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Kraef C, Tusch E, Singh S, Østergaard L, Fätkenheuer G, Castagna A, Moreno S, Kusejko K, Szetela B, Kuznetsova A, Tomažič J, Ranin J, Zangerle R, Mansson F, Marchetti G, De Wit S, Clarke A, Gerstoft J, Podlekareva D, Peters L, Reekie J, Kirk O. All-cause and AIDS-related mortality among people with HIV across Europe from 2001 to 2020: impact of antiretroviral therapy, tuberculosis and regional differences in a multicentre cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2024; 44:100989. [PMID: 39036304 PMCID: PMC11259909 DOI: 10.1016/j.lanepe.2024.100989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 07/23/2024]
Abstract
Background All-cause and AIDS-mortality in Europe has been decreasing between 1996 and 2020. However, regional differences as well as their drivers remain unclear. This study investigates mortality differences and their drivers, including usage of and response to antiretroviral therapy (ART) and active tuberculosis (TB), among people with HIV across Europe. Methods People with HIV enrolled in EuroSIDA were followed from 2001 through 2020. Immunologic-virologic status (IVS) was categorized as poor (CD4-cell count ≤350 cells/mm3 and viral load (VL) > 200 copies/ml), good (CD4 ≥ 500 and VL < 200), or intermediate (remaining combinations). Participants missing either CD4-cell count or VL were categorized as unknown. Regional differences in mortality were analyzed using multivariable Poisson regression with interaction analyses between regions of Europe and IVS, ART, or TB status. Findings 20,364 people with HIV were included: 13,715/20,346 (67.3%) from Western, 3020/20,364 (14.8%) from Central Eastern, and 3629/20,364 (17.8%) from Eastern Europe. At enrolment, median age was 40 years (inter-quartile range (IQR): 33-48), median CD4-cell count 449 cells/mm3 (IQR: 291-638), and most were male 14,993/20,346 (73.3%). A total of 2639 died during 192,591 person-years of follow-up (crude mortality rate 13.7/1000 person-years, 95% CI: 13.2-14.2), 519/2639 (19.7%) from AIDS (2.7/1000 person-years, 2.5-2.9). All-cause and AIDS-mortality rates decreased over time but remained higher in Eastern Europe after adjusting for confounders. Being off ART (aIRR 2.42; 95% CI 2.14-2.74), poor IVS (aIRR 4.2; 95% CI 3.39-5.20) and prior TB (aIRR 3.33; 95% CI 2.75-4.03) were associated with higher all-cause mortality. For all-cause mortality the effect of ART (test for interaction: p < 0.001) and IVS (p = 0.02), but not TB (p = 0.5) varied across regions. Interpretation Overall mortality and AIDS-mortality rates decreased over time, but remained higher in Eastern Europe. A poor IVS, being off ART and prior active TB were related to higher mortality. Eastern Europe had the highest proportion of people with poor or unknown IVS, emphasizing the continued need to improve HIV care with a focus on early diagnosis, ART initiation, and adherence. Funding EuroSIDA has received funding from ViiV Healthcare LLC, Janssen Scientific Affairs, Janssen R&D, Bristol-Myers Squibb Company, Merck Sharp & Dohme Corp, Gilead Sciences and the European Union's Seventh Framework Programme for research, technological development and demonstration under EuroCoord grant agreement n˚ 260694. The study is also supported by a grant from the Danish National Research Foundation and by the International Cohort Consortium of Infectious Disease (RESPOND).
