Mortality and causes of death in people living with HIV in the era of combination antiretroviral therapy compared with the general population in Japan

Incidence of Colon Cancer Among Medicaid Beneficiaries With or Without Human Immunodeficiency Virus Under Comparable Colorectal Cancer Screening Patterns

Background

People with human immunodeficiency virus (HIV; PWH) in the United States have a lower incidence of colon cancer than the general population. The lower incidence may be explained by differences in receipt of screening. Thus, we sought to estimate colon cancer incidence under scenarios in which Medicaid beneficiaries, with or without HIV, followed the same screening protocols.

Methods

We used data from 1.5 million Medicaid beneficiaries who were enrolled in 14 US states in 2001-2015 and aged 50-64 years; 72 747 beneficiaries had HIV. We estimated risks of colon cancer and death by age, censoring beneficiaries when they deviated from 3 screening protocols, which were based on Medicaid's coverage policy for endoscopies during the time period, with endoscopy once every 2, 4, or 10 years. We used inverse probability weights to control for baseline and time-varying confounding and informative loss to follow-up. Analyses were performed overall, by sex, and by race/ethnicity.

Results

PWH had a lower incidence of colon cancer than beneficiaries without HIV. Compared with beneficiaries without HIV, the risk difference at age 65 years was -1.6% lower (95% confidence interval, -2.3% to -.7%) among PWH with the 2-year protocol and -0.8% lower (-1.3% to -.3%) with the 10-year protocol. Results were consistent across subgroup and sensitivity analyses.

Conclusions

Our findings suggest that the lower risk of colon cancer that has been observed among PWH aged 50-64 years compared with those without HIV is not due to differences in receipt of lower endoscopy. Keywords: colon cancer, colorectal cancer screening, endoscopy, Medicaid, human immunodeficiency virus.

Nationwide Longitudinal Annual Survey of HIV/AIDS Referral Hospitals in Japan From 1999 to 2021: Trend in Non-AIDS-defining Cancers Among Individuals Infected With HIV-1

BACKGROUND

Non-AIDS-defining cancers (NADCs) in patients infected with HIV have recently attracted attention because of the improved survival of this patient population. To obtain accurate data, a longitudinal study is warranted for the nationwide surveillance of the current status and national trend of NADCs in patients infected with HIV in Japan.

SETTING

An annual nationwide surveillance of NADCs in patients infected with HIV-1 in Japan from 1999 to 2021.

METHODS

An annual questionnaire was sent to 378 HIV/AIDS referral hospitals across Japan to collect data (clusters of differentiation 4-positive lymphocytes, time of onset, outcomes, and antiretroviral therapy status) of patients diagnosed with any of the NADCs between 1999 and 2021.

RESULTS

The response and case-capture rates for the questionnaires in 2021 were 37.8% and 81.2%, respectively. The number of reported NADC cases subsequently increased since the beginning of this study. Evaluation of the case counts of NADCs demonstrated a high incidence of lung, colorectal, gastric, and liver cancers as the top 4 cancers. Pancreatic cancer (0.63), lung cancer (0.49), and leukemia (0.49) had the highest mortality rates among the NADCs. Trends of NADCs regarding transmission routes were maintained over the years in male individuals who have sex with male individuals compared with heterosexual male individuals and female individuals.

CONCLUSIONS

We demonstrated an increasing trend in the incidence of NADCs over a period of 23 years in Japan. The current data highlighted the importance of raising awareness regarding cancer management for patients infected with HIV in Japan.

