in the prevalence of hepatitic C virus (HCV) coinfection, or in pretreatment and end-of-follow-up CD4 cell counts. In contrast, the viral load achieved during treatment was lower in the survivors (P=0.03), as was the prevalence of hepatitis B virus (HBV) coinfection (P=0.03). Usage of either protease inhibitor (PI)-containing regimens [odds ratio (OR) 9.0, 95% confidence interval (CI) 2.2-35.98, P<0.001] or all three drug classes simultaneously (OR 7.4, 95% CI 2.2-25.1, P<0.001) was associated with long-term survival. Drug holidays incorporated in structured treatment interruption (STI) were also associated with a good prognosis (OR 14.9, 95% CI 2.9-75.6, P<0.001).

CONCLUSIONS

Long-term survival was associated with PI-based HAART regimens and lower viraemia, but not with the immunological status either at baseline or at the end of follow up. STI when CD4 counts reach 350 cells/microL, along with undetectable viraemia, was a strong predictor of long-term survival.

Laboratory investigations for the morphologic, pharmacokinetic, and anti-retroviral properties of indinavir nanoparticles in human monocyte-derived macrophages

The effectiveness of anti-retroviral therapies (ART) depends on its ultimate ability to clear reservoirs of continuous human immunodeficiency virus (HIV) infection. We reasoned that a principal vehicle for viral dissemination, the mononuclear phagocytes could also serve as an ART transporter and as such improve therapeutic indices. A nanoparticle-indinavir (NP-IDV) formulation was made and taken up into and released from vacuoles of human monocyte-derived macrophages (MDM). Following a single NP-IDV dose, drug levels within and outside MDM remained constant for 6 days without cytotoxicity. Administration of NP-IDV when compared to equal drug levels of free soluble IDV significantly blocked induction of multinucleated giant cells, production of reverse transcriptase activity in culture fluids and cell-associated HIV-1p24 antigens after HIV-1 infection. These data provide "proof of concept" for the use of macrophage-based NP delivery systems for human HIV-1 infections.

Increasing proportion of late testers among AIDS cases in Italy, 1996–2002

In recent years, the proportion of individuals who are unaware of being infected with HIV when diagnosed with AIDS (defined as 'late testers') has dramatically increased in several European countries, including Italy. We evaluated the extent and determinants of late testing and its impact in terms of AIDS-defining illnesses among AIDS cases reported to the Italian National AIDS Registry since 1996. Late testers were defined as those persons whose first positive HIV test result was within six months of the AIDS diagnosis. Late testers were more likely to be heterosexual contacts or MSWM, as opposed to IDUs. They were also more likely to come from low prevalence areas of Italy or from foreign countries. At AIDS diagnosis, late testers were less likely to be undergoing HAART or prophylaxis against PCP/toxoplasmosis, compared to non-late testers. The mean CD4 cell count at AIDS diagnosis was significantly lower among late testers. PCP, toxoplasmosis and Kaposi's sarcoma were more frequently diagnosed as an AIDS-defining illness in late testers, who also had a significantly higher risk of presenting with multiple concomitant AIDS-defining illnesses. In conclusion, late testing results in missed opportunities for preventing and treating HIV infection, leading to an increased risk of developing preventable opportunistic infections and death.

The epidemiology of HIV-1 infection in northern Tanzania: results from a community-based study

We conducted a community-based study to determine the predictors of HIV-1 among women aged 20-44 years (N = 1,418) and their regular male partners (N = 566) from randomly selected households in Moshi, Tanzania. The weighted prevalence of HIV-1 was 10.3% in women and 7% in men. The highest risk of HIV-1 was in subjects whose partners were HIV-1 seropositive in both women (adjusted odds ratio (AOR) = 26.63; 95% confidence interval (CI): 10.74-66.02) and men (AOR = 22.25; 95%CI: 7.06-70.15). Herpes simplex virus type 2 (HSV-2) and Mycoplasma genitalium were also significantly associated with HIV-1. Women with male partners >or=12 years older than themselves had increased risk of HIV-1 (AOR = 1.99; 95%CI: 1.01-7.85). Other predictors of HIV-1 were history of infertility and the number of sex partners in the last three years in women and the age at time of circumcision and history of past sexually transmitted diseases (STDs) in male partners. These findings show that HIV-1/STDs were major public health problems among women and their long-term partners in this population. HIV-1 prevention efforts should include promotion of couple's HIV-1 counseling and testing services, control of HSV-2, promotion of safer sexual practices and strategies to reduce the age difference between women and their partners.

Cambio de la supervivencia de los casos de sida en Cataluña (1981-2001)

BACKGROUND AND OBJECTIVE

Our goal was to assess survival changes among AIDS patients in Catalonia.

PATIENTS AND METHOD

We analyzed AIDS cases older than 13 years notified in the Catalonian AIDS Registry from January 1981 to December 2001. Sex, age, transmission category, AIDS-defining disease and diagnostic period were included. The survival cumulative risk was computed for each diagnostic period with Kaplan-Meier methods.

RESULTS

During the study period 13,485 AIDS cases were reported. Median survival time was 0.9 years for 1981-1987, 1.7 for 1988-1993 and 2.4 years for 1994-August 1996. The survival time of 75% of patients diagnosed in September 1996-1997 and 1998-2001 was 1.57 and 2.02 years, respectively. Multivariate analyses showed a higher risk among intravenous drug users (hazard ratio = 1.25; 95% confidence interval, 1.17-1.33) than in homo/bisexual men. When we compared heterosexual and homo/bisexual groups, we found that the result was not significant (hazard ratio = 0.99; 95% confidence interval, 0.92-1.08). The analysis stratified by AIDS-defining disease showed a decrease in the risk of death in most illnesses.

CONCLUSIONS

Our results confirm the increase in survival in AIDS cases related to highly active antirretroviral therapy (HAART).

