1
|
Are we missing opioid-related deaths among people with HIV? Drug Alcohol Depend 2020; 212:108003. [PMID: 32417360 PMCID: PMC9580216 DOI: 10.1016/j.drugalcdep.2020.108003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/28/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Ascertainment of unnatural and overdose death may be unreliable among individuals with life-limiting conditions such as HIV infection. We sought to determine whether the relationship between opioid use and unnatural death differs among decedents with HIV (DWH) and those without. METHODS Decedents in the Veterans Aging Cohort Study (VACS) from 2002 to 14 were linked to the National Death Index cause of death file. Deaths were classified as unnatural, overdose (a subset of unnatural), or other. We defined opioid use as self-reported illicit use or receipt of prescribed opioids. Treating unnatural and overdose deaths as outcomes, we calculated odds ratios for opioid exposure by HIV status, with and without adjustment for disease severity using VACS Index. RESULTS Among 561 decedents without HIV (DWOH) and 884 DWH, 11 % and 8 % respectively were classified as unnatural deaths and 4 % and 2 % were classified as overdose deaths. Among DWOH, opioid use was associated with 2-fold greater odds of unnatural (OR 2.3; 95 % CI 1.3-4.0) and 4-fold greater odds of overdose death (OR 4.5; 95 % CI 1.5-13.7); in adjusted analyses, opioid use was associated with unnatural death (OR 2.6; 95 % CI 1.3-4.9) and with overdose (OR 4.2; 95 % CI 1.4-12.7). Opioid use was not associated with unnatural or overdose death among DWH. CONCLUSION Opioid use was strongly associated with unnatural and overdose death among DWOH but not among DWH suggesting potential differential misclassification. Caution should be used in interpreting prevalence, incidence and risk factors for unnatural and overdose cause of death among patients with life-limiting conditions such as HIV.
Collapse
|
2
|
Performance of self-reported HIV status in determining true HIV status among older adults in rural South Africa: a validation study. J Int AIDS Soc 2017; 20:21691. [PMID: 28782333 PMCID: PMC5577734 DOI: 10.7448/ias.20.1.21691] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: In South Africa, older adults make up a growing proportion of people living with HIV. HIV programmes are likely to reach older South Africans in home-based interventions where testing is not always feasible. We evaluate the accuracy of self-reported HIV status, which may provide useful information for targeting interventions or offer an alternative to biomarker testing. Methods: Data were taken from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) baseline survey, which was conducted in rural Mpumalanga province, South Africa. A total of 5059 participants aged ≥40 years were interviewed from 2014 to 2015. Self-reported HIV status and dried bloodspots for HIV biomarker testing were obtained during at-home interviews. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for self-reported status compared to “gold standard” biomarker results. Log-binomial regression explored associations between demographic characteristics, antiretroviral therapy (ART) status and sensitivity of self-report. Results: Most participants (93%) consented to biomarker testing. Of those with biomarker results, 50.9% reported knowing their HIV status and accurately reported it. PPV of self-report was 94.1% (95% confidence interval (CI): 92.0–96.0), NPV was 87.2% (95% CI: 86.2–88.2), sensitivity was 51.2% (95% CI: 48.2–54.3) and specificity was 99.0% (95% CI: 98.7–99.4). Participants on ART were more likely to report their HIV-positive status, and participants reporting false-negatives were more likely to have older HIV tests. Conclusions: The majority of participants were willing to share their HIV status. False-negative reports were largely explained by lack of testing, suggesting HIV stigma is retreating in this setting, and that expansion of HIV testing and retesting is still needed in this population. In HIV interventions where testing is not possible, self-reported status should be considered as a routine first step to establish HIV status.
Collapse
|
3
|
Vollmer S, Harttgen K, Alfven T, Padayachy J, Ghys P, Bärnighausen T. The HIV Epidemic in Sub-Saharan Africa is Aging: Evidence from the Demographic and Health Surveys in Sub-Saharan Africa. AIDS Behav 2017; 21:101-113. [PMID: 27837426 DOI: 10.1007/s10461-016-1591-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We use the individual-level data from all available Demographic and Health Surveys (DHS) from 27 sub-Saharan African countries conducted between 2003 and 2012 (40 population-based and nationally representative surveys in total) to calculate HIV testing consent rates and HIV prevalence for each country separately, as well as for the pooled sample. The pooled sample comprised of 427,130 individuals. In most countries HIV prevalence in adults aged 45 years and above is higher than in the total population. We further show that over the past decade HIV prevalence has increased in older age groups, while it has decreased in younger ones. While the age patterns of HIV consent rates vary across the 27 countries included in our sample, analysis of the pooled sample across all countries reveals a u-shaped relationship with lowest consent rates around age 35 years and higher consent rates among younger and older people. We argue that future DHS and other population-based HIV surveys should offer HIV testing to all adults without age limits.