Coronary artery stenosis in Japanese people living with HIV-1 with or without haemophilia

An extremely high prevalence (12.2%) of moderate-to-severe coronary artery stenosis (CAS) was documented in asymptomatic Japanese haemophiliacs living with HIV-1 (JHLH) in our previous study. The cause of this phenomenon remains unknown. We conducted the CAS screening in people living with HIV-1 without haemophilia (PLWH without haemophilia) to compare the prevalence of CAS in JHLH and PLWH without haemophilia and to identify the risk factors including inflammation markers. Ninety-seven age-matched male PLWH without haemophilia who consulted our outpatient clinic between June and July 2021 were randomly selected, and 69 patients who provided informed consent were screened for CAS using coronary computed tomography angiography (CCTA). The number of JHLH cases was 62 in this study. The prevalence of moderate (> 50%) to severe (> 75%) CAS was significantly higher in JHLH [14/57 (24.6%) vs. 6/69 (8.7%), p = 0.015], and the ratio of CAS requiring urgent interventions was significantly higher [7 (12.3%) vs. 1 (1.4%), p = 0.013] in JHLH than in PLWH without haemophilia. Among the inflammatory markers, serum titres of intercellular adhesion molecule-1 (p < 0.05) and interleukin-6 (p < 0.05) in JHLH were significantly higher than those in PLWH without haemophilia. Although some patient demographics were different in the age-matched study, it might be possible to speculate that intravascular inflammation might promote CAS in JHLH.

Survival and mortality profile among people living with HIV in a cohort in the Northeastern region of Brazil

Conditions related to the acquired immune deficiency syndrome (AIDS) are still a significant cause of morbidity and mortality among people living with HIV (PLHIV). Longer survival in this population were reported to increase the risk of developing noncommunicable chronic diseases (NCDs). This study aimed to estimate the survival and causes of death according to age group and sex among PLHIV monitored at two referral centers in the Northeastern Brazil. This is a prospective, retrospective cohort with death records from 2007 to 2018, based on a database that registers causes of death using the International Classification of Disease (ICD-10), which were subsequently coded following the Coding Causes of Death in HIV (CoDe). A total of 2,359 PLHIV participated in the study, with 63.2% being men, with a follow-up period of 13.9 years. Annual mortality rate was 1.46 deaths per 100 PLHIV (95% CI: 1.33 - 1.60) with a frequency of 20.9%. Risk of death for men increased by 49% when compared to women, and the risk of death in PLHIV increased by 51% among those aged 50 years and over at the time of diagnosis. It was observed that 73.5% accounted for AIDS-related deaths, 6.9% for non-AIDS defining cancer, 6.3% for external causes, and 3.2% for cardiovascular diseases. Among the youngest, 97.2% presented an AIDS-related cause of death. Highest frequency of deaths from neoplasms was among women and from external causes among men. There is a need for health services to implement strategies ensuring greater adherence to treatment, especially among men and young people. Moreover, screening for chronic diseases and cancer is essential, including the establishment of easily accessible multidisciplinary care centers that can identify and address habits such as illicit drug use and alcoholism, which are associated with violent deaths.

Mortality and comorbidities in a Nationwide cohort of HIV-infected adults: comparison to a matched non-HIV adults' cohort, France, 2006-18

BACKGROUND

Human immunodeficiency virus (HIV) remains a significant cause of morbidity and mortality worldwide. The aim of this study was to describe the mortality rate and associated comorbidities in a nationwide population-based cohort of persons living with HIV (PLWHIV) and to compare it with mortality in an age and gender-matched cohort of non-HIV individuals in France.

METHODS

Using data from the French national health data system, we identified and included 173 712 PLWHIV (66.5% men) and 173 712 non-HIV participants (66.5% men) matched for age and gender. PLHIV were identified based on ICD-10 HIV diagnoses, HIV-specific laboratory tests, and/or prescriptions for antiretroviral therapy specific to HIV. Hazard ratios (HRs) of mortality were assessed using multiple Cox regression models.