Development of a macrophage-based nanoparticle platform for antiretroviral drug delivery

Complex dosing regimens, costs, side effects, biodistribution limitations, and variable drug pharmacokinetic patterns have affected the long-term efficacy of antiretroviral medicines. To address these problems, a nanoparticle indinavir (NP-IDV) formulation packaged into carrier bone marrow-derived macrophages (BMMs) was developed. Drug distribution and disease outcomes were assessed in immune-competent and human immunodeficiency virus type 1 (HIV-1)-infected humanized immune-deficient mice, respectively. In the former, NP-IDV formulation contained within BMMs was adoptively transferred. After a single administration, single-photon emission computed tomography, histology, and reverse-phase-high-performance liquid chromatography (RP-HPLC) demonstrated robust lung, liver, and spleen BMMs and drug distribution. Tissue and sera IDV levels were greater than or equal to 50 microM for 2 weeks. NP-IDV-BMMs administered to HIV-1-challenged humanized mice revealed reduced numbers of virus-infected cells in plasma, lymph nodes, spleen, liver, and lung, as well as, CD4(+) T-cell protection. We conclude that a single dose of NP-IDV, using BMMs as a carrier, is effective and warrants consideration for human testing.

[AIDS epidemic trends after the introduction of antiretroviral therapy in Brazil]

OBJECTIVE

Universal access to antiretroviral (ARV) therapy starting from 1996 has changed HIV/AIDS epidemic profile in Brazil. The objective of this study was to review the epidemiology of HIV/AIDS epidemic in Brazil.

METHODS

Indicators of temporal trends were developed for Brazilian regions from 1990 to 2003 using the Ministry of Health's databases. Exponential regression models adjusted to the 1990-1996 trends were used to estimate expected values for the entire period.

RESULTS

The proportion of AIDS hospitalizations has not changed over the study period but there was a decrease in hospitalizations among those using ARV therapy. There was a 2.7 growth in those receiving ARV therapy from 1997 to 2003. HIV/AIDS incidence and mortality rates rose up to 1995 in all regions. From 1996, there has been a gradual reduction in mortality rates while incidence rates have increased. In all regions, except in the Northern region, expected incidence rates have been greater than the observed ones in the last years but these differences were statistically significant only in the Southeastern and Midwestern regions.

CONCLUSIONS

The observed trend can be explained by universal access to ARV therapy in Brazil, which had a significant impact on HIV/AIDS mortality. But other factors, such as years of epidemic, prevention actions, knowledge on HIV/AIDS, years of schooling, need to be considered as well.

Bacterial lipopolysaccharide enhances cardiac dysfunction but not retroviral replication in murine AIDS: roles of macrophage infiltration and toll-like receptor 4 expression

Cardiovascular disease is an important complication of human immunodeficiency virus/acquired immune deficiency syndrome (AIDS), but the mechanism(s) involved are poorly understood. Although co-infecting pathogens have been implicated as an important factor in AIDS progression, no studies have investigated these interactions in cardiac tissue. We recently demonstrated that the murine AIDS model (LPBM5 retroviral infection) mimics human immunodeficiency virus-related cardiac dysfunction and pathology. We tested the hypothesis that subseptic lipopolysaccharide exposure (LPS) would enhance LPBM5 progression and exacerbate cardiovascular dysfunction during murine AIDS development. LPS (5 mg/kg, Escherichia coli 0111:B4) was administered at 1, 6, and 8 weeks during LPBM5 infection, and cardiac performance was evaluated at 10 weeks using noninvasive echocardiography. LPS alone had no significant effects, whereas it amplified abnormalities in cardiac structure and function observed in murine AIDS. Cardiac dysfunction was associated with selective increases in nonfocal infiltration of CD68(+) cells and correlated with the extent of cardiac dysfunction. Retroviral progression and cardiac retroviral content remained unaltered, but cardiac toll-like receptor 4 was increased in retrovirus + LPS. We provide first-time evidence of multipathogen enhancements to retrovirus-related cardiac complications and implicate innate immune responses, not co-pathogen-induced retroviral replication, as the primary mechanism in this setting.

Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients

BACKGROUND

Although highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available.

RESULTS

We followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19-0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03-0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment.

CONCLUSION

HAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes.

Acute renal failure in hospitalized patients with HIV: risk factors and impact on in-hospital mortality

BACKGROUND

Kidney disease is an increasingly important complication of HIV.

OBJECTIVES

To examine the incidence and predictors of acute renal failure before and after the introduction of HAART, and the impact of acute renal failure on in-hospital mortality in the post-HAART era.

METHODS

Adults hospitalized in acute care hospitals in New York State during 1995 (pre-HAART) or 2003 (post-HAART) were identified from the state Planning and Research Cooperative System database. HIV status was defined by primary or secondary diagnosis code. The impact of HIV and HAART on the incidence of acute renal failure and mortality, and the impact of acute renal failure on mortality, was assessed using chi analysis and multivariate regression.

RESULTS

There were 52,580 HIV-infected patients discharged from hospital in 1995 and 25,114 in 2003. Compared with uninfected patients, HIV-infected patients had an increased incidence of acute renal failure in both the pre-HAART [adjusted odds ratio (OR), 4.62; 95% confidence interval (CI), 4.30-4.95] and post-HAART eras (adjusted OR, 2.82; 95% CI, 2.66-2.99). In the post-HAART cohort, acute renal failure was associated with traditional predictors such as age, diabetes mellitus, and chronic kidney disease, as well as acute or chronic liver failure or hepatitis coinfection (P < 0.001 for all comparisons). Acute renal failure was associated with mortality among HIV-infected patients in the post-HAART era (OR, 5.83; 95% CI, 5.11-6.65).

CONCLUSIONS

Acute renal failure remains common among hospitalized patients with HIV and is associated with chronic kidney disease, liver disease, and increased mortality.

HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe

AIDS has increased the number of orphans and vulnerable children (OVCs) in sub-Saharan Africa who could suffer detrimental life experiences. We investigated whether OVCs have heightened risks of adverse reproductive health outcomes including HIV infection. Data on HIV infection, sexually transmitted infection (STI) symptoms and pregnancy, and common risk factors were collected for OVCs and non-OVCs in a population survey of 1523 teenage children in eastern Zimbabwe between July 2001 and March 2003. Multivariate logistic regression was used to test for statistical association between OVC status, adverse reproductive health outcomes and suspected risk factors. Amongst women aged 15-18 years, OVCs had higher HIV prevalence than non-OVCs (3.2% versus 0.0%; p = 0.002) and more common experience of STI symptoms (5.9% versus 3.3%; adjusted odds ratio = 1.75, 95% CI 0.80-3.80) and teenage pregnancy (8.3% versus 1.9%; 4.25, 1.58-11.42). OVCs (overall), maternal orphans and young women with an infected parent were more likely to have received no secondary school education and to have started sex and married, which, in turn, were associated with poor reproductive health. Amongst men aged 17-18 years, OVC status was not associated with HIV infection (0.5% versus 0.0%; p = 1.000) or STI symptoms (2.7% versus 1.6%; p = 0.529). No association was found between history of medical injections and HIV risk amongst teenage women and men. High proportions of HIV infections, STIs and pregnancies among teenage girls in eastern Zimbabwe can be attributed to maternal orphanhood and parental HIV. Many of these could be averted through further female secondary school education. Predicted substantial expanded increases in orphanhood could hamper efforts to slow the acquisition of HIV infection in successive generations of young adults, perpetuating the vicious cycle of poverty and disease.

Characteristics and survival of AIDS patients with hepatitis C: the Brazilian National Cohort of 1995-1996

BACKGROUND

As AIDS patients live longer, the management of co-morbidities becomes increasingly important. Previous studies from developed countries give conflicting results as to whether co-infection with hepatitis C virus (HCV) lowers the life expectancy of individuals with AIDS.

METHODS

This retrospective cohort study was based on a medical record review of a nationally representative sample of 2821 adult AIDS cases diagnosed in 1995 and 1996 in Brazil. We compared the characteristics and survival of patients known to be positive and negative for HCV.

RESULTS

A total of 833 patients received HCV testing, and the prevalence was 33%. HCV-positive patients received less intensive antiretroviral treatment. The crude mortality was greater for HCV-positive patients (hazard ratio 1.26; P = 0.04), but HCV status was not a significant predictor in a multivariate analysis that included other predictors of survival.

CONCLUSION

Brazilian AIDS patients with hepatitis C have a shorter survival than those without, but this seems to be mainly as a result of their receiving less antiretroviral treatment. We cannot say whether this is because of the fear of hepatotoxicity, an inability to tolerate treatment, or for other reasons. To improve survival, these patients need optimal treatment of their HIV disease.

Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study

BACKGROUND

Evidence on the effectiveness of highly active antiretroviral therapy (HAART) for HIV-infected individuals is limited. Most clinical trials examined surrogate endpoints over short periods of follow-up and there has been no placebo-controlled randomised trial of HAART. Estimation of treatment effects in observational studies is problematic, because of confounding by indication. We aimed to use novel methodology to overcome this problem in the Swiss HIV Cohort Study.

METHODS

Patients were included if they had been examined after January 1996, when HAART became available in Switzerland, were not on HAART, and were free of AIDS at baseline. Cox regression models were weighted to create a statistical population in which the probability of being treated at each time point was unrelated to prognostic factors.

RESULTS

Low CD4 counts and increasing HIV-1 viral load were associated with increased probability of starting HAART. Overall hazard ratios were 0.14 (95% CI 0.07-0.29) for HAART compared with no treatment, and 0.49 (0.31-0.79) compared with dual therapy. Compared with no treatment, HAART became more beneficial with increasing time since initiation but was less beneficial for patients whose presumed mode of transmission was via intravenous drug use (hazard ratio 0.27, 0.12-0.61) than for other patients (0.08, 0.03-0.19).

INTERPRETATION

Our results, which are appropriately controlled for confounding by indication, are consistent with reported declines in rates of AIDS and death in developed countries, and provide a context in which to consider adverse effects of HAART.

Estimating the net effect of HIV on child mortality in African populations affected by generalized HIV epidemics

For a given prevalence, HIV has a relatively higher impact on child mortality when mortality from other causes is low. To project the effect of the epidemic on child mortality, it is necessary to estimate a realistic schedule of "net" age-specific mortality rates that would operate if HIV were the only cause of child death observable. We assume that this net pattern would be independent of mortality from other causes. We used African studies that measured the survival of HIV-infected children (direct data) or survival of children of HIV-infected mothers (indirect data). We developed a mathematic procedure to estimate the mortality of infected children from indirect data sources and obtained net HIV mortality patterns for each study population. The net age-specific HIV mortality pattern for infected children can be described by a double Weibull curve fitted to empiric data; this gives a functional representation of age-specific mortality rates that decline after infancy and rise in the preteens. The fitted curve that we would expect if HIV were the only effective cause of death shows 67% net survival at 1 year and 39% at 5 years. The curve also predicts 13% net survival at 10 years using constraints based on survival of infected adults.

Oral candidosis as a clinical marker of immune failure in patients with HIV/AIDS on HAART

Oral candidosis (OC) has been proposed as a clinical marker of highly active antiretroviral therapy (HAART) success or failure. The principal objective of this work was to assess whether the presence OC is associated with immunologic or virologic failure in patients with HIV/AIDS undergoing HAART. One hundred fifty-one patients with HIV/AIDS from Regional Hospital "Carlos Haya," Malaga, Spain, were examined orally. All patients had been undergoing HAART for a minimum of 6 months prior to oral examination. OC diagnosis was in accordance with World Health Organization-Centers for Disease Control (WHO-CDC) criteria. Age, gender, route of HIV infection, CD4 lymphocyte counts, and viral load were taken from the medical records. In regard to HAART response the patients were classified as: virologic- responders (viral load < 50 copies per milliliter), virologic nonresponders (viral load >50 copies per milliliter); immunologic responders (CD4 cells counts > 500 per milliliter), and immunologic nonresponders (CD4 cells counts < 500 per milliliter). Prevalence of OC was determined for each group. The presence of OC was closely related to immune failure (p 0.006; odds ratio [OR] 3.38 95% confidence interval [CI] 1.262-12.046) in patients with HIV/AIDS undergoing HAART. The probability of immune failure in the presence of OC was 91% for men who have sex with men, 95.5% for heterosexuals, and 96% for intravenous drug users. In conclusion, OC should be considered a clinical marker of immune failure in patients with HIV/AIDS undergoing HAART.

