History of viral suppression on combination antiretroviral therapy as a predictor of virological failure after a treatment change

OBJECTIVES

HIV-infected persons experience different patterns of viral suppression after initiating combination antiretroviral therapy (cART). The relationship between such differences and risk of virological failure after starting a new antiretroviral could help with patient monitoring strategies.

METHODS

A total of 1827 patients on cART starting at least one new antiretroviral from 1 January 2000 while maintaining a suppressed viral load were included in the analysis. Poisson regression analysis identified factors predictive of virological failure after baseline in addition to traditional demographic variables. Baseline was defined as the date of starting new antiretrovirals.

RESULTS

Four hundred and fifty-one patients (24.7%) experienced virological failure, with an incidence rate (IR) of 7.3 per 100 person-years of follow-up (PYFU) [95% confidence interval (CI) 6.7-8.0]. After adjustment, patients who had rebounded in the year prior to baseline had a 2.4-times higher rate of virological failure after baseline (95% CI 1.77-3.26; P<.0001), while there was no increased incidence in patients whose last viral rebound was >3 years prior to baseline [Incidence rate ratio (IRR) 1.06; 95% CI 0.75-1.50; P=0.73] compared with patients who had never virally rebounded. Patients had an 86% (95% CI 1.36-2.55; P<.0001), 53% (95% CI 1.06-2.04; P=0.02) and 5% (95% CI 0.80-1.38; P=0.72) higher virological failure rate after baseline if they were virally suppressed <50%, 50-70% and 70-90% of the time they were on cART prior to baseline, respectively, compared with those virally suppressed >90% of the time.

DISCUSSION

Intensive monitoring after a treatment switch is required in patients who have rebounded recently or have a low percentage of time suppressed while on cART. Consideration should be given to increasing the provision of adherence counselling.

Bridging the gap between adult and paediatric outcomes in HIV-1 vertically infected children: a single-centre comparison with adult data

Prognosis of HIV-1 infection dramatically improved during the last decade. Meanwhile, treatment-induced virological success has always been different in adult and children patients.

AIM

To compare 10 years of follow up in HIV-1 vertically infected children and adult patients.

METHODS

Monocentric retrospective longitudinal analysis of vertically HIV-1-infected children and adult patients followed in the Nice University Hospital between 1999 and 2008. Immunological, virological and antiretroviral treatment data were recorded.

RESULTS

Forty children and 1752 adult patients were included. Between 1996 and 2008, the percentage of children receiving HAART increased from 3.2% to 91%. Mean CD4% in the paediatric group remained stable between 29 +/- 8.1% in 1998 and 30 +/- 9.4% in 2008. Mean adult CD4-cell count significantly increased from 410 in 1998 to 556 cells/mL in 2008. Logistic regression analysis showed that the children-to-adult difference for indetectability (HIV PCR-RNA below 400 copies/mL) was significant (p < 0.0001) with an odds ratio of 0.61 (CI(95th): 0.52-0.72). Year-to-patient interaction was also significant with a decreasing divergence over time (p: 0.038).

CONCLUSION

Nowadays as in adult patients, the control of HIV-1 replication is achieved in nearly eight of 10 children and the percentage of patients with severe immunodeficiency dramatically decreased compared with the mid 1990s.

Presence of the metabolic syndrome is not a better predictor of cardiovascular disease than the sum of its components in HIV-infected individuals: data collection on adverse events of anti-HIV drugs (D:A:D) study

OBJECTIVE

It is much debated whether the metabolic syndrome contributes additional information over and above that provided by the individual components of the syndrome alone. Among HIV-infected individuals, we investigated whether any particular combinations of the components included in the definition of the metabolic syndrome are associated with a higher risk of cardiovascular disease (CVD).

