Decreasing prevalence of HCV coinfection in all risk groups for HIV infection between 2004 and 2011 in Spain

While hepatitis C virus (HCV) infection seems to be expanding among HIV-infected men who have sex with men (MSM), the rate of coinfection in intravenous drug users (IDU) is assumed to remain constant. We evaluated the serial prevalence of HIV/HCV coinfection across all risk groups for HIV infection in Spain. We used data from 7045 subjects included in the multicentre, prospective Spanish Cohort of Adult HIV-infected Patients (CoRIS) between 2004 and 2011. We analysed risk factors for HIV/HCV coinfection by logistic regression analyses. The prevalence of HIV/HCV coinfection decreased from 25.3% (95% CI, 23.1-27.5) in 2004-2005 to 8.2% (95% CI, 6.9-9.5) in 2010-2011. This trend was consistently observed from 2004 to 2011 among all risk groups: IDU, 92.4% to 81.4%; MSM, 4.7% to 2.6%; heterosexual men, 13.0-8.9%; and heterosexual women, 14.5-4.0% (all P < 0.05). Strongest risk factors for HIV/HCV coinfection were IDU (OR, 54.9; 95% CI, 39.4-76.4), birth decade 1961-1970 (OR, 2.1; 95% CI, 1.1-3.7) and low educational level (OR, 2.4; 95% CI, 1.6-3.5). Hence, the prevalence of HIV/HCV coinfection decreased in Spain between 2004 and 2011. This decline was observed across all risk groups and is likely to be explained by a declining burden of HCV in the general population.

Differences in Durability of Treatment with Initial PI-Based Regimens

The durability of virologic response to antiretroviral therapy is dependent on the potency, tolerability, and adherence level of the regimen. In a prospective, nonrandomized cohort study, we compared the treatment outcome of a nelfinavir-based highly active antiretroviral therapy (HAART) regimen with that of an indinavir-based regimen, over 1 year of routine clinical practice. Information was derived from 134 treatment-naïve HIV-1-infected patients initiated on triple therapy with either nelfinavir (n = 44) or indinavir (n = 90). The proportions of patients achieving a virological response were similar between treatment groups (>1 log(10) reduction in HIV RNA at 3 months in 95% of patients taking nelfinavir and 88% taking indinavir; HIV RNA <50 copies/mL after 1 year in 79% and 69% of patients, respectively). Predicting factors for 1-year virological suppression were initial virological response (p =.02) and adherence >90% (p =.0001). Over 90% adherence was achieved in 70% of patients taking nelfinavir compared with 41% of those taking indinavir (p =.01). The probability of remaining on the initial protease inhibitor (PI) after 12 months was 77% in the nelfinavir group and 66% in the indinavir group, with the median time to changing treatment being 519 days and 462 days, respectively. Gastric intolerance and nephritic colic were the most common reasons for changing therapy in the indinavir group. In the clinical setting, HAART based on initial nelfinavir and indinavir therapy was associated with similarly good virological and immunological suppression at 1 year, however, nelfinavir-based treatment was associated with a longer durability, probably due to a better adherence and tolerance pattern.

Higher Virological Effectiveness of NNRTI-Based Antiretroviral Regimens Containing Nevirapine or Efavirenz Compared to a Triple NRTI Regimen As Initial Therapy in HIV-1-Infected Adults

PURPOSE

To compare outcomes of nonnucleoside reverse transcriptase inhibitors (NNRTIs) nevirapine or efavirenz versus abacavir-based regimens with a backbone of zidovudine and lamivudine as initial therapy of treatment-naive adults with HIV-1 infection in routine clinical care.

METHOD

All patients starting their first antiretroviral therapy with any of the studied regimens from January 1999 to December 2002 were included in the analysis. Rates of viral suppression (HIV-RNA below 50 copies/mL) and discontinuation of any component of the regimen were compared at 48 weeks.

RESULTS

Fifty-one patients started with one of the two NNRTI-based regimens and 49 started with the triple nucleoside regimen (3-NRTI). After 48 weeks, more patients in the NNRTI regimens (76.5%) than in the 3-NRTI (51.1%) regimen achieved a HIV-1 RNA level below the limit of detection (<1.7 log10 copies/mL; p = .008). Time to change the antiretroviral regimen was shorter with 3-NRTI (median [range]: 234 [139-329] days) than with NNRTI (346 [0-756] days) (p = .0901). More withdrawals related to drug toxicity or intolerance occurred with the 3-NRTI-based regimen.