Collapse
Affiliation(s)
- Sebastian Vollmer
- Department of Economics, University of Göttingen, Göttingen, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University 665 Huntington Avenue, Boston, USA
| | | | | | | | | | - Till Bärnighausen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health Harvard University 665 Huntington Avenue, Boston, USA.
- Wellcome Trust Africa Centre for Heath and Population Studies, University of KwaZulu-Natal, Kwazulu-Natal, South Africa.
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany.
| |
Collapse
|
4
|
Gaither JR, Goulet JL, Becker WC, Crystal S, Edelman EJ, Gordon K, Kerns RD, Rimland D, Skanderson M, Justice AC, Fiellin DA. The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality. J Gen Intern Med 2016; 31:492-501. [PMID: 26847447 PMCID: PMC4835362 DOI: 10.1007/s11606-015-3571-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes--notably mortality--is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. METHODS Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. RESULTS Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic co-interventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between all-cause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67). CONCLUSIONS Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.
Collapse
Affiliation(s)
- Julie R Gaither
- Yale School of Public Health, Yale University, New Haven, CT, USA. .,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA. .,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA. .,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.
| | - Joseph L Goulet
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - William C Becker
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - E Jennifer Edelman
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Kirsha Gordon
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA
| | - Robert D Kerns
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David Rimland
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Medical Center, Decatur, GA, USA
| | | | - Amy C Justice
- Yale School of Public Health, Yale University, New Haven, CT, USA.,VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, 06516, USA.,Yale Center for Medical Informatics, Yale School of Medicine, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - David A Fiellin
- Yale School of Public Health, Yale University, New Haven, CT, USA.,Center for Interdisciplinary Research on AIDS, Yale School of Public Health, Yale University, New Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| |
Collapse
|
5
|
Vollmer S, Alfven T, Padayachy J, Harttgen K, Ghys PD, Bärnighausen T. HIV surveys in older adults: better data, better health. Lancet HIV 2015; 2:e40-1. [PMID: 26424459 DOI: 10.1016/s2352-3018(15)00004-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 01/05/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Sebastian Vollmer
- Department of Economics, University of Göttingen, Germany; Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA, USA
| | | | | | | | | | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, MA, USA; Wellcome Trust Africa Centre for Heath and Population Studies, University of KwaZulu-Natal, South Africa.
| |
Collapse
|
6
|
Weber R, Ruppik M, Rickenbach M, Spoerri A, Furrer H, Battegay M, Cavassini M, Calmy A, Bernasconi E, Schmid P, Flepp M, Kowalska J, Ledergerber B. Decreasing mortality and changing patterns of causes of death in the Swiss HIV Cohort Study. HIV Med 2012; 14:195-207. [PMID: 22998068 DOI: 10.1111/j.1468-1293.2012.01051.x] [Citation(s) in RCA: 293] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Mortality among HIV-infected persons is decreasing, and causes of death are changing. Classification of deaths is hampered because of low autopsy rates, frequent deaths outside of hospitals, and shortcomings of International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding. METHODS We studied mortality among Swiss HIV Cohort Study (SHCS) participants (1988-2010) and causes of death using the Coding Causes of Death in HIV (CoDe) protocol (2005-2009). Furthermore, we linked the SHCS data to the Swiss National Cohort (SNC) cause of death registry. RESULTS AIDS-related mortality peaked in 1992 [11.0/100 person-years (PY)] and decreased to 0.144/100 PY (2006); non-AIDS-related mortality ranged between 1.74 (1993) and 0.776/100 PY (2006); mortality of unknown cause ranged between 2.33 and 0.206/100 PY. From 2005 to 2009, 459 of 9053 participants (5.1%) died. Underlying causes of deaths were: non-AIDS malignancies [total, 85 (19%) of 446 deceased persons with known hepatitis C virus (HCV) status; HCV-negative persons, 59 (24%); HCV-coinfected persons, 26 (13%)]; AIDS [73 (16%); 50 (21%); 23 (11%)]; liver failure [67 (15%); 12 (5%); 55 (27%)]; non-AIDS infections [42 (9%); 13 (5%); 29 (14%)]; substance use [31 (7%); 9 (4%); 22 (11%)]; suicide [28 (6%); 17 (7%), 11 (6%)]; myocardial infarction [28 (6%); 24 (10%), 4 (2%)]. Characteristics of deceased persons differed in 2005 vs. 2009: median age (45 vs. 49 years, respectively); median CD4 count (257 vs. 321 cells/μL, respectively); the percentage of individuals who were antiretroviral therapy-naïve (13 vs. 5%, respectively); the percentage of deaths that were AIDS-related (23 vs. 9%, respectively); and the percentage of deaths from non-AIDS-related malignancies (13 vs. 24%, respectively). Concordance in the classification of deaths was 72% between CoDe and ICD-10 coding in the SHCS; and 60% between the SHCS and the SNC registry. CONCLUSIONS Mortality in HIV-positive persons decreased to 1.33/100 PY in 2010. Hepatitis B or C virus coinfections increased the risk of death. Between 2005 and 2009, 84% of deaths were non-AIDS-related. Causes of deaths varied according to data source and coding system.