RESULTS

During the 13 years of follow-up (2006-18), we observed 20 018 deaths among PLWHIV compared with 6262 deaths among non-HIV participants (11.52% vs. 3.60%, P < 0.001). The over-mortality of PLWHIV was expressed by univariable HR = 2.135 (2.072-2.199), which remained significant after adjustment for region, Complementary Universal Health Insurance and AME, with multivariable HR = 2.182 (2.118-2.248). The results remained significant after adjusting for comorbidities, including infectious diseases [HR = 1.587 (1.538-1.638)]. Notably, PLWHIV were more importantly associated with mortality in women [HR = 2.966 (2.767-3.180)], compared in men [HR = 1.961 (1.898-2.027)].

CONCLUSION

Although the life expectancy of PLWHIV has globally increased, the causes of death should be prioritized in prevention policies and care management. Gender-specific policies should be highlighted, as we observed a higher impact of HIV mortality in women.

Identification of viral protein R of human immunodeficiency virus-1 (HIV) and interleukin-6 as risk factors for malignancies in HIV-infected individuals: A cohort study

BACKGROUND

Despite effective antiretroviral therapy, patients with human immunodeficiency virus type-1 (HIV) suffer from a high frequency of malignancies, but related risk factors remain elusive. Here, we focused on blood-circulating viral protein R (Vpr) of HIV, which induces proinflammatory cytokine production and genotoxicity by exogenous functions.

METHODS AND FINDINGS

A total 404 blood samples of HIV patients comprising of 126 patients with malignancies (tumor group) and 278 patients without malignancies (non-tumor group), each of 96 samples was first selected by one-to-one propensity score matching. By a detergent-free enzyme-linked immunosorbent assays (detection limit, 3.9 ng/mL), we detected Vpr at a higher frequency in the matched tumor group (56.3%) than in the matched non-tumor group (39.6%) (P = 0.030), although there was no different distribution of Vpr levels (P = 0.372). We also detected anti-Vpr immunoglobulin (IgG), less frequently in the tumor group compared with the tumor group (22.9% for tumor group vs. 44.8% for non-tumor group, P = 0.002), and the proportion of patients positive for Vpr but negative of anti-Vpr IgG was significantly higher in the tumor group than in the non-tumor group (38.6% vs. 15.6%, respectively, P < 0.001). Additionally, Interleukin-6 (IL-6), the levels of which were high in HIV-1 infected patients (P < 0.001) compared to non-HIV-infected individuals, was significantly higher in advanced cases of tumors (P < 0.001), and IL-6 level was correlated with Vpr in the non-tumor group (P = 0.010). Finally, multivariate logistic regression analysis suggested a positive link of Vpr with tumor occurrence in HIV patients (P = 0.002).

CONCLUSION

Vpr and IL-6 could be risk factors of HIV-1 associated malignancies, and it would be importance to monitor these molecules for well managing people living with HIV-1.

Risk factors for suicide among veterans living with and without HIV: a nested case-control study

The rate of suicide among people with HIV (PWH) remains elevated compared to the general population. The aim of the study was to examine the association between a broad range of risk factors, HIV-specific risk factors, and suicide. We conducted a nested case-control study using data from the Veterans Aging Cohort Study (VACS) between 2006 and 2015. The risk of suicide was estimated using conditional logistic regression and models were stratified by HIV status. Most risk factors associated with suicide were similar between PWH and people without HIV; these included affective disorders, use of benzodiazepines, and mental health treatment. Among PWH, HIV-specific risk factors were not associated with suicide. A multiplicative interaction was observed between a diagnosis of HIV and a previous suicide attempt. Among PWH, a high prevalence of psychiatric, substance use disorders and multimorbidity contribute to the risk of suicide.

Comparing Cancer Incidence in an Observational Cohort of Medicaid Beneficiaries With and Without HIV, 2001-2015

BACKGROUND

Life expectancy among people with HIV (PWH) is increasing, making chronic conditions-including cancer-increasingly relevant. Among PWH, cancer burden has shifted from AIDS-defining cancers (ADCs) toward non-AIDS-defining cancers (NADCs).