CONCLUSION

In a routine clinical care setting, initial antiretroviral treatment with an NNRTI (nevirapine or efavirenz) plus zidovudine and lamivudine was virologically superior and safer than a 3-NRTI therapy (abacavir with the same NRTI backbone).

Limitations of a Simplification Antiretroviral Strategy for HIV-Infected Patients with Decreasing Adherence to a Protease Inhibitor Regimen

PURPOSE

To determine the long-term efficacy of a simplification strategy in the clinical setting when used to improve adherence.

METHOD

Prospective study of 70 patients included in a regimen with ddI plus 3TC plus an NNRTI, after viral suppression with a PI-containing regimen, due to decreasing adherence. Adherence to PI was calculated as the percentage of doses taken last week before inclusion, and patients were stratified as high and low adherence (95% and <95% of doses).

RESULTS

Overall, 19 patients (27%) related adherence to PI <95% at inclusion (6 patients [9%], with adherence <80%). Mean adherence improved, with only 8% of patients presenting values <95%. At 104 weeks, 88% of patients on therapy had viral load suppression, but only 43% by ITT analysis. The main cause of therapy change or withdrawal was toxicity or drug interactions (26%). Notably, 16% of patients were lost to follow-up or left therapy, especially in the group of initially low adherent (26% vs. 12%, p = .02).

CONCLUSION

The use of a simplification strategy could be associated with long-term high risk of treatment failure, when used to improve adherence in the clinical setting.

Immigrant women living with HIV in Spain: a qualitative approach to encourage medical follow-up

Background

Immigrant women living with HIV generally have worse adherence to medical treatment and follow-up when compared to native women and immigrant or native men. The general aim of this study was to improve healthcare services for HIV-positive women and to better understand why some of them discontinue treatment. The specific objectives were: (1) to explore the barriers and facilitators to medical follow-up among women and (2) to use the findings to create a guide for healthcare professionals with strategies and tools to encourage the immigrant women to continue with their healthcare treatment.

Methods

We conducted a qualitative, patient-centred research based on semi-structured interviews in order to understand the drivers and barriers for HIV positive immigrant women to adhere to medical follow-up. A total of 26 women in active or discontinued treatment (from sub-Saharan Africa (10), Latin America (8) and Spain (8)) were interviewed in 2012 using a purposive sampling methodology. The semi-structured interviews were transcribed and analysed based on the grounded theory approach and the framework method. Three researchers took part in the triangulation of results.

The study was approved by the Ethical Committee of the Hospital Universitario Ramón y Cajal.

Results

The study revealed eight categories that impacted adherence to treatment and medical follow-up: doctor-patient relationship, relationship between body and HIV, employment, gender roles, representations of AIDS, emotional support received, trust in biomedical system, and psychological condition. Specific barriers and facilitators related to these categories were identified. In immigrant women, the influence of these barriers was greater than in Spanish women.

Recommendations for healthcare professionals based on this study have been compiled in an informative brochure.

Conclusions

Social, cultural, and psychological aspects as well as self-perception of body changes, gender roles, and the relationship with the healthcare system, are key elements that may affect the adherence to medical treatment of immigrant women living with HIV.

Qualitative research focused on the comprehensive experience of living with HIV can be useful for creating tools that pave the way to detect barriers and facilitators to medical follow-up in specific populations.

High levels of CD4⁺ CTLA-4⁺ Treg cells and CCR5 density in HIV-1-infected patients with visceral leishmaniasis

Visceral leishmaniasis (VL) in HIV-1-infected patients has been associated with poor immunological recovery and frequent disease relapses. The aim of this study was to analyse the role of T cell populations, Treg cells and CCR5 density in patients with VL compared to HIV-1-infected patients without leishmaniasis. A cross-sectional study of nine Leishmania-HIV-1-coinfected (LH) patients with VL receiving suppressive cART for at least 1 year were compared to 16 HIV-1-infected patients with non-immunological response (NIR, CD4 count below 250 cells/mm(3)) and 26 HIV-1-infected patients with immunological response (IR, CD4 count above 500 cells/mm(3)) without leishmaniasis. LH patients had a deep depletion of naïve T cells (p = 0.002), despite similar levels of effector T cells compared to NIR patients. CD4 Treg cells were similar compared to NIR patients, but higher compared to IR patients (p < 0.001). Interestingly, CD4 Treg CTLA-4(+) cells were higher in LH patients compared to either NIR or IR patients (p = 0.022 and p < 0.001, respectively), and the CD4 Treg/TEM ratio was similar to NIR patients, but higher compared to IR patients (p = 0.017). CCR5(+) T cell levels were higher compared to IR patients (p < 0.001), while CCR5 density on T cells were higher compared to both NIR and IR patients (p < 0.005 in both cases). Higher levels of CD4(+) CTLA-4(+) Treg cells and CCR5 density on CD8(+) T cells are strongly associated with VL in HIV-1-infected patients. Also, these patients have a poor immunological profile that might explain the persistence and relapse of the pathogen.

