Declining AIDS mortality in Amsterdam: contributions of declining HIV incidence and effective therapy

Incidence and risk factors for AIDS-related mortality in HIV patients in China: a cross-sectional study

BACKGROUND

To estimate the incidence and risk factors for mortality in HIV-1-infected patients in China.

METHODS

Information on AIDS-related deaths was collected from the Chinese Center for Disease Control and Prevention's Disease Surveillance Information Reporting System and AIDS Prevention and Control Information System.

RESULTS

A total of 379,348 HIV cases were recorded in the databases from 2006. Among those, 138,288 patients were reported as having developed AIDS and 72,616 (19%) died of AIDS after data was extracted from the databases in January 2011. Mortality was higher among those patients aged 50 years old or older (AOR: 3.41, CI: 1.47-7.91) who had been infected by intravenous drug use (AOR: 1.65, CI: 1.28-2.14) or blood transfusion/donation (AOR: 2.18: 1.18-3.99). Compared to patients who had not initiated highly active antiretroviral therapy (HAART), those who had initiated HAART were more likely to have a long interval of time between infection confirmation and AIDS-related death.

CONCLUSIONS

The effective reduction of AIDS mortality could be improved through timely treatment.

Excess mortality in patients with AIDS in the era of highly active antiretroviral therapy: temporal changes and risk factors

BACKGROUND

Excess mortality has decreased among human immunodeficiency virus (HIV)-infected patients but without evidence of a decrease among patients with AIDS. We assessed temporal changes in excess mortality and elucidated risk factors for excess mortality in patients with AIDS diagnosed in the era of highly active antiretroviral therapy (HAART).

METHODS

We included 1188 patients of the Longitudinal Study of Ocular Complications in AIDS who were aged 25-64 years at enrollment and who received a diagnosis of AIDS after 1995. We calculated excess mortality as the age-, year-, and sex-adjusted difference in mortality rates between patients with AIDS and persons in the US general population during the period 1999-2007. We used a relative survival model to identify risk factors for excess mortality.

RESULTS

There were a mean of 50 excess deaths per 1000 person-years (95% confidence interval [CI], 44-57 excess deaths per 1000 person-years) during 1999-2007. Excess mortality almost halved, with an annual decrease of 8.0% per year (95% CI, 3.0%-12.7%; P = .002) but remained high at 36 excess deaths per 1000 person-years in 2007. Viral load >400 copies/mL (compared with <or= 400 copies/mL; risk ratio, 3.4; 95% CI, 2.3-5.0), CD4(+) count <200 cells/μL (compared with >or= 200 cells/μL; risk ratio, 2.7; 95% CI, 1.9-3.9), and cytomegalovirus retinitis (risk ratio, 1.6; 95% CI, 1.2-2.1) were the strongest risk factors for excess mortality.

CONCLUSIONS

Excess mortality among patients with AIDS was nearly halved in the HAART era and most strongly linked to stage of HIV disease. These results reflect the continuing improvements in AIDS management but also highlight that excess mortality remains ∼5 times higher in patients with AIDS than in HIV-infected patients without AIDS.

Incremental role of male circumcision on a generalised HIV epidemic through its protective effect against other sexually transmitted infections: from efficacy to effectiveness to population-level impact

BACKGROUND

Male circumcision (MC) can reduce HIV acquisition. However, a better understanding of the indirect protective effect of MC on sexually transmitted infections (STIs) is required.

OBJECTIVE

To assess the incremental benefits conferred by MC on HIV infection at the individual level in circumcision trials (no herd immunity effect) and at the population level (with herd immunity effect) owing to its protective effect against other STIs.

METHODS

A dynamic stochastic model of HIV and STI infections in a Kenyan population was used to simulate the impact of MC offered to a few trial participants or to a large proportion of men in order to study the protective role of MC on HIV infection at the individual and population levels.