RESEARCH DESIGN AND METHODS

We followed 33,347 HIV-infected individuals in a prospective observational study. The effect of combinations of components of the metabolic syndrome (low HDL cholesterol, high triglycerides, high BMI, hypertension, and diabetes) on the risk of CVD was assessed by Poisson regression incorporating interactions between each component pair and adjusting for age, sex, family history of CVD, smoking status, calendar year, and exposure to antiretroviral therapy. We reduced the risk of type 1 errors by randomly splitting the data set for training (70% of sample) and validation (remaining 30%).

RESULTS

In the training data set, 671 patients experienced a CVD event over 110,652 person-years. Unadjusted, the presence of metabolic syndrome at study enrollment (>or=3 of the factors) was associated with a 2.89 higher risk of CVD (95% CI 2.34-3.59; P = 0.0001) compared with individuals without the metabolic syndrome. After adjustment for the individual components, the metabolic syndrome as an entity no longer predicted the risk of CVD (adjusted relative risk 0.85; 95% CI 0.61-1.17; P = 0.32). No significant positive interactions were found among the components of the metabolic syndrome.

CONCLUSIONS

The presence of the metabolic syndrome in HIV-infected individuals did not appear to increase the CVD risk over and above that conferred by the components of the syndrome separately.

HIV-induced immunodeficiency and mortality from AIDS-defining and non-AIDS-defining malignancies

OBJECTIVE

To evaluate deaths from AIDS-defining malignancies (ADM) and non-AIDS-defining malignancies (nADM) in the D:A:D Study and to investigate the relationship between these deaths and immunodeficiency.

DESIGN

Observational cohort study.

METHODS

Patients (23 437) were followed prospectively for 104 921 person-years. We used Poisson regression models to identify factors independently associated with deaths from ADM and nADM. Analyses of factors associated with mortality due to nADM were repeated after excluding nADM known to be associated with a specific risk factor.

RESULTS

Three hundred five patients died due to a malignancy, 298 prior to the cutoff for this analysis (ADM: n = 110; nADM: n = 188). The mortality rate due to ADM decreased from 20.1/1000 person-years of follow-up [95% confidence interval (CI) 14.4, 25.9] when the most recent CD4 cell count was <50 cells/microl to 0.1 (0.03, 0.3)/1000 person-years of follow-up when the CD4 cell count was more than 500 cells/microl; the mortality rate from nADM decreased from 6.0 (95% CI 3.3, 10.1) to 0.6 (0.4, 0.8) per 1000 person-years of follow-up between these two CD4 cell count strata. In multivariable regression analyses, a two-fold higher latest CD4 cell count was associated with a halving of the risk of ADM mortality. Other predictors of an increased risk of ADM mortality were homosexual risk group, older age, a previous (non-malignancy) AIDS diagnosis and earlier calendar years. Predictors of an increased risk of nADM mortality included lower CD4 cell count, older age, current/ex-smoking status, longer cumulative exposure to combination antiretroviral therapy, active hepatitis B infection and earlier calendar year.

CONCLUSION

The severity of immunosuppression is predictive of death from both ADM and nADM in HIV-infected populations.

Changes over time in risk factors for cardiovascular disease and use of lipid-lowering drugs in HIV-infected individuals and impact on myocardial infarction

BACKGROUND

Because of the known relationship between exposure to combination antiretroviral therapy and cardiovascular disease (CVD), it has become increasingly important to intervene against risk of CVD in human immunodeficiency virus (HIV)-infected patients. We evaluated changes in risk factors for CVD and the use of lipid-lowering therapy in HIV-infected individuals and assessed the impact of any changes on the incidence of myocardial infarction.

METHODS

The Data Collection on Adverse Events of Anti-HIV Drugs Study is a collaboration of 11 cohorts of HIV-infected patients that included follow-up for 33,389 HIV-infected patients from December 1999 through February 2006.