Prevalence and correlates of nonadherence to antiretroviral therapy in a population of HIV patients using Medication Event Monitoring System

Nonadherence to antiretroviral therapy (ART) jeopardizes good clinical outcome in people living with HIV. In a single-center prospective study, prevalence and correlates of nonadherence were investigated in 43 patients on ART. Nonadherence was assessed using Medication Event Monitoring System (MEMS), self-report and collateral report of treating physicians. Based on MEMS data, median taking adherence, dosing adherence, and timing adherence was 98% (interquartile range [IQR] = 5.3), 91.5% (IQR = 18), and 86% (IQR = 31.5), respectively. The median number of drug holidays per 100 days was 0.8 (IQR = 4.8). The prevalence of nonadherence measured by MEMS was 40%. Self-reported nonadherence and collateral report of nonadherence by physicians varied from 5% to 41% and 24% to 28%, respectively. Patients were categorized as adherent or nonadherent based on a clinically validated algorithm derived from MEMS parameters. Nonadherent patients used significantly more escaping coping strategies (p = 0.003) and planned problem solving strategies (p = 0.049), were prescribed significantly more antiretroviral medications (p = 0.02) and were significantly longer on ART (p = 0.04) than adherent patients. Identified correlates of nonadherence may help clinicians in detecting patients with HIV at risk for nonadherence and can support the development of adherence enhancing interventions.

Modeling the Impact of Modified Directly Observed Antiretroviral Therapy on HIV Suppression and Resistance, Disease Progression, and Death

A simulation model that used Markov assumptions with Monte Carlo uncertainty analysis was evaluated 1500 times at 10,000 iterations. Modified directly observed therapy (MDOT) for human immunodeficiency virus was assumed to improve adherence to therapy to 90% of prescribed doses. The impact of MDOT interventions on modeled biological and clinical outcomes was compared for populations with mean rates of adherence (i.e., the mean percentage of prescribed doses taken by each member of the population who had not discontinued therapy) of 40%, 50%, 60%, and 70%. MDOT reduced the risk of virological failure, development of opportunistic infections, and death, yet increased the risk of drug resistance, for each adherence distribution among persons with detectable plasma virus loads. Over 1500 trials, for a population with 50% adherence to therapy and a 12-month period, MDOT increased the median rate of virological suppression from 13.2% to 37.0% of patients, decreased the rate of opportunistic infection from 5.7% to 4.3% of patients, and decreased the death rate from 2.9% to 2.2% of patients. In the same population, however, MDOT increased the rate of new drug resistance mutations from 1.00 to 1.41 per person during the 12-month period. The impact of MDOT was smaller in populations with higher levels of adherence. MDOT interventions will likely improve clinical outcomes in populations with low levels of adherence but may not be effective at preventing drug resistance in treatment-experienced populations. MDOT may be more effective in preventing drug resistance with potent regimens in treatment-naive patients.

Increasing incidence of critical liver disease among causes of death in Japanese hemophiliacs with HIV-1

Critical liver diseases are now major causes of death in HIV-1-infected patients after the remarkable improvement in the clinical status resulting from highly active antiretroviral therapy. We report the results of an analysis on causes of deaths related to liver diseases based on our surveillance of hemophiliacs infected with HIV-1 up until May 31, 2002. A total of 1,405 patients (hemophilia A, 1,084, and hemophilia B, 321) were registered. The cumulative number of deaths was 534 (hemophilia A, 414, and hemophilia B, 120) by May 31, 2002. Hepatic disease due to HCV infection was found in 29.8% (95% confidence interval: 20.3-40.7%) of the total cases with known causes of death after 1997, whereas this value was 14.0% (95% confidence interval: 10.8-17.7%) before 1997 (p < 0.01). We observed an increasing incidence of critical hepatic diseases among HIV-1-infected hemophiliacs, thus suggesting that treatment of HCV infection is essential for HIV-1-infected hemophiliacs.

HIV-1 disease progression and fertility: the incidence of recognized pregnancy and pregnancy outcome in Uganda

OBJECTIVES

To estimate the association between HIV disease progression and the incidence of recognized pregnancy; to estimate the risk of subsequent fetal loss.

METHODS

A total of 191 women (92 HIV seropositive and 99 HIV seronegative at enrolment) aged 15-49 years in an HIV clinical cohort were invited to attend routine clinic visits every 3 months. Information on HIV progression collected at the visit was related to whether there was a pregnancy beginning in the following 3 months. Visits were excluded where the woman was already pregnant, lactating, using modern contraceptives or if there was inadequate follow-up.

RESULTS

There were 2524 eligible visits and 216 recognized pregnancies. The reported frequency of sexual intercourse diminished with advancing HIV disease. The adjusted odds ratio (OR) for pregnancy when the woman was in WHO stage 1 compared with HIV seronegatives was 0.58 [95% confidence interval (CI), 0.36-0.93]; stage 2, 0.47 (95% CI, 0.25-0.91); stage 3, 0.43 (95% CI, 0.25-0.74); and stage 4, (AIDS) 0.14 (95% CI, 0.02-1.09). The findings were similar for CD4 cell count, time from seroconversion and time before AIDS. There was an increase in fetal loss from the early stages of HIV infection (adjusted OR for stage 1, 5.38; 95% CI, 1.57-18.44), there were very few recognized pregnancies in the advanced stages.

CONCLUSIONS

Fertility is reduced from the earliest asymptomatic stage of HIV infection resulting from both a reduced incidence of recognized pregnancy and increased fetal loss. The greatest reduction in fertility was observed following progression to AIDS when there was a very low incidence of recognized pregnancies.