RESULTS

Fewer than 20% of the HIV infections prevented in the circumcised arm of the circumcision trials (individual level) could be attributable to the efficacy of MC against STIs rather than against HIV. At the population level, MC can significantly reduce the prevalence of HIV, especially among men and women in the longer term. However, even at the population level, the long-term incremental impact of MC on HIV due to the protection against STI is modest (even if MC efficacy against the STI and STI prevalence was high).

CONCLUSIONS

The protection of MC against STI contributes little to the overall effect of MC on HIV. Additional work is needed to determine whether, and under what conditions, the protective effect of MC efficacy against STIs can have a significant incremental benefit on the HIV epidemic.

Major reduction in AIDS-mortality inequalities after HAART: the importance of absolute differences in evaluating interventions

This study estimates the magnitude of inequalities in AIDS mortality in the period when highly active antiretroviral therapy (HAART) was introduced and after its widespread dissemination in the Region of Madrid, Spain. Two population cohorts were constructed by linking records from 1996 and 2001 population censuses with mortality registry records after initial and full implementation of HAART, respectively. Absolute and relative differences in AIDS mortality in people aged 20-49 years were estimated in each population cohort according to neighbourhood and individual socioeconomic position. The absolute difference in mortality between neighbourhoods with highest and lowest socioeconomic position (unemployment rate, per capita income) declined from about 30/100,000 person-years in the 1996 population cohort to 8/100,000 person-years in the 2001 population cohort. The absolute difference in mortality between individuals with the highest and lowest socioeconomic position fell from about 60/100,000 person-years in the first cohort to about 20/100,000 in the second. Relative differences in mortality by neighbourhood socioeconomic position and by individual education level also decreased in the 2001 cohort with respect to the 1996 cohort. Although relative differences by individual occupation increased, there was no evidence of a significant change. These findings show major reduction in absolute socioeconomic differences in AIDS mortality after HAART and indicate that the use of relative differences alone may be inadequate to fully evaluate the results of health interventions.

Effect of a single dose of ritonavir on the pharmacokinetic behavior of elvucitabine, a nucleoside reverse transcriptase inhibitor, administered in healthy volunteers

The purpose of this study was to determine the effect of a single dose of 300 mg of ritonavir on the plasma pharmacokinetics (PK) of a single dose of 20 mg of elvucitabine when the two drugs were coadministered in healthy subjects. In a three-way crossover design, 30 subjects received 20 mg of elvucitabine, 300 mg of ritonavir, or 20 mg of elvucitabine coadministered with 300 mg of ritonavir. Elvucitabine concentrations were analyzed using a validated liquid chromatography-tandem mass spectrometry assay. The PK of elvucitabine was determined using both noncompartmental and compartmental analyses. Models were developed and tested using ADAPT-II, while a population analysis was performed using IT2S. Comparisons of PK parameters between groups were done with SAS. The pharmacokinetic behavior of elvucitabine was best described by a two-compartment linear model using two absorption rates and a first-order elimination rate. Ritonavir significantly impacted the PK of elvucitabine by reducing elvucitabine's bioavailability, with the most plausible explanation being an inhibition on influx transporters by ritonavir. The decrease in elvucitabine bioavailability when elvucitabine was coadministered with ritonavir may be due to ritonavir's inhibiting influx gut transporters. Continued development of elvucitabine is warranted to better characterize its PK and to determine its in vivo efficacy against human immunodeficiency virus.

Novel tight binding PETT, HEPT and DABO-based non-nucleoside inhibitors of HIV-1 reverse transcriptase