RESULTS

The proportion of patients at high risk of CVD increased from 35.3% during 1999-2000 to 41.3% during 2005-2006. Of 28,985 patients, 2801 (9.7%) initiated lipid-lowering therapy; initiation of lipid-lowering therapy was more common for those with abnormal lipid values and those with traditional risk factors for CVD (male sex, older age, higher body mass index [calculated as the weight in kilograms divided by the square of the height in meters], family and personal history of CVD, and diabetes mellitus). After controlling for these, use of lipid-lowering drugs became relatively less common over time. The incidence of myocardial infarction (0.32 cases per 100 person-years [PY]; 95% confidence interval [CI], 0.29-0.35 cases per 100 PY) appeared to remain stable. However, after controlling for changes in risk factors for CVD, the rate decreased over time (relative rate in 2003 [compared with 1999-2000], 0.73 cases per 100 PY [95% CI, 0.50-1.05 cases per 100 PY]; in 2004, 0.64 cases per 100 PY [95% CI, 0.44-0.94 cases per 100 PY]; in 2005-2006, 0.36 cases per 100 PY [95% CI, 0.24-0.56 cases per 100 PY]). Further adjustment for lipid levels attenuated the relative rates towards unity (relative rate in 2003 [compared with 1999-2000], 1.06 cases per 100 PY [95% CI, 0.63-1.77 cases per 100 PY]; in 2004, 1.02 cases per 100 PY [95% CI, 0.61-1.71 cases per 100 PY]; in 2005-2006, 0.63 cases per 100 PY [95% CI, 0.36-1.09 cases per 100 PY]).

CONCLUSIONS

Although the CVD risk profile among patients in the Data Collection on Adverse Events of Anti-HIV Drugs Study has decreased since 1999, rates have remained relatively stable, possibly as a result of a more aggressive approach towards managing the risk of CVD.

Incidence of inflammatory bowel disease in Corsica from 2002 to 2003

OBJECTIVES

The aim of this prospective epidemiological study was to determine the incidence of inflammatory bowel diseases (IBD) in Corsica using the same methodology as that of the EPIMAD registry.

METHODS

Between January 1st, 2002 and December 31, 2003, all gastroenterologists in Corsica (N=19) enrolled patients consulting for the first time with clinical symptoms compatible with IBD. Each case was reviewed by another expert gastroenterologist to assign a diagnosis of definite, probable, possible Crohn's disease (CD), ulcerative colitis (UC) or unclassified/able chronic colitis.

RESULT

Eighty-one new cases were recorded, including seventy-one diagnoses of IBD (definite and probable cases), with 20 (28%) CD, 49 (69%) UC and 2 (3%) unclassifiable chronic colitis. The age-adjusted incidence (per 105 inhabitants/year) was 4.05 for CD and 9.5 for UC. The female/male ratio and median age at time of diagnosis were 1.3 and 29 years for CD and 0.63 and 44 years for UC, respectively. The median time from symptom onset to diagnosis was five months for both diseases.

CONCLUSION

In Corsica, the observed incidence of CD is close to that observed in other metropolitan French regions. These data are contrary to the north-south gradient reported for this disease. Our figure of 9.5/10(5) for UC in Corsica is two-fold higher than reported in other metropolitan French regions. Genetic and/or environmental factors may explain these findings.

Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: a multi-cohort collaboration

BACKGROUND

Whether nucleoside reverse transcriptase inhibitors increase the risk of myocardial infarction in HIV-infected individuals is unclear. Our aim was to explore whether exposure to such drugs was associated with an excess risk of myocardial infarction in a large, prospective observational cohort of HIV-infected patients.

METHODS

We used Poisson regression models to quantify the relation between cumulative, recent (currently or within the preceding 6 months), and past use of zidovudine, didanosine, stavudine, lamivudine, and abacavir and development of myocardial infarction in 33 347 patients enrolled in the D:A:D study. We adjusted for cardiovascular risk factors that are unlikely to be affected by antiretroviral therapy, cohort, calendar year, and use of other antiretrovirals.