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Affiliation(s)
- Christian Kraef
- Department of Infectious Diseases, Rigshospitalet, Denmark
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
| | - Erich Tusch
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
| | - Sabine Singh
- Department of Infectious Diseases, Rigshospitalet, Denmark
| | | | - Gerd Fätkenheuer
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Santiago Moreno
- Department of Infectious Diseases, Hospital Universitario Ramón Y Cajal, Madrid, Spain
| | - Katharina Kusejko
- Division of Infectious Diseases, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | - Janez Tomažič
- Clinic for Infectious Diseases, Ljubljana University Medical Center, Ljubljana, Slovenia
| | - Jovan Ranin
- Infectious and Tropical Diseases University Hospital, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Fredrik Mansson
- Skåne University Hospital, Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Giulia Marchetti
- Dept of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, Italy
| | - Stéphane De Wit
- CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Amanda Clarke
- Royal Sussex County Hospital, and Brighton & Sussex Medical School, Brighton, UK
| | - Jan Gerstoft
- Department of Infectious Diseases, Rigshospitalet, Denmark
| | - Daria Podlekareva
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Lars Peters
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
| | - Joanne Reekie
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
| | - Ole Kirk
- Department of Infectious Diseases, Rigshospitalet, Denmark
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
| | - the EuroSIDA Study Group
- Department of Infectious Diseases, Rigshospitalet, Denmark
- CHIP, Centre of Excellence for Health, Immunity and Infections, Rigshospitalet, Copenhagen, Denmark
- Aarhus University Hospital, Skejby, Denmark
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
- Department of Infectious Diseases, Hospital Universitario Ramón Y Cajal, Madrid, Spain
- Division of Infectious Diseases, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Wroclaw Medical University, Wroclaw, Poland
- Kharkov State Medical University, Kharkov, Ukraine
- Clinic for Infectious Diseases, Ljubljana University Medical Center, Ljubljana, Slovenia
- Infectious and Tropical Diseases University Hospital, Clinical Centre of Serbia, Belgrade, Serbia
- Medical University of Innsbruck, Innsbruck, Austria
- Skåne University Hospital, Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
- Dept of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, Italy
- CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Royal Sussex County Hospital, and Brighton & Sussex Medical School, Brighton, UK
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital, Bispebjerg, Denmark
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Trickey A, Zhang L, Rentsch CT, Pantazis N, Izquierdo R, Antinori A, Leierer G, Burkholder G, Cavassini M, Palacio-Vieira J, Gill MJ, Teira R, Stephan C, Obel N, Vehreschild JJ, Sterling TR, Van Der Valk M, Bonnet F, Crane HM, Silverberg MJ, Ingle SM, Sterne JA. Care interruptions and mortality among adults in Europe and North America. AIDS 2024; 38:1533-1542. [PMID: 38742863 PMCID: PMC11239093 DOI: 10.1097/qad.0000000000003924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE Interruptions in care of people with HIV (PWH) on antiretroviral therapy (ART) are associated with adverse outcomes, but most studies have relied on composite outcomes. We investigated whether mortality risk following care interruptions differed from mortality risk after first starting ART. DESIGN Collaboration of 18 European and North American HIV observational cohort studies of adults with HIV starting ART between 2004 and 2019. METHODS Care interruptions were defined as gaps in contact of ≥365 days, with a subsequent return to care (distinct from loss to follow-up), or ≥270 days and ≥545 days in sensitivity analyses. Follow-up time was allocated to no/preinterruption or postinterruption follow-up groups. We used Cox regression to compare hazards of mortality between care interruption groups, adjusting for time-updated demographic and clinical characteristics and biomarkers upon ART initiation or re-initiation of care. RESULTS Of 89 197 PWH, 83.4% were male and median age at ART start was 39 years [interquartile range (IQR): 31-48)]. 8654 PWH (9.7%) had ≥1 care interruption; 10 913 episodes of follow-up following a care interruption were included. There were 6104 deaths in 536 334 person-years, a crude mortality rate of 11.4 [95% confidence interval (CI): 11.1-11.7] per 1000 person-years. The adjusted mortality hazard ratio (HR) for the postinterruption group was 1.72 (95% CI: 1.57-1.88) compared with the no/preinterruption group. Results were robust to sensitivity analyses assuming ≥270-day (HR 1.49, 95% CI: 1.40-1.60) and ≥545-day (HR 1.67, 95% CI: 1.48-1.88) interruptions. CONCLUSIONS Mortality was higher among PWH reinitiating care following an interruption, compared with when PWH initially start ART, indicating the importance of uninterrupted care.