The effect of antiretroviral therapy on the prevalence of HIV-associated oral candidiasis in a Spanish cohort

OBJECTIVE

To investigate the temporal changes in the prevalence of oral candidiasis in a cohort of Spanish human immunodeficiency virus (HIV)-infected individuals, before and after the introduction of highly active antiretroviral therapy (HAART).

STUDY DESIGN

Retrospective analysis of a clinical database from "Carlos Haya" Hospital, Málaga, Spain, from 1995 to 2000. The prevalence of oral candidiasis was assessed in 807 HIV/AIDS patients and the temporal progression of its major variants evaluated using a linear regression model.

RESULTS

Overall oral candidiasis was prevalent in 30.0% to 48.3% of the cohort throughout and no significant variation in its incidence was noted during the study period. Prevalence of erythematous candidiasis increased from 24.5% (1995) to 45.0% (2000) and pseudomembranous candidiasis decreased from 22.4% (1995) to 5.2% (2000) (P<.05). Hyperplastic candidiasis was not detected in the cohort after the introduction of HAART therapy.

CONCLUSIONS

Although oral candidiasis in HIV-infected Spanish individuals has not decreased significantly after the introduction of HAART, there appears to be a significant reduction in hyperplastic and pseudomembranous variants of the disease with a compensatory increase in erythematous candidiasis.

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.

Clinical and immunologic progression in HIV-infected US women before and after the introduction of highly active antiretroviral therapy

OBJECTIVE

To examine factors associated with clinical and immunologic HIV disease progression in a cohort of US women.

DESIGN

Analysis of data from a prospective, longitudinal, case-control study of HIV-infected women followed every 6 months for 7 years.

SETTING

Four urban clinical centers in the United States.

PARTICIPANTS

648 HIV-infected women who did not have AIDS at time of entry into the study.

MEASUREMENTS

Structured clinical and behavioral interviews; protocol-directed physical examinations; CD4 lymphocyte counts; plasma HIV RNA; infectious pathogen serologies. RESULTS With 2304 women-years of follow-up, 46.1% of the women developed AIDS; however, 93.3% of the diagnoses were based on CD4 counts dropping to <200 cells/mm(3). Only 10.6% of the women with CD4 counts <200 cells/mm(3) developed an opportunistic infection. Baseline CD4 count was the strongest predictor of subsequent clinical progression. Illicit substance use, multiple pregnancies, demographic variables, and other infections were not associated with progression. Among women with CD4 counts >500 cells/mm(3) at baseline, those who were anemic or had hepatitis C were more likely to progress to AIDS. By the end of the study, only 52% of the participants were on highly active antiretroviral therapy (HAART).

CONCLUSIONS

Despite underutilization of HAART in this multicenter cohort of urban women, opportunistic infections were uncommon, despite CD4 declines.

Dramatic improvement in survival among adult Brazilian AIDS patients

BACKGROUND

Since the last study of survival time among Brazilian AIDS patients, care has improved steadily, culminating in a controversial policy of universal free access to triple antiretroviral treatment since 1996. This large, national study examined how these changes have impacted survival.

METHODS

Using national data for cases diagnosed in 1995 and 1996, we randomly selected 3930 adult AIDS cases from 18 cities in seven states representing all regions of Brazil. Trained abstracters reviewed medical records, determining dates of diagnosis and death or last contact, exposure category, treatment, and demographics. After review, 2821 cases met the inclusion criteria and were available for Kaplan-Meier and proportional hazards analysis. Data from the earlier study were re-analyzed for comparison.

RESULTS

Median survival was 5 months for cases diagnosed in the 1980s, 18 months for those diagnosed in 1995, and 58 months for those diagnosed in 1996. Predictors of longer survival in univariate analysis included antiretroviral treatment, year of diagnosis, higher education, sexual exposure category, female sex, and Pneumocystis carinii pneumonia prophylaxis. In multivariate analysis, the predictive value of most of these was attenuated or disappeared, leaving antiretroviral treatment as the main predictor of survival.

CONCLUSIONS

Survival time has increased substantially for adult Brazilian AIDS patients. The timing of these gains and analysis of the predictors of survival both indicate antiretroviral treatment as the cause. These findings demonstrate that universal access to antiretroviral treatment in a developing country can produce benefits on the same scale as in richer countries.

Marked improvement in survival following AIDS dementia complex in the era of highly active antiretroviral therapy

OBJECTIVE

To determine the effect of introduction of highly active antiretroviral therapy (HAART) on survival following AIDS dementia complex (ADC).

METHODS

Australian AIDS notification data in the period 1993-2000 were examined. In order to examine the impact of HAART, two periods of AIDS diagnoses were chosen: pre-HAART (1993-1995) and HAART (1996-2000). Median survival was based on Kaplan-Meier estimates, with examination of factors influencing survival in a Cox proportional hazards model.

RESULTS

In the period 1993-2000 in Australia, 5017 initial AIDS illnesses were diagnosed among 4351 AIDS patients. The proportion of AIDS cases with ADC increased from 5.2% in 1993-1995 to 6.8% in 1996-2000 (P = 0.029). Median survival following AIDS increased from 19.6 months for those diagnosed with AIDS in 1993-1995 to 39.6 months for those diagnosed in 1996-2000 (P < 0.0005). Median survival following ADC increased to a greater extent than that for all other AIDS illnesses, from 11.9 months in 1993-1995 to 48.2 in 1996-2000 (P < 0.0005). Most striking was the increase in survival among those with ADC and a CD4 cell count < 100 x 10(6) cells/l at diagnosis; 5.1 months in 1993-1995 to 38.5 months in 1996-2000 (P < 0.0005).

CONCLUSION

Although there has been a proportional increase in ADC at AIDS diagnosis, survival following ADC has improved markedly in the era of HAART.