SETTING

We described incidence of cancer in a claims-based cohort of Medicaid beneficiaries. We included 43,426,043 Medicaid beneficiaries (180,058 with HIV) from 14 US states, aged 18-64, with >6 months of enrollment (with no dual enrollment in another insurance) and no evidence of a prveious cancer.

METHODS

We estimated cumulative incidence of site-specific cancers, NADCs, and ADCs, by baseline HIV status, using age as the time scale and accounting for death as a competing risk. We compared cumulative incidence across HIV status to estimate risk differences. We examined cancer incidence overall and by sex, race/ethnicity, and calendar period.

RESULTS

PWH had a higher incidence of ADCs, infection-related NADCs, and death. For NADCs such as breast, prostate, and colon cancer, incidence was similar or higher among PWH below age 50, but higher among those without HIV by age 65. Incidence of lung and head and neck cancer was always higher for female beneficiaries with HIV, whereas the curves crossed for male beneficiaries. We saw only small differences in incidence trends by race/ethnicity.

CONCLUSION

Our findings suggest an increased risk of certain NADCs at younger ages among PWH, even when compared against other Medicaid beneficiaries, and highlight the importance of monitoring PWH for ADCs and NADCs. Future work should explore possible mechanisms explaining the differences in incidence for specific cancer types.

Cost-effectiveness analysis of HIV pre-exposure prophylaxis in Japan

BACKGROUND

While global efforts have been made to prevent transmission of HIV, the epidemic persists. Men who have sex with men (MSM) are at high risk of infection. Despite evidence of its cost-effectiveness in other jurisdictions, pre-exposure prophylaxis (PrEP) for MSM is neither approved nor reimbursed in Japan.

METHOD

The cost-effectiveness analysis compared the use of once daily PrEP versus no PrEP among MSM over a 30-year time horizon from a national healthcare perspective. Epidemiological estimates for each of the 47 prefectures informed the model. Costs included HIV/AIDS treatment, HIV and testing for sexually transmitted infections, monitoring tests and consults, and hospitalization costs. Analyses included health and cost outcomes, as well as the incremental cost-effectiveness ratio (ICER) reported as the cost per quality-adjusted life year (QALY) for all of Japan and each prefecture. Sensitivity analyses were performed.

FINDINGS

The estimated proportion of HIV infections prevented with the use of PrEP ranged from 48% to 69% across Japan, over the time horizon. Cost savings due to lower monitoring costs and general medical costs were observed. Assuming 100% coverage, for Japan overall, daily use of PrEP costs less and was more effective; daily use of PrEP was cost-effective at a willingness to pay threshold of ¥5,000,000 per QALY in 32 of the 47 prefectures. Sensitivity analyses found that the ICER was most sensitive to the cost of PrEP.

INTERPRETATION

Compared to no PrEP use, once daily PrEP is a cost-effective strategy in Japanese MSM, reducing the clinical and economic burden associated with HIV.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Efficacy of Antibodies Targeting TfR1 in Xenograft Mouse Models of AIDS-Related Non-Hodgkin Lymphoma