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Affiliation(s)
- Adam Trickey
- Population Health Sciences, University of Bristol, UK
| | - Lei Zhang
- School of Public Finance and Management, Yunnan University of Finance and Economics, China
| | - Christopher T. Rentsch
- Yale School of Medicine, New Haven, CT, USA; London School of Hygiene & Tropical Medicine, London, UK
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Rebeca Izquierdo
- National Center for Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Carlos III Health Institute, Madrid, Spain
| | - Andrea Antinori
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Gisela Leierer
- Department of Dermatology and Venereology, Medical University of Innsbruck, Innsbruck, Austria
| | - Greer Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - M. John Gill
- Dept of Medicine, University of Calgary, Alberta, Canada
| | - Ramon Teira
- Servicio de Medicina Interna, Hospital Universitario de Sierrallana, Torrelavega, Cantabria, Spain
| | - Christoph Stephan
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Frankfurt, Germany
| | - Niels Obel
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jorg-Janne Vehreschild
- Department I for Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Timothy R. Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Marc Van Der Valk
- Stichting HIV Monitoring, Amsterdam, the Netherlands. Amsterdam University Medical Centers, Dept of Infectious diseases, University of Amsterdam, Amsterdam Institute for Infection and Immunity, Amsterdam, The Netherlands
| | - Fabrice Bonnet
- Université de Bordeaux, INSERM U1219, Bordeaux Population Health and CHU de Bordeaux, Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Bordeaux, France
| | - Heidi M. Crane
- Department of Medicine, University of Washington, Seattle, WA
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Relf MV. The Social Determinants of Health Are the Key Drivers of HIV Prevention, Care, and Treatment Inequities. J Assoc Nurses AIDS Care 2024; 35:307-308. [PMID: 38920314 DOI: 10.1097/jnc.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Affiliation(s)
- Michael V Relf
- Michael V. Relf, PhD, RN, AACRN, ANEF, FAAN, is the Editor-in-Chief of JANAC and Interim Dean and Mary T. Champagne Distinguished Professor, Duke University, School of Nursing and a Research Professor, Duke Global Health Institute, Durham, North Carolina, USA
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Ambia J, Ingle SM, McGinnis K, Pantazis N, Silverberg MJ, Wittkop L, Kusejko K, Crane H, van Sighem A, Sarcletti M, Cozzi-Lepri A, Domingo P, Jarrin I, Wyen C, Hessamfar M, Zhang L, Cavassini M, Berenguer J, Sterling TR, Reiss P, Abgrall S, Gill MJ, Justice A, Sterne JAC, Trickey A. Discrimination of the Veterans Aging Cohort Study Index 2.0 for Predicting Cause-specific Mortality Among Persons With HIV in Europe and North America. Open Forum Infect Dis 2024; 11:ofae333. [PMID: 39015347 PMCID: PMC11249920 DOI: 10.1093/ofid/ofae333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/13/2024] [Indexed: 07/18/2024] Open
Abstract
Background Predicting cause-specific mortality among people with HIV (PWH) could facilitate targeted care to improve survival. We assessed discrimination of the Veterans Aging Cohort Study (VACS) Index 2.0 in predicting cause-specific mortality among PWH on antiretroviral therapy (ART). Methods Using Antiretroviral Therapy Cohort Collaboration data for PWH who initiated ART between 2000 and 2018, VACS Index 2.0 scores (higher scores indicate worse prognosis) were calculated around a randomly selected visit date at least 1 year after ART initiation. Missingness in VACS Index 2.0 variables was addressed through multiple imputation. Cox models estimated associations between VACS Index 2.0 and causes of death, with discrimination evaluated using Harrell's C-statistic. Absolute mortality risk was modelled using flexible parametric survival models. Results Of 59 741 PWH (mean age: 43 years; 80% male), the mean VACS Index 2.0 at baseline was 41 (range: 0-129). For 2425 deaths over 168 162 person-years follow-up (median: 2.6 years/person), AIDS (n = 455) and non-AIDS-defining cancers (n = 452) were the most common causes. Predicted 5-year mortality for PWH with a mean VACS Index 2.0 score of 38 at baseline was 1% and approximately doubled for every 10-unit increase. The 5-year all-cause mortality C-statistic was .83. Discrimination with the VACS Index 2.0 was highest for deaths resulting from AIDS (0.91), liver-related (0.91), respiratory-related (0.89), non-AIDS infections (0.87), and non-AIDS-defining cancers (0.83), and lowest for suicides/accidental deaths (0.65). Conclusions For deaths among PWH, discrimination with the VACS Index 2.0 was highest for deaths with measurable physiological causes and was lowest for suicide/accidental deaths.