Non-nucleoside reverse transcriptase (RT) inhibitors (NNRTIs) are a key component of effective combination antiretroviral therapies for HIV/AIDS. NNRTIs despite their chemical diversity, bind to a common allosteric site of HIV-1 RT, the primary target for anti-AIDS chemotherapy, and noncompetitively inhibit DNA polymerization. NNRTIs currently in clinical use have a low genetic barrier to resistance and therefore, the need for novel NNRTIs active against drug-resistant mutants selected by current therapies is of paramount importance. We describe the chemistry and biological evaluation of highly potent novel phenethylthiazolylthiourea (PETT), 1-[(2-hydroxyethoxy)methyl]-6-(phenylthio)thymine (HEPT) and dihydroalkoxybenzyloxopyrimidine (DABO) derivatives targeting the hydrophobic binding pocket of HIV-1 RT. These NNRTIs were rationally designed by molecular modeling and docking studies using a novel composite binding pocket that predicted how drug-resistant mutations would change the RT binding pocket shape, volume, and chemical make-up and how these changes could affect NNRTI binding. Several ligand derivatization sites were identified for docked NNRTIs that fit the composite binding pocket. The best fit was determined by calculating an inhibition constant (Ludi Ki) of the docked compound for the composite binding pocket. Compounds with a Ludi Ki of <1 microM were identified as the most promising tight binding NNRTIs. These NNRTIs displayed high selective indices with robust anti-HIV-1 activity against the wild-type and drug-resistant isolates carrying multiple RT gene mutations. The high rate of treatment failure due to the emergence of drug resistance mutations makes the discovery of broad-spectrum PETT, HEPT and DABO-based NNRTIs useful as a component of effective combination regimens.

Modeling the impact of HIV chemoprophylaxis strategies among men who have sex with men in the United States: HIV infections prevented and cost-effectiveness

BACKGROUND AND OBJECTIVE

HIV chemoprophylaxis may be a future prevention strategy to help control the global epidemic of HIV/AIDS. Safety and efficacy trials of two agents are currently underway. We assess the expected number of HIV cases prevented and cost-effectiveness of a hypothetical HIV chemoprophylaxis program among men who have sex with men in a large US city.

DESIGN AND METHODS

We developed a stochastic compartmental mathematical model using HIV/AIDS surveillance data to simulate the HIV epidemic and the impact of a 5-year chemoprophylaxis program under varying assumptions for epidemiological, behavioral, programmatic and cost parameters. We estimated program effectiveness and costs from the perspective of the US healthcare system compared with current HIV prevention practices. The main outcome measures were number of HIV infections prevented and incremental cost per quality-adjusted life-years saved.

RESULTS

A chemoprophylaxis program targeting 25% of high-risk men who have sex with men in New York City could prevent 780 (4%) to 4510 (23%) of the 19 510 HIV infections predicted to occur among all men who have sex with men in New York City in 5 years. More than half of prevented infections would be among those not taking chemoprophylaxis but who benefit from reduced HIV prevalence in the community. Under base-case assumptions, incremental cost was US$ 31 970 per quality-adjusted life-years saved. The program was cost-effective under most variations in efficacy, mechanism of protection and adherence.

CONCLUSION

HIV chemoprophylaxis among high-risk men who have sex with men in a major US city could prevent a significant number of HIV infections and be cost-effective.

A resurgent HIV-1 epidemic among men who have sex with men in the era of potent antiretroviral therapy

OBJECTIVE

Reducing viral load, highly active antiretroviral therapy has the potential to limit onwards transmission of HIV-1 and thus help contain epidemic spread. However, increases in risk behaviour and resurgent epidemics have been widely reported post-highly active antiretroviral therapy. The aim of this study was to quantify the impact that highly active antiretroviral therapy had on the epidemic.

DESIGN

We focus on the HIV-1 epidemic among men who have sex with men in the Netherlands, which has been well documented over the past 20 years within several long-standing national surveillance programs.

METHODS

We used a mathematical model including highly active antiretroviral therapy use and estimated the changes in risk behaviour and diagnosis rate needed to explain annual data on HIV and AIDS diagnoses.

RESULTS

We show that the reproduction number R(t), a measure of the state of the epidemic, declined early on from initial values above two and was maintained below one from 1985 to 2000. Since 1996, when highly active antiretroviral therapy became widely used, the risk behaviour rate has increased 66%, resulting in an increase of R(t) to 1.04 in the latest period 2000-2004 (95% confidence interval 0.98-1.09) near or just above the threshold for a self-sustaining epidemic. Hypothetical scenario analysis shows that the epidemiological benefits of highly active antiretroviral therapy and earlier diagnosis on incidence have been entirely offset by increases in the risk behaviour rate.