Transferrin receptor 1 (TfR1), also known as CD71, is a transmembrane protein involved in the cellular uptake of iron and the regulation of cell growth. This receptor is expressed at low levels on a variety of normal cells, but is upregulated on cells with a high rate of proliferation, including malignant cells and activated immune cells. Infection with the human immunodeficiency virus (HIV) leads to the chronic activation of B cells, resulting in high expression of TfR1, B-cell dysfunction, and ultimately the development of acquired immunodeficiency syndrome-related B-cell non-Hodgkin lymphoma (AIDS-NHL). Importantly, TfR1 expression is correlated with the stage and prognosis of NHL. Thus, it is a meaningful target for antibody-based NHL therapy. We previously developed a mouse/human chimeric IgG3 specific for TfR1 (ch128.1/IgG3) and showed that this antibody exhibits antitumor activity in an in vivo model of AIDS-NHL using NOD-SCID mice challenged intraperitoneally with 2F7 human Burkitt lymphoma (BL) cells that harbor the Epstein-Barr virus (EBV). We have also developed an IgG1 version of ch128.1 that shows significant antitumor activity in SCID-Beige mouse models of disseminated multiple myeloma, another B-cell malignancy. Here, we aim to explore the utility of ch128.1/IgG1 and its humanized version (hu128.1) in mouse models of AIDS-NHL. To accomplish this goal, we used the 2F7 cell line variant 2F7-BR44, which is more aggressive than the parental cell line and forms metastases in the brain of mice after systemic (intravenous) administration. We also used the human BL cell line JB, which in contrast to 2F7, is EBV-negative, allowing us to study both EBV-infected and non-infected NHL tumors. Treatment with ch128.1/IgG1 or hu128.1 of SCID-Beige mice challenged locally (subcutaneously) with 2F7-BR44 or JB cells results in significant antitumor activity against different stages of disease. Treatment of mice challenged systemically (intravenously) with either 2F7-BR44 or JB cells also showed significant antitumor activity, including long-term survival. Taken together, our results suggest that targeting TfR1 with antibodies, such as ch128.1/IgG1 or hu128.1, has potential as an effective therapy for AIDS-NHL.

Longitudinal impact of compliance with routine CD4 monitoring on all cause deaths among treated people with HIV in China

Keeping adherence to the continuous and standardized CD4 follow-up monitoring service is of great significance to the control of disease progression and the reduction of avoidable mortality for HIV-infected patients. As non-communicable diseases (NCDs) have become main causes of deaths for people with HIV (PWH) in the era of combination antiretroviral therapy (cART), how and to what extent does adherence to routine CD4 monitoring differentially impact on AIDS-related versus NCDs-related deaths in low- and middle-income countries (LMIC) remains elucidated. A CD4 test index was developed by dividing the actual number of received CD4 tests by the theoretical number of CD4 tests that should have been performed according to national treatment guidelines during the study period, with an index value of 0.8-1.2 reflecting compliance. From 1989 to 2020, 14,571 adults were diagnosed with HIV infection in Dehong Prefecture of Yunnan province in Southwestern China, 6,683 (45.9%) PWH had died with the all-cause mortality of 550.13 per 10,000 person-years, including 3,250 (48.6%) AIDS-related deaths (267.53 per 10,000 person-years). Among patients on cART, the median CD4 test index was 1.0 (IQR 0.6-1.3), and 35.2% had a CD4 test index less than 0.8. Cox proportional hazards regression analysis indicated that PWH with CD4 test index at 0.8-1.2 were at the lowest risk of both AIDS-related (aHR = 0.06; 95%CI: 0.05-0.07) and NCDs-related (aHR = 0.13; 95%CI: 0.11-0.16)deaths. Adherence to routine CD4 monitoring is critical for reducing both AIDS-related and NCDs-related mortality of PWH. An appropriate (once or twice a year) rather than an unnecessarily higher frequency of routine CD4 testing could be most cost-effective in reducing mortality in LMIC.

Pandemics and Suicide Risk: Lessons From COVID and Its Predecessors

ABSTRACT

In its mortality and global reach, COVID-19 is among the worst pandemics to hit the globe since the 1918 influenza. During a pandemic, it is not uncommon for deaths from suicide to be downplayed as communities respond to the immediate mortality of the disease. In this analysis, we review pandemic history to uncover its impact on suicide rates, a frequent proxy for community mental health, and whether public health responses were effective. We incorporate lessons from more than 100 years of epidemics to assess whether the current public health response can benefit from the lessons of history.

Suicidality Among People Living With HIV From 2010 to 2021: A Systematic Review and a Meta-regression

OBJECTIVE

The association between human immunodeficiency virus (HIV)/AIDS and suicidality is not well understood, partly because of variability in results. This meta-analysis aimed to investigate the predictive value of HIV/acquired immune deficiency syndrome for incident suicidality.

