Clinical manifestations and survival trends during the first 12 years of the AIDS epidemic in Mexico

A retrospective cohort study on the mortality of AIDS patients in Guangxi, China (2001-2011)

The purpose of this article is to describe mortality trends in different highly active antiretroviral therapy (HAART) periods and associated factors among AIDS patients in Guangxi, China. We prospectively analyzed AIDS patients in Guangxi between 2001 and 2011; demographic characteristics were compared among AIDS patients diagnosed in three treatment periods (pre-HAART: 2001-2004, early-HAART: 2005-2008, and late-HAART: 2009-2011). AIDS mortality was calculated by person-years, and treatment coverage was defined as the proportion of time that patients who were eligible for treatment received treatment. Factors of AIDS mortality were determined by a Cox proportional hazard regression. Of 19,020 AIDS patients, overall mortality declined from 41.1 per 100 person-years in 2001 to 13.3 per 100 person-years in 2011 with treatment coverage increasing from zero to 72.1%. The overall median survival figure was 5.6 years (95% CI: 4.4-6.8) with 60.3% for 5-year survival rate. After AIDS diagnosis, the mortality rate peaked in the first year, and 37.4% patients were still active in the ninth year. Protective factors for mortality were AIDS patients diagnosed from 2009 to 2011 (AHR=0.75, 95% CI: 0.58-0.89), having received HAART (AHR=0.71, 95% CI: 0.50-0.87), and having a CD4 count of higher than 350 cells/μl at AIDS diagnosis (AHR=0.79, 95% CI: 0.60-0.92). Risk factors for mortality included being male (AHR=1.28, 95% CI: 1.07-1.43), living in a rural area (AHR=1.40, 95% CI: 1.18-1.94), and being aged ≥60 years at AIDS diagnosis (AHR=1.36, 95% CI: 1.18-1.73). A decline in AIDS mortality was observed in Guangxi with a concomitant increase in treatment coverage. Some subpopulations of AIDS patients, such as males, rural residents, and the old, require more medical care.

Determinants of progression to AIDS and death following HIV diagnosis: a retrospective cohort study in Wuhan, China

OBJECTIVE

To identify determinants associated with disease progression and death following human immunodeficiency virus (HIV) diagnosis.

METHODS

Disease progression data from the diagnosis of HIV infection or acquiring immunodeficiency syndrome (AIDS) to February 29, 2012 were retrospectively collected from the national surveillance system databases and the national treatment database in Wuhan, China. Kaplan-Meier method, Logistic regression and Cox proportional hazards model were applied to identify the related factors of progression to AIDS or death following HIV diagnosis.

RESULTS

By the end of February 2012, 181 of 691 HIV infectors developed to AIDS, and 129 of 470 AIDS patients died among whom 289 cases received concurrent HIV/AIDS diagnosis. Compared with men infected through homosexual behavior, injection drug users possessed sharply decreased hazard ratio (HR) for progression to AIDS following HIV diagnosis [HR = 0.31, 95% confidence interval (CI), 0.18-0.54, P = 4.01×10(-5)]. HIV infectors at least 60 years presented 1.15-fold (HR = 2.15, 95% CI, 1.15-4.03, P = 0.017) increased risk to develop AIDS when compared with those aged 17-29 years. Similarly, AIDS patients with diagnosis ages between 50 and 59 years were at a 1.60-fold higher risk of death (HR = 2.60, 95% CI, 1.18-5.72, P = 0.017) compared to those aged 19-29 years. AIDS patients with more CD4(+) T-cells within 6 months at diagnosis (cell/µL) presented lower risk of death (HR = 0.29 for 50- vs <50, 95% CI, 0.15-0.59, P = 0.001). The highly active antiretroviral therapy (HAART) delayed progression to AIDS from HIV diagnosis (HR = 0.15, 95% CI, 0.07-0.34, P = 6.46×10(-6)) and reduced the risk of death after AIDS diagnosis (HR = 0.02, 95% CI, 0.01-0.04, P = 7.25×10(-25)).

CONCLUSIONS

Progression to AIDS and death following HIV diagnosis differed in age at diagnosis, transmission categories, CD4(+) T-cell counts and HAART. Effective interventions should target those at higher risk for morbidity or mortality, ensuring early diagnosis and timely treatment to slow down the disease progression.

[Clinical manifestations of HIV infection in distinct geographical areas]

The clinical manifestations of HIV infection vary widely in distinct geographical areas. While HIV-related disease has been well characterized in western countries, relatively few publications have described the clinical manifestations of these diseases in tropical areas, where the vast majority of HIV-infected people are concentrated. In addition, HIV infection may alter the natural history of tropical diseases in several ways and tropical diseases influence the course of HIV infection. The present review describes the major opportunistic infections afflicting people with HIV/AIDS in Africa, Latin America, and Asia and discusses the mutual interactions between HIV and the major tropical diseases.