Current situation and regional perspective on HIV/AIDS surveillance in europe

AIDS reporting has been the principal means of monitoring the HIV/AIDS situation in Europe since 1984 [corrected]. HIV reporting was set up at the European level in 1999, although it has existed in most European countries since the 1980s. Anonymous individual data on AIDS and, if available, new HIV diagnoses, and data on HIV prevalence in various populations are reported from the 51 countries of the WHO European Region to EuroHIV, and aggregate data on HIV prevalence in various populations [corrected]. Data are presented after grouping the 51 countries into three geographic areas: the West, Center, and East. At end of 2000, in the West, AIDS incidence continued to decline except among those infected heterosexually; numbers of newly diagnosed HIV infections are relatively stable, but rising among heterosexually infected persons, many of whom originate from countries with generalized HIV epidemics. In the East, numbers of newly diagnosed HIV cases (mostly injection drug users) continue to rise steeply, particularly in the Russian Federation, Latvia, and Estonia. In the Center, levels of HIV and AIDS remain low. HIV reporting is becoming a central element of HIV/AIDS surveillance in Europe. Heterogeneity between countries in health care systems, HIV testing patterns and surveillance systems remain challenging for data standardization at the European level. Efforts should be made to use surveillance data for evaluating the effectiveness of HIV/AIDS prevention interventions.

Impact of highly active antiretroviral therapy on individual AIDS-defining illness incidence and survival in Australia

OBJECTIVE

To determine the effect of highly active antiretroviral therapy (HAART) on incidence of initial AIDS-defining illnesses (ADIs) and survival after individual ADIs.

METHODS

Australian AIDS notification data over the period 1993 to 2000 were examined. Analyses were based on all initial ADIs. To examine the impact of HAART, two periods of AIDS diagnosis were chosen: pre-HAART (1993-1995) and HAART (1996-2000). Comparisons between these two periods included proportion of individual ADIs, median CD4 lymphocyte counts at and survival following AIDS and individual ADIs. Median survival was based on Kaplan-Meier estimates, with examination of factors influencing survival in a Cox proportional hazards model.

RESULTS

Over the period 1993 to 2000 in Australia, 5017 initial ADIs were diagnosed among 4351 AIDS cases. At AIDS diagnosis, changes from the pre-HAART (1993-1995) to HAART (1996-2000) periods included an increased proportion of Pneumocystis carinii pneumonia (PCP) (25.9% to 30.4%; p =.001), AIDS dementia complex (5.2% to 6.8%; p = 0.029), non-Hodgkin lymphoma (NHL) (4.4% to 6.3%; p =.005), and tuberculosis (0.5% to 2.7%; p <.0005). Median survival following AIDS increased from 19.6 months for AIDS cases diagnosed in 1993 to 1995 to 39.6 months for AIDS cases diagnosed in 1996 to 2000 (p <.0005). Median survival was stable for NHL (7.5-8.8 months; p =.26), but increased significantly for almost all other ADIs.

CONCLUSIONS

An increased proportion of PCP relative to other ADIs suggests an increasing proportion of AIDS patients not receiving specific prophylaxis, presumably because of "late" HIV diagnosis. Survival following almost all ADIs has increased in the era of HAART, although the prognosis after NHL remains extremely poor.

Effectiveness of highly active antiretroviral therapy among HIV-1 infected women

STUDY OBJECTIVE

To describe the impact of highly active antiretroviral therapy (HAART) on mortality, morbidity, and markers of HIV disease progression in HIV infected women.

DESIGN

Data collected from the Women's Interagency HIV Study, a prospective cohort study that enrolled women between October 1994 and November 1995.

SETTING

Six clinical consortia based in five cities in the United States (New York, NY; Washington, DC; Los Angeles, CA; San Francisco, CA; and Chicago, IL).

PARTICIPANTS

A total of 1691 HIV seropositive women with a study visit after April 1996.

MAIN RESULTS

Beginning in April 1996, the self reported use of HAART increased over time, with more than 50% of the cohort reporting HAART use in 1999. There was a 23% decline per semester in the incidence of AIDS from April 1996 (95% confidence intervals (CI) -29% to -16%). Furthermore, there was a 21% decline of the semiannual mortality rates among those with AIDS at baseline (95% CI -27% to -14%) and an 11% decline among those AIDS free at baseline (95% CI -3% to -18%). CD4+ lymphocyte counts either increased (women with baseline AIDS) or stabilised (women without baseline AIDS) after April 1996, and HIV RNA levels dramatically declined in both groups, although the percentage of women with HIV RNA above 4000 cps/ml remained stable at approximately 40% since mid-1997.

CONCLUSIONS

Despite concerns regarding the use of antiretroviral therapies in this population, the use of therapies led to improved immunological function, suppressed HIV disease activity, and dramatic declines in morbidity and mortality.

Predictors of use of highly active antiretroviral therapy (HAART) among persons with AIDS in San Francisco, 1996-1999

Highly active antiretroviral therapy (HAART) has contributed to a decrease in AIDS-related morbidity and mortality. This study used population-based AIDS surveillance data to evaluate the prevalence and predictors of HAART use among persons with AIDS in San Francisco. Use of HAART among persons living with AIDS increased from 41% in 1996 to 72% in 1999. Fourteen percent of persons diagnosed with AIDS between 1996 and 1999 initiated HAART before their AIDS diagnosis. Use of HAART before an AIDS diagnosis increased from 5% in 1996 to 26% in 1999. In the multivariable analysis, African Americans, injection drug users, and those without insurance at the time of AIDS diagnosis were less likely to use HAART before AIDS diagnosis. Delayed initiation of HAART after AIDS was more likely to occur among African Americans, injection drug users, homeless persons, those with public insurance, and those with higher CD4 counts. Although the overall prevalence of HAART use was high, disparity in use of HAART existed by race and risk group, patient's insurance status, and facility of diagnosis. Barriers in use of treatment should be identified so all persons with AIDS can benefit from improved therapies.