FINDINGS

Over 157,912 person-years, 517 patients had a myocardial infarction. We found no associations between the rate of myocardial infarction and cumulative or recent use of zidovudine, stavudine, or lamivudine. By contrast, recent-but not cumulative-use of abacavir or didanosine was associated with an increased rate of myocardial infarction (compared with those with no recent use of the drugs, relative rate 1.90, 95% CI 1.47-2.45 [p=0.0001] with abacavir and 1.49, 1.14-1.95 [p=0.003] with didanosine); rates were not significantly increased in those who stopped these drugs more than 6 months previously compared with those who had never received these drugs. After adjustment for predicted 10-year risk of coronary heart disease, recent use of both didanosine and abacavir remained associated with increased rates of myocardial infarction (1.49, 1.14-1.95 [p=0.004] with didanosine; 1.89, 1.47-2.45 [p=0.0001] with abacavir).

INTERPRETATION

There exists an increased risk of myocardial infarction in patients exposed to abacavir and didanosine within the preceding 6 months. The excess risk does not seem to be explained by underlying established cardiovascular risk factors and was not present beyond 6 months after drug cessation.

Risk of cancer following immunosuppression in organ transplant recipients and in HIV-positive individuals in southern Europe

This investigation highlighted the risk of cancer in 8074 HIV-infected people and in 2875 transplant recipients in Italy and France. Observed and expected numbers of cancer were compared through sex- and age-standardised incidence ratios (SIRs) and 95% confidence intervals (CIs). After 15 years of follow-up, the cumulative probability of cancer was 14.7% in transplant recipients and 13.3% in HIV-positives. The SIRs for all cancers were 9.8 in HIV-positives and 2.2 in transplants. Kaposi's sarcoma (SIR=451 in HIV-positives, 125 in transplants) and non-Hodgkin lymphoma (SIR=62 and 11.1, respectively) were the most common cancers. A significantly increased SIR for liver cancer also emerged in both groups. The risk of lung cancer was significantly elevated in heart transplant recipients (SIR=2.8), and of borderline statistical significance in HIV-positive people (95% CI:0.9-2.8). Immune depression entails a two-fold increased overall risk of cancers, mainly related to cancers associated with a viral aetiology.

HCV/HIV co-infection, HCV viral load and mode of delivery: risk factors for mother-to-child transmission of hepatitis C virus?

BACKGROUND

Hepatitis C virus (HCV) infection in children is mainly acquired via maternal transmission. Our aim was to identify mother-to-child-transmission (MTC) risk factors, namely those associated with maternal virological characteristics and mode of delivery.

METHODS

Women were included between October 1998 and September 2002 in six hospitals in Southern France on the basis of positive HCV serological status. Recorded data included maternal characteristics, circumstances of delivery and laboratory data concerning mother and child. Paediatric follow-up lasted 1 year, and 2 years for children with circulating HCV RNA.

RESULTS

A total of 214 mother-and-child pairs were analysed; 55 (26%) were HCV/HIV co-infected. The probability of HCV transmission was three-fold higher for HCV/HIV-co-infected women (P = 0.05). Twelve children were HCV RNA positive at 1 year of age (MTC = 5.6%); three became HCV RNA negative between 12 (M12) and 18 months of age (M18) and recovered normal alanine aminotransferase levels. Circulating HCV RNA was found in 137 (69%) mothers. Mothers of infected children all displayed HCV viraemia (MTC = 8.8%): six children were born of HCV/HIV-co-infected HCV RNA positive women (MTC = 13.6%) and six from HCV monoinfected women with positive HCV RNA (MTC = 6.5%). When maternal HCV RNA levels were below 6 log-IU/ml, the rate of transmission was significantly higher in the case of HCV/HIV co-infection (odds ratio = 8.3, 95% confidence interval, 1.4-47.5) P = 0.01. This association did not, however, exist for HCV RNA-positive mothers with levels of at least 6 log-IU/ml. Rate of transmission did not differ significantly between children born by vaginal delivery or caesarean section after membrane rupture and those born by elective caesarean section independently of HIV status.