Retinal and extraocular cytomegalovirus end-organ disease in HIV-infected patients in Europe: a EuroSIDA study, 1994-2001

This multicentre prospective cohort study by the EuroSIDA study group was designed to determine the factors affecting the incidence of cytomegalovirus (CMV) end-organ disease (CMVD) and the rate of survival after diagnosis in patients with AIDS during the years 1994-2001. This period includes two eras, the pre-HAART era and the HAART era, because HAART affects the natural history of HIV infection, especially with respect to opportunistic infections, including CMV infection. Clinical and laboratory data were collected from the charts of 8,556 patients in 63 AIDS clinics in Europe. A total of 707 patients had CMVD at recruitment and at follow-up: 449 with retinitis (CMVR), 190 with extraocular CMV disease (EOCMVD), and 58 with both. Of the cases of EOCMVD, 66% involved the gastrointestinal tract and 17% the central nervous system. Of patients with a CD4+ count of < or =200 mm(-3) initially, 1.8% on HAART developed CMVD within a 24-month period, as compared to 11.1% on dual therapy and 14.3% without treatment (P<0.0001). There were highly significant differences in survival according to the calendar year (P<0.0001), with mortality declining from 79% during the years 1994-1995 to 42% in 2000-2001. The incidence of death after any CMVD was 28.4 per 100 patient-years of follow-up. Median survival of CMVR patients and EOCMVD patients was 11 and 7 months, respectively, the prognosis being better among patients with gastrointestinal rather than neurological CMVD. The initiation of HAART was associated with a 37% decrease in mortality (P<0.05). Eighteen percent of all deaths were caused by EOCMVD itself. This study describes a decline in the incidence and mortality of CMVR and EOCMVD during the HAART era of the HIV epidemic. It furthermore serves as a reminder of the importance of EOCMVD as a cause of morbidity and mortality in AIDS in the pre-HAART era.

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.

The Changing Clinical Spectrum of Human Immunodeficiency Virus (HIV)-Related Oral Lesions in 1,000 Consecutive Patients: A 12-Year Study in a Referral Center in Mexico

In developing countries, the variations in the clinical spectrum of human immunodeficiency virus (HIV)-related oral lesions over time, and the possible effects of antiretroviral therapy, have not been described. In this study we evaluate the clinical spectrum of oral lesions in a series of HIV-infected patients when first examined at the acquired immunodeficiency syndrome (AIDS) clinic of a tertiary care institution in Mexico City, Mexico, and the changes observed over 12 years. All HIV-infected adult patients had an oral examination performed by specialists in oral pathology and medicine who used established clinical diagnostic criteria for oral lesions. Four periods were defined according to the evolving pattern of antiretroviral use: the first 2 were before the introduction of highly active antiretroviral therapy (HAART) and the last 2 were during more established use of HAART. For the statistical analysis the chi-square test for contingency tables and the chi-square test for trend were utilized. For dimensional variables, except age, the Kruskal-Wallis or Mann-Whitney rank sum tests were used when applicable and trend was tested with the Spearman correlation coefficient. Age was tested through analysis of variance (ANOVA) and linear regression analysis. Alpha value was set at p = 0.05 for each test. In the 12-year study, 1,000 HIV-infected patients were included (87.9% male). At the baseline examination, oral lesions strongly associated with HIV were present in 47.1% of HIV-infected patients. Oral candidosis (31.6%), hairy leukoplakia (22.6%), erythematous candidosis (21.0%), and pseudomembranous candidosis (15.8%) were the most frequent lesions. Oral Kaposi sarcoma (2.3%), HIV-associated periodontal disease (1.7%), and oral non-Hodgkin lymphoma (0.1%) were less frequent. HIV-related oral lesions decreased systematically-by half during the course of the 4 study periods (p < 0.001). Except for Kaposi sarcoma, all oral lesions strongly associated with HIV showed a trend to decrease significantly during the study period. No apparent variation in the occurrence of salivary gland disease or human papillomavirus-associated oral lesions was found. A significant trend to a lower prevalence was observed in the group of patients who were already taking antiretroviral therapy, non-HAART and HAART (p < 0.001 and p = 0.004, respectively). Only a discrete reduction, barely significant, was noted among untreated patients (p = 0.060). By Period IV (1999-2001), those who received HAART showed the lowest prevalence of oral lesions strongly associated with HIV (p < 0.001). Patients with oral lesions strongly associated with HIV had significantly lower median CD4+ counts and higher viral loads than those without oral lesions strongly associated with HIV (p < 0.001 and p = 0.005, respectively). When CD4+ counts were correlated with prevalence of oral candidosis, a consistently negative association was found; this association prevailed even after the study group was partitioned according to period. In this selected cohort of 1,000 patients with HIV infection, the clinical spectrum of HIV-related oral lesions has changed over the 12-year study, with a decreased prevalence of most oral lesions. Our findings probably represent improvements in medical care of HIV-infected persons, earlier detection of HIV-infected patients at the AIDS clinic, the increasing use of prophylactic drugs to prevent secondary AIDS-related opportunistic infections, and, perhaps most important, the availability of potent antiretroviral therapy in recent years, since the introduction of HAART.