Collapse
Affiliation(s)
- R Weber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Simard EP, Pfeiffer RM, Engels EA. Mortality due to cancer among people with AIDS: a novel approach using registry-linkage data and population attributable risk methods. AIDS 2012; 26:1311-8. [PMID: 22472857 PMCID: PMC3377813 DOI: 10.1097/qad.0b013e328353f38e] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Deaths related to HIV/AIDS have declined due to improved HIV therapies. However, people with AIDS remain at elevated risk for cancer and cancer deaths. Prior studies evaluated cancer deaths using death certificates, which may be inaccurate. We utilized population attributable risk methods (which do not rely on death certificates) to assess cancer mortality. DESIGN Data from a US population-based record linkage study were used to identify incident cancers and deaths in 372 364 people with AIDS (1980-2006) followed for up to 5 years after AIDS onset. We utilized Cox regression to compare mortality in individuals with and without cancer and to calculate cancer-attributable mortality across calendar periods (AIDS onset in 1980-1989, 1990-1995, and 1996-2006). RESULTS Mortality declined across calendar periods for all people with AIDS but remained higher among those with cancer relative to those without. During 1996-2006, among individuals with an AIDS-defining cancer (ADC) who died, 88.3% of deaths were attributable to their ADC; likewise, among individuals with a non-AIDS-defining cancer (NADC), 87.1% of deaths were attributable to their NADC. The fraction of all deaths in people with AIDS attributable to ADC (i.e. population-attributable risk) decreased significantly from 6.3% (1980-1990) to 3.9% (1996-2006), but NADC population attributable mortality increased significantly over time from 0.5% (1980-1989) to 2.3% (1996-2006). CONCLUSION Among individuals with AIDS and cancer who subsequently die, most deaths are attributable to cancer. With a decline in overall mortality, the proportion of all deaths attributable to NADCs has increased. These results highlight the need for improved cancer prevention and treatment.
Collapse
Affiliation(s)
- Edgar P. Simard
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
- Surveillance Research Program, American Cancer Society, Atlanta, GA
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| |
Collapse
|
8
|
CD4 cell count and the risk of AIDS or death in HIV-Infected adults on combination antiretroviral therapy with a suppressed viral load: a longitudinal cohort study from COHERE. PLoS Med 2012; 9:e1001194. [PMID: 22448150 PMCID: PMC3308938 DOI: 10.1371/journal.pmed.1001194] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 02/09/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Most adults infected with HIV achieve viral suppression within a year of starting combination antiretroviral therapy (cART). It is important to understand the risk of AIDS events or death for patients with a suppressed viral load. METHODS AND FINDINGS Using data from the Collaboration of Observational HIV Epidemiological Research Europe (2010 merger), we assessed the risk of a new AIDS-defining event or death in successfully treated patients. We accumulated episodes of viral suppression for each patient while on cART, each episode beginning with the second of two consecutive plasma viral load measurements <50 copies/µl and ending with either a measurement >500 copies/µl, the first of two consecutive measurements between 50-500 copies/µl, cART interruption or administrative censoring. We used stratified multivariate Cox models to estimate the association between time updated CD4 cell count and a new AIDS event or death or death alone. 75,336 patients contributed 104,265 suppression episodes and were suppressed while on cART for a median 2.7 years. The mortality rate was 4.8 per 1,000 years of viral suppression. A higher CD4 cell count was always associated with a reduced risk of a new AIDS event or death; with a hazard ratio per 100 cells/µl (95% CI) of: 0.35 (0.30-0.40) for counts <200 cells/µl, 0.81 (0.71-0.92) for counts 200 to <350 cells/µl, 0.74 (0.66-0.83) for counts 350 to <500 cells/µl, and 0.96 (0.92-0.99) for counts ≥500 cells/µl. A higher CD4 cell count became even more beneficial over time for patients with CD4 cell counts <200 cells/µl. CONCLUSIONS Despite the low mortality rate, the risk of a new AIDS event or death follows a CD4 cell count gradient in patients with viral suppression. A higher CD4 cell count was associated with the greatest benefit for patients with a CD4 cell count <200 cells/µl but still some slight benefit for those with a CD4 cell count ≥500 cells/µl.