METHODS

A literature review was conducted of articles published between January 1, 2010, and October 31, 2021. The following databases were searched: Embase, MEDLINE, CINAHL, Web of Science, and Scopus. The search terms included human immunodeficiency virus (HIV), suicidal behavior, auto mutilation, and self-injurious behavior. Observational studies were screened following a registered protocol, and eligible ones were meta-analyzed and followed by meta-regression.

RESULTS

A total of 43 studies were included in this systematic review, and a meta-regression included 170,234 participants. The pooled prevalence estimates of suicidal ideation, attempted suicide, and deaths by suicide were 22.3%, 9.6%, and 1.7%, respectively. The following significant risk factors for suicide ideation were found: substance use, depression, low quality of life, low social support, without HIV status disclosure, living alone, low level of memory problems, family history of suicide, and stage III of HIV. Risk factors for suicide attempts were depression and family history of suicide. An elevated risk for suicide-related death was found for people living with HIV (PLHIV) who had a psychiatric disorder and in studies conducted in hospital-based settings (versus national database studies or HIV clinic settings).

CONCLUSIONS

The risk of suicidality is high among PLHIV within all six World Health Organization regions during the modern antiretroviral therapy era. Assessment of socioeconomic and psychological factors is recommended for further management to prevent suicide among PLHIV. The present findings are useful for design of intervention protocols and development of clinical practice guidelines intended to manage the well-being of PLHIV worldwide.

Safety and efficacy of pharmacotherapy containing INSTIs and chemotherapy drugs in people living with HIV and concomitant colorectal cancer

Background

Previous clinical data have shown that raltegravir-based antiretroviral therapy (ART) with fewer drug-drug interactions (DDIs) and adverse events (AEs) is a good regimen in patients with HIV infection who need cancer chemotherapy. There are currently few data on ART regimens that include Integrase inhibitors (INSTIs) other than RAL among this patient subgroup.

Methods

We evaluated the safety and efficacy of different kinds of INSTI-based regimens among patients with HIV and concomitant colorectal cancer (CRC) who received antineoplastic agents.

Results

From January 2020 to November 2021, 66 patients were enrolled. The patients were divided into three groups: 20 patients treated with dolutegravir (DTG)/lamivudine (3TC)/tenofovir (TDF) (group I), 24 patients treated with DTG/albuvirtide (ABT) (group II), and 22 patients treated with bictegravir (BIC)/tenofovir alafenamide (TAF)/emtricitabine (FTC) (group III). The majority of AEs during treatment were of grade 1–2. Treatment‐related AEs of grade 3–4 occurred in 6 patients (9.09%), and no grade 5 AEs occurred. The most common AEs were nausea (100%) and neutrophils (84.85%) attributed to anticancer agents, and there was no significant difference in the incidence of these AEs among the three groups (P > 0.05). Viral load rebound was not observed among pretreated patients during chemotherapy. The viral load of untreated patients who started their ART concomitant with chemotherapy almost decreased to the lower limit of detection 6 months after ART initiation (only one patient in group III had a viral load of 102 copies/ml). At the 6th month, the CD4 count in group I decreased significantly from baseline (P < 0.05). However, the change in CD4 count was not significant in group II (P = 0.457) or group III (P = 0.748).

Conclusions

DTG- or BIC-containing regimens are good options for patients with HIV and concomitant CRC.

Mortality and Causes of Death among Individuals Diagnosed with Human Immunodeficiency Virus in Korea, 2004-2018: An Analysis of a Nationwide Population-Based Claims Database