CONCLUSION

We provide the first detailed quantitative analysis of the HIV epidemic in a well defined population and find a resurgent epidemic in the era of highly active antiretroviral therapy, most likely predominantly caused by increasing sexual risk behaviour.

The epidemiological transition: the current status of infectious diseases in the developed world versus the developing world

Wealthy, industrialized countries of the developed world successfully underwent the "epidemiologic transition" from infectious diseases to degenerative diseases, but developing countries have not yet achieved that transition. This article reviews the current status of Omran's Theory of Epidemiologic Transition, comparing the burden of infectious diseases in the developed world versus the developing world. The advent of modern sanitation and hygiene practices, effective vaccines, and antibiotics have significantly diminished the burden in the developed world, but infectious diseases remain the most common cause of death worldwide. The persistence of this disease burden has been due to a failure to employee effective strategies and to unforeseen developments, such as the emergence of HIV and the re-emergence of malaria and tuberculosis driven by newly developed drug resistance. The challenge in accurately assessing infectious disease burden and developing effective interventions is reviewed along with the most common diseases and current intervention strategies.

Negative Social Impacts Among Volunteers in an HIV Vaccine Efficacy Trial

OBJECTIVE

Describe the negative social impacts (NSIs) and their predictors in an HIV vaccine efficacy trial.

METHODS

Volunteers in the North American phase 3 trial of AIDSVAX B/B vaccine were questioned semiannually about NSIs. Multivariable logistic models identified independent predictors of NSI reporting.

RESULTS

Of 5417 volunteers (94% male), 18% reported at least 1 NSI. Most events occurred early during trial participation and involved concerns by family and friends that the volunteer was HIV-infected or at risk for infection. Problems with disability/life insurance and employment occurred less frequently (<1%). Individuals who became HIV-infected reported NSIs similar to HIV-negative volunteers. In multipredictor analysis of male volunteers, NSI reporters were younger (adjusted odds ratio [OR(Adj)] = 1.6, 95% confidence interval [CI]: 1.2 to 2.1 and OR(Adj) = 1.4, 95% CI: 1.1 to 1.8 for ages 18 to 25 years and 26 to 35 years vs. > or =46 years, respectively), enrolled at sites with 50 or fewer volunteers (OR(Adj) = 2.3, 95% CI: 1.7 to 3.1), or lived in cities with high AIDS case rates (OR(Adj) = 1.4, 95% CI: 1.1 to 1.8).

CONCLUSIONS

A modest proportion of vaccine efficacy trial volunteers reported problems in interpersonal relationships from trial participation. Serious harms involving insurance and employment were rare. Strategies to prevent harm from disclosure, particularly for younger volunteers and those from high seroincidence sites, may reduce NSIs in future trials.

Bilateral leg swelling as the initial and predominant presentation of HIV and associated pulmonary arterial hypertension

Although mortality from HIV has decreased over the last several years as a result of effective antiretroviral therapy, the infection continues to pose significant morbidity. Pulmonary arterial hypertension (PAH), for instance, has been reported to occur in the setting of established HIV infection on only rare occasions and carries a universally poor prognosis. The current case report is unique in describing a previously well patient who presents initially with complaints of debilitating leg swelling and is subsequently diagnosed with HIV and associated PAH.

Continued improvement in survival among HIV-infected individuals with newer forms of highly active antiretroviral therapy

OBJECTIVE

To characterize the temporal changes in mortality and life expectancy among HIV-positive individuals initiating antiretroviral therapy in British Columbia, Canada, from 1993 to 2004.