Sexual and reproductive life of women informed of their HIV seropositivity: a prospective cohort study in Burkina Faso

BACKGROUND

In the context of the DITRAME-ANRS 049 research program that evaluated interventions aimed at reducing mother-to-child transmission of HIV (MTCT) in Bobo-Dioulasso (Burkina Faso), Voluntary HIV counseling and testing (VCT) services were established for pregnant women. HIV-infected women were advised to disclose their HIV serostatus to their male partners who were also offered VCT, to use condoms to reduce sexual transmission, and to choose an effective contraception method to avoid unwanted pregnancies. This study aimed at assessing how HIV test results were shared with male sexual partners, the level of use of modern contraceptive methods, and the pregnancy incidence among these women informed of the risks surrounding sexual and reproductive health during HIV infection.

METHODS

From 1995 to 1999, a quarterly prospective follow-up of a cohort of HIV-positive women.

RESULTS

Overall, 306 HIV-positive women were monitored over an average period of 13.5 months following childbirth, accounting for a total of 389 person-years. The mean age at enrollment in the cohort was 25.1 (standard deviation, 5.2 years). In all, 18% of women informed their partners, 8% used condoms at each instance of sexual intercourse to avoid HIV transmission, and 39% started using hormonal contraception. A total of 48 pregnancies occurred after HIV infection was diagnosed, an incidence of 12.3 pregnancies per 100 person-years. Pregnancy incidence was 4 per 100 person-years in the first year of monitoring and this rose significantly to 18 per 100 person-years in the third year. The only predictor of the occurrence of a pregnancy after HIV diagnosis was the poor outcome of the previous pregnancy (stillbirth, infant death). Severe immunodeficiency and change in marital status were the only factors that prevented the occurrence of a pregnancy after HIV diagnosis.

CONCLUSION

Our study shows a poor rate of HIV test sharing and a poor use of contraceptive methods despite regular advice and counseling. Pregnancy incidence remained comparable with the pregnancy rate in the general population. To improve this situation, approaches for involving husbands or partners in VCT and prevention of MTCT interventions should be developed, evaluated, and implemented.

Risk of HIV and other blood-borne infections in the cardiac setting: patient-to-provider and provider-to-patient transmission

Health care workers (HCWs) face a well-recognized risk of acquiring blood-borne pathogens in their workplace, in particular hepatitis B and C viruses (HBV/HBC) and human immunodeficiency virus (HIV). Additionally, infected HCWs performing invasive exposure-prone procedures, including in the cardiac setting, represent a potential risk for patients. An increasing number of infected persons could need specific cardiac diagnostic procedures and surgical treatment in the future, regardless of their sex or age. The risk of acquiring HIV, HCV, HBV infection after a single at-risk exposure averages 0.5%, and 1-2%, and 4-30%, respectively. The frequency of percutaneous exposure ranges from 1 to 15 per 100 surgical interventions, with cardiothoracic surgery reporting the highest rates of exposures; mucocutaneous contamination by blood-splash occurs in 50% of cardiothoracic operations. In the Italian Surveillance (SIROH), a total of 987 percutaneous and 255 mucocutaneous exposures were reported in the cardiac setting; most occurred in cardiology units (46%), and in cardiovascular surgery (44%). Overall, 257 source patients were anti-HCV+, 54 HBsAg+, and 14 HIV+. No seroconversions were observed. In the literature, 14 outbreaks were reported documenting transmission of HBV from 12 infected HCWs to 107 patients, and 2 cases of HCV to 6 patients, during cardiothoracic surgery, especially related to sternotomy and its suturing. The transmission rate was estimated to be 5% to 13% for HBV, and 0.36% to 2.25% for HCV. Strategies in risk reduction include adequate surveillance, education, effective sharps disposal, personal protective equipment, safety devices, and innovative technology-based intraoperative procedures.

The changing picture of the HIV/AIDS epidemic

Twenty years after it was first recognized, the HIV/AIDS epidemic continues to expand, but its impact varies greatly in different parts of the World. The worst of the epidemic is now centered in developing countries, especially sub-Saharan Africa, and areas such as Eastern Europe, which was only marginally involved a few years ago but has recently experienced the largest growth in the epidemic. In industrialized countries Highly Active Antiretroviral Therapy (HAART) has changed the natural history of HIV/AIDS, causing a reduction in mortality and morbidity due to HIV/AIDS and related diseases. Many interlocking factors determine the impact of HAART at the population level, including reduction of morbidity and mortality, changes in the natural history of HIV/AIDS and associated illnesses, and the effects of HAART on HIV transmission. To fully appreciate the potential benefits of HAART, the epidemic should continue to be monitored in the future, and the effects of HAART on reducing HIV transmission should also be evaluated. Interventions addressed to encourage the adoption of safer sex practices are badly needed, since a "rebound" in risky sexual behaviors was recently reported among high risk groups, which is, at least in part, attributable to the optimism about new treatments.

Antiretroviral therapy in HIV-infected individuals in clinical practice: are the criteria for initiating and choosing the type of drug regimen based only on immunologic and virologic values?

OBJECTIVES

To determine factors associated with beginning antiretroviral therapy and with the number of drugs used.

METHODS

Longitudinal study of 3169 HIV-infected individuals naïve from antiretroviral drugs at enrollment in 65 infectious disease clinics in Italy. Initiation of antiretroviral therapy and number of drugs used (i.e., < 3 vs. > or = 3 drugs) were the main outcome measures. Adjusted odds ratios were calculated by logistic models to establish cofactors of these two measures.

RESULTS

From January 1997 to December 1998, 1288 (40.6%) individuals started therapy, 58.0% of whom were given a triple combination regimen. This regimen became more frequent over time. By multivariate analysis, high levels of HIV-RNA and low CD4 counts were the most important independent predictors of starting any type of therapy. A significant association was also found with HIV exposure category, reason for being antiretroviral-naïve, presence/absence of liver disease, presence/absence of a new AIDS-defining disease, and clinical centre. High levels of HIV-RNA and low CD4 counts were also the most important predictors of starting with > or = 3 drugs, compared to < 3 drugs, and men had an independent higher probability of starting with > or = 3 drugs, compared to women. The probability of starting with > or = 3 drugs significantly increased with calendar time.

CONCLUSIONS

CD4 and HIV-RNA were the main cofactors of initiating both any type of therapy and therapy with > or = 3 drugs. The large variability among clinical centres suggests that clinicians are uncertain as to the exact timing of beginning therapy and the specific regimen, especially among women.