First-line Highly Active Antiretroviral Regimens in 2001–2002 in the French Hospital Database on HIV: Combination Prescribed and Biological Outcomes

Introduction

We compared biological outcomes in anti-retroviral-naive patients with viral load (VL) >5,000 copies/ml starting combivir-based, three-drug highly active antiretroviral therapy regimens in 2001–2002 according to the third component, namely abacavir (ABC), nelfinavir (NFV), indinavir/ritonavir (IDV/r), lopinavir/ritonavir (LPV/r), nevirapine (NVP) or efavirenz (EFV).

Methods

We evaluated virological response (HIV RNA <500 copies/ml) and immunological response (increase of ≥50 CD4+ T-cells/u, l) separately in patients with baseline VL <100,000 copies/ml ( n=992) and ≥100,000 copies/ml ( n=1,048). Hazard ratios (HR) were calculated with Cox models stratified for quintiles of propensity scores, estimated by multinomial regression from baseline characteristics.

Results

Median follow up was 19 months. EFV had better virological efficacy than NFV and IDV/r among patients with baseline VL <100,000 copies/ml, with respective HRs of 0.71 and 0.72, compared with 0.81 for NVP, 0.89 for ABC and 0.99 for LPV/r. The immunological efficacy of EFV was lower than that of LPV/r (1.37) and similar to that of NFV (0.96), IDV/r (0.81), NVP (1.08) and ABC (1.04). Among patients with baseline VL ≥100,000 copies/ml, the virological efficacy of EFV was similar to that of NVP (0.90) and LPV/r (0.97) and better than that of NFV (0.62), ABC (0.75) and IDV/r (0.78). The immunological results found in these patients were similar to those observed in patients with baseline VL <100,000 copies/ml.

Conclusions

For first-line therapy, in this observational setting, EFV, LPV/r and NVP, when added to the combivir backbone, were more likely to drive viral load <500 copies/ml. LPV/r showed the best immunological effectiveness.

Impact d'une équipe d'urgence spécialisée sur les hospitalisations non désirées de patients en phase terminale à domicile

OBJECTIVES

This study was undertaken to evaluate the impact of paramedical hospice specialists on hospitalization of terminally-ill patients in acute medical emergencies.

METHOD

In this intervention, the SAMU (French medical emergency call center) responded to requests for emergency aid at the homes of terminally-ill patients by sending to the patient's home, together with a physician and the emergency ambulance team, a team composed of a nurse and a volunteer, both trained in hospice (terminal) care . When the patient wished to stay at home, the hospice team remained to support the patient and family and to provide comfort care until the crisis situation stabilized. This before-and-after study compares SAMU calls during the first year of the intervention to those in the preceding year.

RESULTS

During the intervention period, 14% of patients were hospitalized compared with 48% during the reference year (p<0.0001), for a relative risk of hospitalization of 0.29. The emergency hospice team was considered to be not only complementary but also essential in emergency medical situations for patients receiving palliative care at home. Interaction with existing services did not present problems. Families benefited from considerable assistance in particularly difficult situations.

CONCLUSION

A team of paramedical hospice specialists, acting on request of the SAMU, provides a concrete and useful response to problems of unwanted hospitalization in acute emergencies for home-based terminally ill patients. This type of organization is consistent with respect for the patient's choice to remain at home until the end of life. Prevention of unwanted hospitalization and heroic measures should undoubtedly result in cost savings more than sufficient to fund this program.