Prevalence of primary resistance mutations to integrase inhibitors in treatment-naïve and -experienced patients infected with B and non-B HIV-1 variants

BACKGROUND

Raltegravir (RAL) constitutes the first available integrase strand transfer inhibitor (INSTI) available in clinical practice. Three independent pathways have been described to confer resistance to RAL. Secondary mutations with little effect on INSTI susceptibility and additional substitutions with an uncertain role have also been described especially in HIV-1 non-B variants.

METHODS

We evaluated the prevalence of primary, secondary, and additional resistance mutations to INSTIs in patients naïve to RAL or elvitegravir (EGV) carrying different HIV-1 variants.

RESULTS

A total of 83 patients infected by B HIV-1 subtype (64%) or non-B HIV-1 variants (36%) were evaluated. No primary mutations to RAL or EGV were found in the inte-grase sequences analyzed. Secondary mutations were detected in only 5 patients. Additional mutations were found in both in B and non-B variants. According to the geno2pheno algorithm, some of the secondary mutations detected (L74V, E138K, G163RS, and V151I) have been associated with a reduced estimated susceptibility to RAL and only the E138K mutation has been associated with a decreased estimated susceptibility to EGV. No virological failure was observed after RAL was administrated in 17 patients carrying 1 or more additional substitutions in the absence of primary or secondary mutations.

CONCLUSIONS

No primary resistance mutations to INSTI were found in treatment-naïve or -experienced patients infected with B or non-B HIV-1 variants. The vast majority had some polymorphic and non-polymorphic substitutions; however response to RAL was excellent in patients who harbored one or more of these mutations. We could not identify any clinical factors associated with the presence of any of these mutations.

Virological response to short-course maraviroc monotherapy does not predict viral tropism in HIV-1-infected treatment-naive patients

OBJECTIVES

We aimed to evaluate whether virological response to a short course of maraviroc monotherapy could predict HIV-1 tropism.

METHODS

A clinical trial was performed in HIV-1 treatment-naive patients infected with R5- or non-R5-tropic virus determined using the Trofile(®) assay, with >1000 HIV-1 RNA copies/mL. Maraviroc was administered for 10 days. Viral load was measured at baseline and days 4, 7, 10 and 28. The main outcome measurement was the decline in HIV-1 RNA at day 10. The trial was registered in the ClinicalTrials.gov database (NCT01060618; TROPISMVC).

RESULTS

Forty patients [30 R5 and 10 dual/mixed (D/M)] were recruited. There was a significant decrease in HIV-1 RNA after 10 days of maraviroc treatment in patients with R5-tropic virus (median 1.52 log10 RNA copies/mL; 95% CI 1.23-1.63; P < 0.0001), but also in patients with D/M-tropic virus (median 1.62 log(10) RNA copies/mL; 95% CI 0.33-1.88; P = 0.00024). The difference in the HIV-1 RNA decrease (-0.16 log(10) RNA copies/mL; 95% CI -0.53 to 0.22) was not significant (P = 0.410). A decrease >0.5 log(10) RNA copies/mL was found in 96.3% of patients with R5-tropic virus and in 70% of patients with D/M-tropic virus (P = 0.052). The differences were not significant when a decline of 1 log(10) RNA copies/mL was considered (92.6% versus 70%; P = 0.11).

CONCLUSIONS

Treatment-naive patients infected with R5- or D/M-tropic virus have similar virological responses to a short course of maraviroc monotherapy. This clinical test thus cannot be used as a surrogate marker of viral tropism in this population.