Collapse
|
9
|
Affiliation(s)
- Edward J Mills
- Faculty of Health Sciences, University of Ottawa, ON, Canada.
| | | | | |
Collapse
|
10
|
Abstract
OBJECTIVE To examine if there is a significant difference in survival between elderly (>50 years) and nonelderly adult patients receiving combination antiretroviral therapy in Uganda between 2004 and 2010. DESIGN Prospective observational study. METHODS Patients 18-49 years of age (nonelderly) and 50 years of age and older enrolled in the AIDS Support Organization Uganda HIV/AIDS national programme were assessed for time to all-cause mortality. We applied a Weibull multivariable regression. RESULTS Among the 22 087 patients eligible for analyses, 19 657 (89.0%) were aged between 18 and 49 years and 2430 (11.0%) were aged 50 years or older. These populations differed in terms of the distributions of sex, baseline CD4 cell count and death. The age group 40-44 displayed the lowest crude mortality rate [31.4 deaths per 1000 person-years; 95% confidence interval (CI) 28.1, 34.7) and the age group 60-64 displayed the highest crude mortality rate (58.9 deaths per 1000 person-years; 95% CI 42.2, 75.5). Kaplan-Meier survival estimates indicated that nonelderly patients had better survival than elderly patients (P < 0.001). Adjusted Weibull analysis indicated that elderly age status was importantly associated (adjusted hazard ratio 1.23, 95% CI 1.08-1.42) with mortality, when controlling for sex, baseline CD4 cell count and year of therapy initiation. CONCLUSION As antiretroviral treatment cohorts mature, the proportion of patients who are elderly will inevitably increase. Elderly patients may require focused clinical care that extends beyond HIV treatment.
Collapse
|
11
|
A CD4+ cell count <200 cells per cubic millimeter at 2 years after initiation of combination antiretroviral therapy is associated with increased mortality in HIV-infected individuals with viral suppression. J Acquir Immune Defic Syndr 2011; 55:451-9. [PMID: 21105259 DOI: 10.1097/qai.0b013e3181ec28ff] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the long-term impact of immunologic discordance (viral load <50 copies/mL and CD4+ count <=200 cells/mm3) in antiretroviral-naive patients initiating combination antiretroviral therapy (cART). METHODS Our analysis included antiretroviral-naive individuals from a population-based Canadian Observational Cohort that initiated cART after January 1, 2000, and achieved virologic suppression. Multivariable Cox proportional hazards regression was used to examine the association between 1-year and 2-year immunologic discordance and time to death from all-causes. Correlates of immunologic discordance were assessed with logistic regression. RESULTS Immunologic discordance was observed in 19.9% (404 of 2028) and 10.2% (176 of 1721) of individuals at 1 and 2 years after cART initiation, respectively. Two-year immunologic discordance was associated with an increased risk of death [adjusted hazard ratio = 2.69; 95% confidence interval (CI): 1.26 to 5.78]. One-year immunologic discordance was not associated with death (adjusted hazard ratio = 1.12; 95% CI: 0.54 to 2.30). Two-year immunologic discordance was associated with older age (aOR per decade = 1.23; 95% CI: 1.03 to 1.48), male gender (aOR = 1.86; 95% CI: 1.09 to 3.16), injection drug use (aOR = 2.75; 95% CI: 1.81 to 4.17), and lower baseline CD4+ count (aOR per 100 cells = 0.24; 95% CI: 0.19 to 0.31) and viral load (aOR per log10 copies/mL = 0.46; 95% CI: 0.33 to 0.65). CONCLUSIONS Immunologic discordance after 2 years of cART in antiretroviral-naive individuals was significantly associated with an increased risk of mortality.
Collapse
|
12
|
Abstract
The population of patients with HIV infection achieving viral suppression on combination antiretroviral therapy is growing, aging, and experiencing a widening spectrum of non-AIDS diseases. Concurrently, AIDS-defining conditions are becoming less common and are variably associated with outcome. Nonetheless, the spectrum of disease experienced by those aging with HIV remains strongly influenced by HIV, its treatment, and the behaviors, conditions, and demographics associated with HIV infection. Our focus must shift from a narrow interest in CD4 counts, HIV-RNA, and AIDS-defining illnesses to determining the optimal management of HIV infection as a complex chronic disease in which the causes of morbidity and mortality are multiple and overlapping. We need a new paradigm of care with which to maximize functional status, minimize frailty, and prolong life expectancy. A composite index that summarizes a patient's risk of morbidity and mortality could facilitate this work and help chart its progress.
Collapse
Affiliation(s)
- Amy C Justice
- Yale University Schools of Medicine and Public Health, New Haven, USA.
| |
Collapse
|