Optimal investment in a portfolio of HIV prevention programs

OBJECTIVES

In this article, the authors determine the optimal allocation of HIV prevention funds and investigate the impact of different allocation methods on health outcomes.

METHODS

The authors present a resource allocation model that can be used to determine the allocation of HIV prevention funds that maximizes quality-adjusted life years (or life years) gained or HIV infections averted in a population over a specified time horizon. They apply the model to determine the allocation of a limited budget among 3 types of HIV prevention programs in a population of injection drug users and nonusers: needle exchange programs, methadone maintenance treatment, and condom availability programs. For each prevention program, the authors estimate a production function that relates the amount invested to the associated change in risky behavior.

RESULTS

The authors determine the optimal allocation of funds for both objective functions for a high-prevalence population and a low-prevalence population. They also consider the allocation of funds under several common rules of thumb that are used to allocate HIV prevention resources. It is shown that simpler allocation methods (e.g., allocation based on HIV incidence or notions of equity among population groups) may lead to alloctions that do not yield the maximum health benefit.

CONCLUSIONS

The optimal allocation of HIV prevention funds in a population depends on HIV prevalence and incidence, the objective function, the production functions for the prevention programs, and other factors. Consideration of cost, equity, and social and political norms may be important when allocating HIV prevention funds. The model presented in this article can help decision makers determine the health consequences of different allocations of funds.

AIDS policy modeling for the 21st century: an overview of key issues

Decisions about HIV prevention and treatment programs are based on factors such as program costs and health benefits, social and ethical issues, and political considerations. AIDS policy models--that is, models that evaluate the monetary and non-monetary consequences of decisions about HIV/AIDS interventions--can play a role in helping policy makers make better decisions. This paper provides an overview of the key issues related to developing useful AIDS policy models. We highlight issues of importance for researchers in the field of AIDS policy modeling as well as for policy makers. These include geographic area, setting, target groups, interventions, affordability and effectiveness of interventions, type and time horizon of policy model, and type of economic analysis. This paper is not intended to be an exhaustive review of the AIDS policy modeling literature, although many papers from the literature are discussed as examples; rather, we aim to convey the composition, achievements, and challenges of AIDS policy modeling.

Selection by AZT and rapid replacement in the absence of drugs of HIV type 1 resistant to multiple nucleoside analogs

We studied the intrahost evolution and dynamics of a multidrug-resistant HIV-1, which contains an insertion of two amino acids (aa) and several aa changes within the reverse transcriptase (RT) gene. From an individual receiving intermittent therapy, sequences of 231 full-length molecular clones of HIV-1 RT were obtained from serum-derived viruses at 12 consecutive time points over a period of 6 years, 17 to 20 clones per time point. In the 3.5-year period prior to the first course of therapy, only wild-type (wt) viruses were found. As soon as 6 months after the start of zidovudine (AZT) monotherapy, all viruses contained an insertion of two aa between positions 68 and 69 of the RT and aa changes at positions 67 and 215, a combination conferring resistance to multiple nucleoside analogs. After termination of therapy, the insertion mutants were rapidly and completely replaced by the wt viruses. In turn, the insertion mutants replaced the wt viruses after initiation of therapy with 3TC, d4T, and saquinavir. After termination of triple therapy, the wt viruses completely replaced the mutants within 1 month, which is markedly faster than has been observed earlier for the replacement of AZT-resistant viruses. Fast replacements of the mutant virus populations after termination of therapy indicate gross competitive disadvantage of the insertion mutant in the absence of therapy, which we estimated by using several models. The insertion mutants attained high virus loads, demonstrating that virus load cannot be used as a direct measure of virus fitness.

Health related quality of life among persons with HIV after the use of protease inhibitors

OBJECTIVE

This study was conducted to determine the effect of the use of HIV protease inhibitors on the quality of life among persons infected with HIV.

METHODS

Subjects were participants in the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program who had completed two annual participant surveys, one prior to initiating therapy with a protease inhibitor and one after. Quality of life was measured using the Medical Outcomes Study Short Form Health Survey (MOS-SF). Statistical analyses were conducted using parametric and multivariate methods.

RESULTS

Our analysis was based on 179 HIV-positive individuals. Compared to quality of life at baseline, we found no statistically significant changes in the health perception, pain, physical, role and social functioning MOS-SF subscale scores at follow-up. The measure of mental health was the only component to decline significantly over time. Subanalyses found significant increases in the measures of health perception (p = 0.004), physical (p = 0.037), role (p < 0.001) and social functioning (p = 0.053) for individuals with a low baseline quality of life. For those with a higher quality of life before starting a protease inhibitor containing regimen we observed a significant decline in the subscales of mental health (p = 0.001), physical (p = 0.007), role (p = 0.021) and social functioning (p = 0.003) over the study period.

CONCLUSIONS

Our findings indicate that despite strict dosage requirements and adverse side effects associated with protease inhibitor use patients are on the whole maintaining their quality of life after starting on a protease inhibitor containing regimen. Continued follow-up of this cohort will be required to determine the long term implications of these observations.

Resource allocation for epidemic control over short time horizons

We present a model for allocation of epidemic control resources among a set of interventions. We assume that the epidemic is modeled by a general compartmental epidemic model, and that interventions change one or more of the parameters that describe the epidemic. Associated with each intervention is a 'production function' that relates the amount invested in the intervention to values of parameters in the epidemic model. The goal is to maximize quality-adjusted life years gained or the number of new infections averted over a fixed time horizon, subject to a budget constraint. Unlike previous models, our model allows for interacting populations and non-linear interacting production functions and does not require a long time horizon. We show that an analytical solution to the model may be difficult or impossible to derive, even for simple cases. Therefore, we derive a method of approximating the objective functions. We use the approximations to gain insight into the optimal resource allocation for three problem instances. We also develop heuristics for solving the general resource allocation problem. We present results of numerical studies using our approximations and heuristics. Finally, we discuss implications and applications of this work.