METHODS

This analysis was restricted to 2238 antiretroviral-naive HIV-positive individuals who started antiretroviral therapy between January 1993 and September 2004. The primary analysis endpoint was all-cause mortality stratified by four time periods: 1993-1995, 1996-1998, 1999-2001, and 2002-2004. Cox proportional hazard models, with associated 95% confidence intervals (CI), were used to estimate the hazard of death. Abridged life tables were constructed to compare life expectancies at the age of 20 years.

RESULTS

Product limit estimates of the cumulative mortality rate at 12 months after therapy initiation decreased from 15.8% (+/- 1.6%) in 1993-1995 to 6.1% (+/- 1.1%) in 2002-2004. Life expectancy at the age of 20 years has increased from 9.1 years (+/- 2.3 years) in 1993-1995 to 23.6 years (+/- 4.4 years) in 2002-2004. Subjects in 1993-1995 were more likely to die than those who started therapy in 2002-2004 (hazard ratio 2.78; 95% CI 1.92-3.85). Patients who initiated dual therapy or therapies containing three or more antiretroviral drugs were, respectively, 1.49 (95% CI 1.23-1.82) and 2.56 (95% CI 2.13-3.13) times less likely to die than those who started on monotherapy.

CONCLUSION

A significant and progressive decrease in mortality and increase in life expectancy were observed over the 12-year study period. The increase in life expectancy and decrease in mortality were directly associated with the use of modern forms of HAART.

Response to highly active antiretroviral therapy among severely immuno-compromised HIV-infected patients in Cambodia

BACKGROUND

HAART efficacy was evaluated in a real-life setting in Phnom Penh (Médecins Sans Frontières programme) among severely immuno-compromised patients.

METHODS

Factors associated with mortality and immune reconstitution were identified using Cox proportional hazards and logistic regression models, respectively.

RESULTS

From July 2001 to April 2005, 1735 patients initiated HAART, with median CD4 cell count of 20 (inter-quartile range, 6-78) cells/microl. Mortality at 2 years increased as the CD4 cell count at HAART initiation decreased, (4.4, 4.5, 7.5 and 24.7% in patients with CD4 cell count > 100, 51-100, 21-50 and < or = 20 cells/microl, respectively; P < 10). Cotrimoxazole and fluconazole prophylaxis were protective against mortality as long as CD4 cell counts remained < or = 200 and < or = 100 cells/microl, respectively. The proportion of patients with successful immune reconstitution (CD4 cell gain > 100 cells/microl at 6 months) was 46.3%; it was lower in patients with previous ART exposure [odds ratio (OR), 0.16; 95% confidence interval (CI), 0.05-0.45] and patients developing a new opportunistic infection/immune reconstitution infection syndromes (OR, 0.71; 95% CI, 0.52-0.98). Similar efficacy was found between the stavudine-lamivudine-nevirapine fixed dose combination and the combination stavudine-lamivudine-efavirenz in terms of mortality and successful immune reconstitution. No surrogate markers for CD4 cell change could be identified among total lymphocyte count, haemoglobin, weight and body mass index.

CONCLUSION

Although CD4 cell count-stratified mortality rates were similar to those observed in industrialized countries for patients with CD4 cell count > 50 cells/microl, patients with CD4 cell count < or = 20 cells/microl posed a real challenge to clinicians. Widespread voluntary HIV testing and counselling should be encouraged to allow HAART initiation before the development of severe immuno-suppression.

The role of sexually transmitted infections in male circumcision effectiveness against HIV--insights from clinical trial simulation

Background

A landmark randomised trial of male circumcision (MC) in Orange Farm, South Africa recently showed a large and significant reduction in risk of HIV infection, reporting MC effectiveness of 61% (95% CI: 34%–77%). Additionally, two further randomised trials of MC in Kisumu, Kenya and Rakai, Uganda were recently stopped early to report 53% and 48% effectiveness, respectively. Since MC may protect against both HIV and certain sexually transmitted infections (STI), which are themselves cofactors of HIV infection, an important question is the extent to which this estimated effectiveness against HIV is mediated by the protective effect of circumcision against STI. The answer lies in the trial data if the appropriate statistical analyses can be identified to estimate the separate efficacies against HIV and STI, which combine to determine overall effectiveness.