Increased risk of serious non-AIDS-related events in HIV-infected subjects on antiretroviral therapy associated with a low CD4/CD8 ratio

BACKGROUND

A low CD4/CD8 ratio has been identified in the general population as a hallmark of inmmunosenescence and a surrogate of all-cause mortality. We aimed to investigate in treated HIV-infected individuals the relationship between the CD4/CD8 ratio and serious non-AIDS events.

METHODS

Case-control study within a prospective hospital-based cohort of HIV-infected subjects during at least one year of ART-mediated viral suppression. Cases were patients with serious non-AIDS events (non-AIDS malignancies, cardiovascular disease, and end-stage kidney disease), and controls individuals who did not developed non-AIDS events during follow-up. Data were analyzed using ROC analysis and multivariate logistic regression. Conditional logistic regression was performed in 200 cases/controls matched by age, sex, nadir CD4 and proximal CD4 counts.

RESULTS

We analyzed 407 subjects (109 cases, 298 controls). The CD4/CD8 ratio was lower in cases (0.44 vs. 0.70, P<0.0001), with higher discriminatory ability for the detection of non-AIDS events than the CD4 count, CD8 count and nadir CD4. Multivariate analyses (adjusted for age, sex, nadir CD4, proximal CD4 count, year of ART initiation and ART duration) confirmed the independent association of a low CD4/CD8 ratio with the risk of non-AIDS morbidity (per CD4/CD8 ratio quartile decrease, OR, 2.9; 95% CI, 1.3-6.2) and non-AIDS mortality (OR, 2.8; 95% CI, 1.5-5.3).

CONCLUSIONS

The CD4/CD8 ratio provides additional information to the CD4 counts and nadir CD4 in treated HIV-infected individuals, since it is independently associated with the risk of non-AIDS-related morbidity and mortality. This association is robust and maintained within different subgroups of patients.

Validation of a Specific Questionnaire on Psychological and Social Repercussions of the Lipodystrophy Syndrome in HIV-infected Patients

OBJECTIVE

To validate a questionnaire to identify psychosocial repercussions of the lipodystrophy syndrome (LD) in HIV-infected patients.

METHODS

A questionnaire containing 35 items in 6 subscales [body image, anxiety, depression, social support, social distress, quality of life (QoL)] was consecutively administered to 128 patients with LD, 25 naive patients or on therapy without LD, and to 15 HIV negative patients from January to July '04. Reliability was assessed using Cronbach's alpha and the intraclass correlation coefficient (ICC). The area under the curve (AUC) was used for discrimination between patients and control groups, and the scores were compared according to the severity of the LD.

RESULTS

In all the subscales, the relationship between higher scores and LD severity was statistically significant (0.37-0.64, p<0.01), whereas the control groups had significantly lower scores. The internal consistency showed Cronbach's alpha coefficients ranging from 0.64 to 0.93. Test-retest reliability after 15 days in 30 patients showed ICC values of 0.8-0.94. AUC values for the different subscales were higher than 0.7 with the exception of QoL score, and construct validity showed a significant correlation with the Beck Depression Inventory and the MOS-HIV scores (0.49 and 0.51, respectively, p<0.01).

CONCLUSIONS

Our questionnaire shows satisfactory psychometric properties for identifying psychosocial repercussions of the LD in HIV-infected patients.

Peliosis hepatis due to disseminated tuberculosis in a patient with AIDS

Peliosis hepatis is a rare histopathological entity of unknown etiology. We present a case of peliosis hepatis in a 44-year-old man with disseminated tuberculosis and acquired immunodeficiency syndrome. The diagnosis of peliosis hepatis was based on liver biopsy results which were suggestive of tuberculous etiology. Diagnosis of tuberculosis was confirmed by auramine stain, rRNA amplification and culture of Mycobacterium tuberculosis from synovial fluid of the elbow joint. The patient responded favourably to tuberculostatic treatment with four drugs and the early initiation of highly active antiretroviral therapy. Histopathological evidence of peliosis hepatis, without an obvious cause, makes it necessary to rule out tuberculosis, especially in the context of immunodeficiency diseases and immigrants from endemic areas.

Neutropenia during therapy with peginterferon and ribavirin in HIV-infected subjects with chronic hepatitis C and the risk of infections

BACKGROUND

It is unclear whether pegylated interferon (peg-IFN) -induced neutropenia in subjects coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) is associated with increased risk of serious infections.