Liver-related mortality in human-immunodeficiency-virus-infected patients between 1995 and 2003 in the French GERMIVIC Joint Study Group Network (MORTAVIC 2003 Study)

The objective of the present study was to determine mortality because of end-stage liver disease (ESLD) in a nationwide population of HIV-infected patients, 7 years following the introduction of highly active antiretroviral therapy (HAART). All departments of internal medicine and infectious diseases from the GERMIVIC Study Group prospectively recorded all deaths in HIV-infected patients during 2003. Fifty-nine departments, following a total of 20 940 HIV-infected patients, participated in the study. Results were compared with those of previous surveys conducted using similar methodology in 1995, 1997 and 2001. Among 215 deaths observed during 2003, 101 (46.9%) were related to AIDS, 27 (12.6%) to ESLD and 87 (40.5%) to other causes. Mortality because of ESLD represented 23.7% of non-AIDS-related deaths. Patients dying from ESLD had chronic hepatitis because of hepatitis C virus (HCV) in 92.6% of cases and moderate (30-60 g) or high (>60 g) alcohol consumption (43.5% and 26.0%, respectively). In this population, deaths because of ESLD were 1.5% in 1995, 6.6% in 1997, 14.3% in 2001 and 12.6% in 2003. The prevalence of hepatocellular carcinoma as a cause of death remained high in 2003 but stable when compared with 2001 (25%vs 14.8%). Treatment of hepatitis C in patients who died from ESLD was more frequent in 2003 (44.4%) than in 2001 (26.3%). Seven years after the introduction of HAART, ESLD associated with HCV infections is a leading cause of mortality in HIV-infected patients, which did not increase between the years 2001 and 2003.

First-line highly active antiretroviral regimens in 2001-2002 in the French Hospital Database on HIV: combination prescribed and biological outcomes

INTRODUCTION

We compared biological outcomes in antiretroviral-naive patients with viral load (VL) > 5,000 copies/ml starting combivir-based, three-drug highly active antiretroviral therapy regimens in 2001-2002 according to the third component, namely abacavir (ABC), nelfinavir (NFV), indinavir/ritonavir (IDV/r), lopinavir/ritonavir (LPV/r), nevirapine (NVP) or efavirenz (EFV).

METHODS

We evaluated virological response (HIV RNA < 500 copies/ml) and immunological response (increase of > or = 50 CD4+ T-cells/microl) separately in patients with baseline VL < 100,000 copies/ml (n = 992) and a100,000 copies/ml (n = 1,048). Hazard ratios (HR) were calculated with Cox models stratified for quintiles of propensity scores, estimated by multinomial regression from baseline characteristics.

RESULTS

Median follow up was 19 months. EFV had better virological efficacy than NFV and IDV/r among patients with baseline VL < 100,000 copies/ml, with respective HRs of 0.71 and 0.72, compared with 0.81 for NVP, 0.89 for ABC and 0.99 for LPV/r. The immunological efficacy of EFV was lower than that of LPV/r (1.37) and similar to that of NFV (0.96), IDV/r (0.81), NVP (1.08) and ABC (1.04). Among patients with baseline VL > or = 100,000 copies/ml, the virological efficacy of EFV was similar to that of NVP (0.90) and LPV/r (0.97) and better than that of NFV (0.62), ABC (0.75) and IDV/r (0.78). The immunological results found in these patients were similar to those observed in patients with baseline VL < 100,000 copies/ml.

CONCLUSIONS

For first-line therapy, in this observational setting, EFV, LPV/r and NVP, when added to the combivir backbone, were more likely to drive viral load < 500 copies/ml. LPV/r showed the best immunological effectiveness.

Immunosuppression and Cancer: A Comparison of Risks in Recipients of Organ Transplants and in HIV-Positive Individuals