Objectives and Methods

Focusing on the MC trial in Kisumu, we used a stochastic prevention trial simulator (1) to determine whether statistical analyses can validly estimate efficacy, (2) to determine whether MC efficacy against STI alone can produce large effectiveness against HIV and (3) to estimate the fraction of all HIV infections prevented that are attributable to efficacy against STI when both efficacies combine.

Results

Valid estimation of separate efficacies against HIV and STI as well as MC effectiveness is feasible with available STI and HIV trial data, under Kisumu trial conditions. Under our parameter assumptions, high overall effectiveness of MC against HIV was observed only with a high MC efficacy against HIV and was not possible on the basis of MC efficacy against STI alone. The fraction of all HIV infections prevented which were attributable to MC efficacy against STI was small, except when efficacy of MC specifically against HIV was very low. In the three MC trials which reported between 48% and 61% effectiveness (combining STI and HIV efficacies), the fraction of HIV infections prevented in circumcised males which were attributable to STI was unlikely to be more than 10% to 20%.

Conclusion

Estimation of efficacy, attributable fraction and effectiveness leads to improved understanding of trial results, gives trial results greater external validity and is essential to determine the broader public health impact of circumcision to men and women.

Extrapulmonary tuberculosis by nationality, The Netherlands, 1993-2001

This study describes the epidemiology of extrapulmonary tuberculosis (TB) in the Netherlands from 1993 through 2001. We assessed whether the increasing numbers of inhabitants with a non-Western ethnic background had an effect on the number of extrapulmonary patients. We used data from the Netherlands Tuberculosis Register and included all cases of TB diagnosed in the Netherlands between January 1, 1993, and December 31, 2001. Information on age, sex, nationality, year of diagnosis, culture result, anatomic location of the site of disease, and HIV status was retrieved from the register. Of 13,258 patients with TB, 8216 (62%) had pulmonary TB, and 5042 (38%) had extrapulmonary TB. Non-Dutch nationals were more likely to have most types of extrapulmonary TB. The growth of the number of inhabitants with a non-Western ethnic background in the Netherlands explains the proportional growth of extrapulmonary TB. Physicians need to be aware of the changing clinical picture of TB.

Effective therapy has altered the spectrum of cause-specific mortality following HIV seroconversion

INTRODUCTION

Although HAART has led to a reduction in overall mortality among HIV-infected individuals, its impact on death from specific causes is unknown.

METHODS

Twenty-two cohorts of HIV-infected individuals with known dates of seroconversion are pooled in the CASCADE collaboration. Causes of death (COD) were categorized into three AIDS-related and seven non-AIDS-related causes. The unknown causes were assigned a separate category. The cumulative incidence for each COD was calculated in the presence of the other competing COD, for the pre-HAART and HAART eras. A multivariate regression analyses for the cumulative rate of progression to the different COD was performed.

RESULTS

A total of 1938 of 7680 HIV-seroconverters died. Pre-HAART, AIDS opportunistic infections (OI) was the most common COD, followed by unknown and HIV/AIDS-unspecified. In the HAART era, the cumulative incidence for all AIDS-related COD decreased, OI remaining the most important. Large reductions in death due to other infections and organ failure were seen. Cumulative death risk decreased in the HAART era for most causes. The effect of HAART was not the same for all risk groups. The cumulative risk of death from AIDS-related malignancies, OI and non-AIDS-related malignancies decreased significantly among homosexual men (MSM), whereas the risk of dying from (un)-intentional death increased significantly among injecting drug users (IDU). A non-significant increase in hepatitis/liver-related death was seen in MSM, IDU and haemophiliacs.

CONCLUSION

Overall and cause specific mortality decreased following the introduction of HAART. OI remain the most common COD in the HAART era, suggesting that AIDS-related events will continue to be important in the future. Future trends in COD should be monitored using standardized guidelines.