METHODS

This was a prospective cohort study conducted between 2000 and 2012 in HIV/HCV-coinfected subjects initiating treatment with peg-IFN plus ribavirin (RBV). Infections were defined as serious when patients required hospitalization, treatment was discontinued, or the patient died. The association between neutropenia (severe, <500 cells/μL; nonsevere, 500 -1500 cells/μL) and infections (serious infections and infections of any severity) was determined by logistic regression analysis.

RESULTS

Among 418 subjects (3928 person-weeks of therapy), infections occurred in 123 (29%), accounting for 149 episodes (3.8 infections per 100 person-weeks of therapy). Most infections (47%) involved the upper respiratory tract and were minor. After a multivariate analysis adjusted by age, sex, CD4 count, AIDS, antiretroviral therapy, cirrhosis, neutrophil count, type of peg-IFN, and granulocyte colony-stimulating factor use, none of these variables remained independently associated with the risk of infection. Twenty subjects developed a serious infection (4.8% of all patients). The frequency of serious infections was higher in subjects with severe neutropenia compared to those with nonsevere neutropenia and without neutropenia, although it was not statistically significant (8.6%, 4.8%, and 3.6%, respectively; trend test P = .281). In multivariate analysis, neutropenia was not independently associated with increased risk of serious infections.

CONCLUSIONS

In this large prospective cohort of HIV/HCV-coinfected patients treated with peg-IFN plus RBV, serious infections were uncommon, nonfatal, and unrelated to peg-IFN -induced severe neutropenia.

Safety and pharmacokinetics of lopinavir in HIV/HCV coinfected patients with advanced liver disease

PURPOSE

There are few data about the safety and pharmacokinetics of lopinavir in HIV/HCV coinfected patients with very advanced liver disease.

METHOD

Prospective study of 60 HIV/HCV coinfected patients who underwent a liver biopsy and received a lopinavir-based regimen. The rate of hepatotoxiciy and plasma trough levels were determined in absence/presence of cirrhosis (25 cases), especially in 11 patients with Child-Pugh stage B-C.

RESULTS

Overall, geometric mean level of lopi-navir was 7,109 ng/mL (interquartile range [IQR], 5,163-9,029), without differences according to cirrhosis (7,662; IQR, 5,165-10,442) or not (6,708; IQR, 5,524-8,526; P = .6). In 11 patients with Child-Pugh stage B-C, trough level was 9,640 ng/mL (IQR, 1,620-11,622 ng/mL), but there was a 99% interpatient variability (72 to 13,331 ng/mL). During a follow-up of 195.2 patient-years, there were 7 cases of hepatotox-icity, with an incidence of 3.39 episodes/100 patient-years (2.2 to 7.9). This incidence was higher in patients with Child-Pugh stage B-C (5.43 episodes/100 patient-years). There were no differences in lopinavir trough levels between patients with or without liver toxicity (7,100 vs 7,119 ng/mL; P = .9).

CONCLUSION

The risk of lopinavir-associated hepatotoxicity in patients with very advanced liver disease is low. However, lopinavir plasma trough levels are increased, and there is a high interpatient variability.

Intensification of antiretroviral therapy with a CCR5 antagonist in patients with chronic HIV-1 infection: effect on T cells latently infected

OBJECTIVE

The primary objective was to assess the effect of MVC intensification on latently infected CD4(+) T cells in chronically HIV-1-infected patients receiving antiretroviral therapy.

METHODS

We performed an open-label pilot phase II clinical trial involving chronically HIV-1-infected patients receiving stable antiretroviral therapy whose regimen was intensified with 48 weeks of maraviroc therapy. We analyzed the latent reservoir, the residual viremia and episomal 2LTR DNA to examine the relationship between these measures and the HIV-1 latent reservoir, immune activation, lymphocyte subsets (including effector and central memory T cells), and markers associated with bacterial translocation.

RESULTS

Overall a non significant reduction in the size of the latent reservoir was found (p = 0.068). A mean reduction of 1.82 IUPM was observed in 4 patients with detectable latent reservoir at baseline after 48 weeks of intensification. No effect on plasma residual viremia was observed. Unexpectedly, all the patients had detectable 2LTR DNA circles at week 24, while none of them showed those circles at the end of the study. No changes were detected in CD4(+) or CD8(+) counts, although a significant decrease was found in the proportion of HLA-DR(+)/CD38(+) CD4(+) and CD8(+) T-cells. LPS and sCD14 levels increased.