The comparison of cancers occurring excessively among HIV-infected and transplanted individuals may help to elucidate the relationship between immune surveillance, viral infections, and cancer. A longitudinal study was conducted on 2002 HIV-infected Italian subjects, 6072 HIV-infected French individuals, and 2878 Italian recipients of solid organ transplants. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed to quantify the risk for cancer, compared with the French and Italian general populations. The SIRs for all cancers were 9.8 (95% CI: 9.0-10.6) for HIV-infected individuals versus 2.2 (95% CI: 1.9-2.5) for transplant recipients. In both groups, most of the excess risk was attributable to virus-related cancers, such as Kaposi's sarcoma (KS; SIR = 451 in HIV-positive individuals, 125 in transplant recipients), non-Hodgkin's lymphoma (NHL; SIR = 62.1 and 11.1, respectively), and liver cancer (SIR = 9.4 and 4.1, respectively). Significantly increased SIRs for anal cancer and Hodgkin's lymphoma were found only among HIV-positive individuals. Among women younger than 40 years of age, a more than 10-fold increase in cervical cancer risk was found in both groups. Among HIV-infected individuals treatment with highly active antiretroviral therapies drastically reduced SIRs for KS and NHL only. These results show that HIV-infected individuals and transplant recipients share a similar pattern of cancer risk, largely due to virus-related cancers.

Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study

BACKGROUND

An increasing proportion of deaths among human immunodeficiency virus (HIV)-infected persons with access to combination antiretroviral therapy (cART) are due to complications of liver diseases.

METHODS

We investigated the frequency of and risk factors associated with liver-related deaths in the Data Collection on Adverse Events of Anti-HIV Drugs study, which prospectively evaluated 76 893 person-years of follow-up in 23 441 HIV-infected persons. Multivariable Poisson regression analyses identified factors associated with liver-related, AIDS-related, and other causes of death.

RESULTS

There were 1246 deaths (5.3%; 1.6 per 100 person-years); 14.5% were from liver-related causes. Of these, 16.9% had active hepatitis B virus (HBV), 66.1% had hepatitis C virus (HCV), and 7.1% had dual viral hepatitis co-infections. Predictors of liver-related deaths were latest CD4 cell count (adjusted relative rate [RR], 16.1; 95% confidence interval [CI], 8.1-31.7 for <50 vs > or =500/microL), age (RR, 1.3; 95% CI, 1.2-1.4 per 5 years older), intravenous drug use (RR, 2.0; 95% CI, 1.2-3.4), HCV infection (RR, 6.7; 95% CI, 4.0-11.2), and active HBV infection (RR, 3.7; 95% CI, 2.4-5.9). Univariable analyses showed no relationship between cumulative years patients were receiving cART and liver-related death (RR, 1.00; 95% CI, 0.93-1.07). Adjustment for the most recent CD4 cell count and patient characteristics resulted in an increased risk of liver-related mortality per year of mono or dual antiretroviral therapy before cART (RR, 1.09; 95% CI, 1.02-1.16; P = .008) and per year of cART (RR, 1.11; 95% CI, 1.02-1.21; P = .02).

CONCLUSIONS

Liver-related death was the most frequent cause of non-AIDS-related death. We found a strong association between immunodeficiency and risk of liver-related death. Longer follow-up is required to investigate whether clinically significant treatment-associated liver-related mortality will develop.