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Affiliation(s)
- Julie Ambia
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Suzanne M Ingle
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Kathleen McGinnis
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, Connecticut, USA
| | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Linda Wittkop
- University of Bordeaux, INSERM, Institut Bergonié, BPH, U1219, CIC-EC 1401, F-33000, Bordeaux, France
- INRIA SISTM team, Talence. CHU de Bordeaux, Service d’information médicale, INSERM, Institut Bergonié, CIC-EC 1401, F-33000, Bordeaux, France
| | - Katharina Kusejko
- Division for Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Heidi Crane
- Division of Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Mario Sarcletti
- Department of Dermatology and Venereology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Pere Domingo
- Department of Infectious Diseases, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Inma Jarrin
- National Centre of Epidemiology, Carlos III Health Institute, Madrid, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Christoph Wyen
- Department I for Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Mojgan Hessamfar
- Department of Internal Medicine and Infectious Disease, Bordeaux University Hospital F-33000, Bordeaux, France
| | - Lei Zhang
- Population Health Sciences, University of Bristol, Bristol, UK
- School of Public Finance and Management, Yunnan University of Finance and Economics, Kunming, China
| | - Matthias Cavassini
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón, IiSGM, CIBERINFEC, Madrid, Spain
| | - Timothy R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Global Health, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Sophie Abgrall
- APHP, Hôpital Béclère, Service de Médecine Interne, Clamart, France
- APHP, Université Paris-Saclay, Univ. Paris-Sud, UVSQ, CESP INSERM U1018, Le Kremlin-Bicêtre, France
| | - M John Gill
- Department of Medicine, University of Calgary, South Alberta HIV Clinic, Calgary, Alberta, Canada
| | - Amy Justice
- VA Connecticut Healthcare System, US Department of Veteran Affairs, West Haven, Connecticut, USA
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Adam Trickey
- Population Health Sciences, University of Bristol, Bristol, UK
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Rosenfeld D, Ramirez-Valles J. Beyond identity and generations: bringing life course theory to studies of older gay men. FRONTIERS IN SOCIOLOGY 2024; 9:1393607. [PMID: 38813397 PMCID: PMC11134570 DOI: 10.3389/fsoc.2024.1393607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/22/2024] [Indexed: 05/31/2024]
Abstract
The last century's numerous, rapid social changes affecting gay men make studies of gay male aging a ripe topic for life course theory, which views later life as the product of historical grounded interchanges between individual lives, social change, and structural contexts. That identifying as gay can occur at any point in the life course widens some life course theorists' primary focus on early-life events to include those occurring throughout the life course. Yet most historically-attentive research on older gay men focuses on generations and identity development rather than on cohorts - groups who entered a system or context at the same time - or on the cumulative, concrete outcomes of encountering social change at a particular point in the life course. This article argues for gay male aging studies' use of life course theory, specifically, its focus on cohort membership's implications for later life, including cumulative disadvantage, in addition to more generationally-focused investigations. After briefly reviewing scholarship on older gay men, we introduce the life course approach and its critique by queer gerontologists for adopting a heteronormative view of the LGBT life course and eliding its distinctive contours. With particular attention to later-life concrete outcomes rather than identity formation, we explore key historical events in gay men's lives that have produced (in the case of the AIDS epidemic) or could produce (for example, the Marriage Equality Act, the Don't Ask, Don't Tell policy) distinctive gay male cohorts. We then consider intra-cohort variation within gay male cohorts before exploring some the barriers to investigating cohorts and cohort effects among older gay men.
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Affiliation(s)
- Dana Rosenfeld
- College of Liberal Arts and Sciences, University of Westminster, London, United Kingdom
| | - Jesus Ramirez-Valles
- School of Medicine, Univeristy of California San Francisco, San Francisco, CA, United States
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Seguin-Devaux C. HIV and people who inject drugs: inequality until death. Lancet HIV 2024; 11:e136-e137. [PMID: 38280394 DOI: 10.1016/s2352-3018(23)00295-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 01/29/2024]
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