CONCLUSIONS

Intensification with MVC was associated with a trend to a decrease in the size of the latent HIV-1 reservoir in memory T cells. No impact on residual viremia was detected. Additional studies with larger samples are needed to confirm the results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00795444.

Clinical utility of maraviroc

Maraviroc belongs to the family of chemokine (C-C motif) receptor 5 (CCR5) antagonists that prevent the entry of human immunodeficiency virus (HIV) into host CD4+ T cells by blocking the CCR5 co-receptor R5. Maraviroc is currently the only CC5R co-receptor inhibitor that has been approved for clinical use in HIV-1-infected patients carrying the CCR5 tropism who are antiretroviral-naïve or have experienced therapeutic failure following traditional antiretroviral therapies. This article is a review of the main characteristics of maraviroc and the latest data regarding its clinical application. Maraviroc is effective and well tolerated in pre-treated and antiretroviral-naïve patients with HIV-1 infections carrying the CCR5 tropism. Data from the phase III programme of maraviroc, which includes the MOTIVATE 1 and 2 studies and the MERIT study, indicate that maraviroc significantly (p < 0.001) increases CD4+ cell counts compared with placebo in pre-treated patients and to a similar extent as efavirenz in antiretroviral-naïve patients. Even in cases where viral load is not completely suppressed, maraviroc improves immunological response compared with placebo. In addition, promising research suggests that maraviroc has favourable pharmacokinetic and safety profiles in patients with high cardiovascular risk or those co-infected with tuberculosis or hepatitis and could be considered an option for treatment of HIV-infected patients with these co-morbidities. Resistance to maraviroc is low and mainly related to the presence of chemokine (C-X-C motif) receptor 4 (CXCR4) tropism HIV-1-infections or to mutations in the V3 region of glycoprotein (gp) 120; however, the exact mechanisms by which resistance is acquired and their genotypic and phenotypic pattern have not yet been established. It is recommended that a tropism test should be performed when considering maraviroc as an alternate drug in HIV-1-infected patients. Current tropism assays have increased sensitivity to reliably detect CXCR4 HIV with rapid turn-around and at a low cost. Improved detection together with positive data on the drug's efficacy and safety profiles should help physicians to identify more accurately the appropriate candidates for commencement of treatment with maraviroc. In summary, maraviroc improves immunological response and has shown favourable pharmacokinetic and safety profiles in patients with high cardiovascular risk or in those co-infected with tuberculosis or hepatitis. Long-term studies are needed to confirm whether therapeutic expectations resulting from clinical trials with maraviroc translate into a real benefit for HIV-1-infected patients for whom traditional antiretroviral therapies have failed or are not suitable.

Response to HAART in treatment-naive HIV-infected patients with a prior diagnosis of tuberculosis or other opportunistic infections

We aimed to evaluate immunological, virological and clinical response to HAART, as well as all-cause mortality, in treatment-naive patients with a diagnosis of tuberculosis (TB) in the prior 6 months, compared to subjects with another AIDS-defining illness (ADI) or event-free individuals in an open, prospective and multicenter hospital-based cohort of HIV-infected naive adults (2004-2008). All cause mortality rates were calculated by Cox regression models. Among 4407 patients, 2400 (54.5%) started HAART: 110 (4.6%) had had previous TB and 414 (17.3%) another ADI. Median time from TB diagnosis to inititation of HAART was 53 days (IQR: 25.75-83.25), and for other ADI was 22 days (IQR: 8-42). Overall, 151 (6.3%) patients developed a new ADI during follow-up; 63% reached virological suppression and 69.4% had increases of ≥50 CD4+/µl, at 6 months. No statistically significant differences were found according to a previous history of TB or another ADI. Overall, 85 subjects died in 4031 person-years of follow-up with a mortality rate of 2.1 (95%CI: 1.7-2.6). When compared to subjects who started HAART in the absence of a previous ADI (HR 1), a prior diagnosis of an ADI other than TB was significantly associated with an increased risk of death. (HR 1.6; 95%CI: 1.1-2.3), but not a diagnosis of TB (HR 1.15; 95%CI: 0.5-2.5). In conclusion, a previous diagnosis of TB or another ADI before HAART did not compromise short-term virological and immunological response to treatment. A prior diagnosis of an ADI different to TB significantly increased all cause mortality.