Cancer risk of aged people with HIV infection and of transplant people

20063

Background: Acquired immunesuppression due to HIV-infection or to anti-rejection therapies following organ transplantation is a well known risk factor for cancer. This increased risk has been well documented for young adults, whereas few data are available on older persons. In this study, we assessed the impact of cancer in HIV-positive persons (HIV+) and in transplant persons (TRP) who were 50 years of age or older. Methods: Data from a multi-cohort study conducted in Italy and France were analysed. Individuals ≥50 years of age were selected from the original study group constituted by 2002 HIV+ seroconverters from Italy, 6072 HIV+ from France and 2755 Italian TRP (1844 kidney, 702 heart, 159 liver and 50 lung TRP). Sex- and age-standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed to quantify the cancer risk as compared to the general population. Among HIV+, the risk of cancer was also assessed according to treatment with highly active antiretroviral therapies (HAART). Results: This analysis was based on 94 cancers diagnosed in 833 HIV+, and on 154 cancers diagnosed in 1558 TRP ≥50 years of age. The SIRs for all cancers decreased with ageing, ranging from 5.1 (95% CI: 4.0–6.5) in HIV+ aged 50–59 to 2.1 (95% CI: 1.4–3.1) in HIV+ aged 60 or older. In TRP, the SIRs for all cancer were 2.5 (95% CI:2.0–3.1) and 1.6 (95% CI: 1.2–2.0), respectively. In HIV+, the protective effect of HAART was more evident in those aged 50–59 (SIR = 6.8 in never treated and SIR = 2.4 in ever treated) than in HIV+ aged ≥60 (SIR = 2.8 and SIR = 1.6, respectively). This pattern of cancer occurrence was peculiar to virus-related cancers (e.g., Kaposi’s sarcoma, non-Hodgkin’s lymphoma, liver cancer). SIRs for lung cancer in both groups were significantly increased but did not significantly differ according to HAART and/or age. The survival of both HIV+ and TRP was significantly reduced by the diagnosis of cancer, but the difference in survival was not associated with ageing (p = 0.20). Conclusions: Aged individuals with acquired immunesuppression have a cancer pattern similar to younger persons with immunosuppression, but the burden of cancer will increase in absolute terms because of the increasing proportion of older individuals among both HIV+ and TRP.

No significant financial relationships to disclose.

[An epidemic of unidentified illness experienced by a hospital's staff: a qualitative study]

An outbreak of non-specific complaints of illness and poor health occurred among 40% of the staff at the Archet 2 Hospital in Nice, France, between October 26 and November 26, 2000. This study utilises a psychosocial approach to describe how health-care workers experienced this unusually extensive phenomenon, and aims to contribute useful findings to the management of this type of emergency situation. A qualitative survey was conducted through face to face personal interviews with the first twelve staff members concerned; moreover, articles published in the press during that period were analysed in order to asses the impact of the media on this event. The study demonstrates that, although the source of the problem originated from an issue possibly related to questionable air quality, there were actually an array of factors which contributed to generate a mass psychogenic phenomenon: substantial collective societal complaints and staff members' perceived non-acknowledgement of the reality of their symptoms, lack of an obvious cause to account for those symptoms and collective representation regarding toxic gases, which were all claims promulgated by articles in the press. In addition to the need for technical improvements on the building and premises, the study underlines the relevance of simultaneously addressing related issues with the social structure, represented by the community of concerned hospital personnel, in order to facilitate a solution to the problem and avoid its potential recurrence in the future.

Visites confraternelles aux médecins libéraux généralistes et pédiatres des Alpes-Maritimes lors de la campagne “Antibios quand il faut”

OBJECTIVES

As part of a public health campaign promoting prudent antibiotic use to combat bacterial resistance in southeastern France, a multidisciplinary group organized peer-conducted educational outreach (academic detailing) visits to all the community-based general practitioners and pediatricians in the district. The visits, which took place in 2000 and were repeated in 2003, were intended to provide epidemiological data and professional guidelines to these doctors.

METHOD

A group of local experts created special academic detailing sheets based on French and international recommendations. Peers with similar experience received special training in the relevant scientific material and in communications skills and then visited the local physicians and discussed the detailing sheets.

RESULTS

The project contacted 95% of the target doctors (1079/1174 in 2000 and 1119/1135 in 2003), 94% (1024/1079 and 1042/1119, respectively) of whom agreed to be visited. The visitors reported positive feedback in over 80% of cases. Many of the visited doctors showed keen interest that led to ongoing dialogue, including participation in a regional influenza surveillance program. A sample of the visited doctors received a questionnaire to evaluate the method in 2001: 93% of the responders endorsed the method and 92% requested for more recommendations and guidelines.

DISCUSSION

Carefully prepared individual academic detailing visits conducted by peers succeeded in visiting nearly all the physicians in the district twice, two years apart, and provided them with useful support for implementing important guidelines in everyday practice. This method can be used to improve cooperation between healthcare providers and improve the quality of health care in France.