The mortality rate and causes of death among individuals diagnosed with human immunodeficiency virus (HIV) infection in Korea were described and compared to those of the general population of Korea using a nationwide population-based claims database. We included 13,919 individuals aged 20-79 years newly diagnosed with HIV between 2004 and 2018. The patients' vital status and cause of death were linked until 31 December 2019. Standardized mortality ratios (SMRs) for all-cause death and specific causes of death were calculated. By the end of 2019, 1669 (12.0%) of the 13,919 HIV-infected participants had died. The survival probabilities of HIV-infected individuals at 1, 5, 10, and 15 years after diagnosis in Korea were 96.2%, 91.6%, 85.9%, and 79.6%, respectively. The main causes of death during the study period were acquired immunodeficiency syndrome (AIDS; 59.0%), non-AIDS-defining cancer (8.2%), suicide (7.4%), cardiovascular disease (4.9%), and liver disease (2.7%). The mortality rate of men and women infected with HIV was 5.60-fold (95% CI = 5.32-5.89) and 6.18-fold (95% CI = 5.30-7.09) that of men and women in the general population, respectively. After excluding deaths due to HIV, the mortality remained significantly higher, with an SMR of 2.16 (95% CI = 1.99-3.24) in men and 3.77 (95% CI = 3.06-4.48) in women. HIV-infected individuals had a higher overall mortality than the general population, with AIDS the leading cause of mortality. Additionally, mortality due to non-AIDS-related causes was higher in HIV-infected individuals.

Determinants of Survival of HIV Patients Receiving Dolutegravir: A Prospective Cohort Study in Conflict-Affected Bunia, Democratic Republic of Congo

This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan-Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group (adjusted hazard ratio = 6.04; 95% CI: 1.78-20.43). One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women's inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.

Nationwide population-based incidence of cancer among patients with HIV/AIDS in South Korea

Cancers are the leading cause of death among people living with HIV/AIDS (PLWHA); however, nationwide studies on cancer incidence are limited. We aimed to determine the trends in the incidence rates of AIDS-defining cancers (ADCs) and non-AIDS-defining cancers (NADCs) among Korean PLWHA. Data from the National Health Insurance Sharing Service from 2004 to 2017 were collected. Age- and sex-adjusted standardized incidence ratios (SIRs) for various cancer types relative to the general population were calculated. Of the 11,737 PLWHA followed-up for 65,052 person-years (PYs), 445 (ADCs, 130 and NADCs, 298) developed cancer. The incidence rate of ADCs decreased, whereas that of NADCs remained unchanged. PLWHA were at an increased risk of ADCs (SIR: 12.6, 95% CI: 10.6–15.0), including Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and cervical cancer, and some NADCs, including anal cancer, lung cancer, liver cancer, and oropharyngeal cancer. Of the 396 patients who received antiretroviral therapy (ART), 215 with optimal adherence had lower incidence rates for ADCs and NADCs than those with non-optimal adherence. The 5-year survival rate of PLWHA with NADCs was 57.8%. Close surveillance and routine screening of cancers and improvement in ART adherence are required to improve the clinical outcomes of PLWHA.

The Association of HLA-B*35 and GSTT1 Genotypes and Hepatotoxicity in Thai People Living with HIV

Glutathione s-transferase (GST) is a family of drug-metabolizing enzymes responsible for metabolizing and detoxifying drugs and xenobiotic substances. Therefore, deletion polymorphisms of GSTs can be implicated in developing several pathological conditions, including antiretroviral drug-induced liver injury (ARVDILI). Notably, GST polymorphisms have been shown to be associated with ARVDILI risk. However, data on GST polymorphisms in the Thai population are limited. Therefore, this study investigated possible associations between GST genetic polymorphisms and ARVDILI development. A total of 362 people living with HIV (PLHIV) and 85 healthy controls from multiple centers were enrolled. GSTM1 and GSTT1 genetic polymorphisms were determined using polymerase chain reactions. In addition, HLA genotypes were determined using a sequence-based HLA typing method. After comparing GST genotypic frequencies, there was no significant difference between PLHIV and healthy volunteers. However, while observing the PLHIV group, GSTT1 wild type was significantly associated with a 2.04-fold increased risk of ARVDILI (95%CI: 1.01, 4.14; p = 0.045). Interestingly, a combination of GSTT1 wild type and HLA-B*35:05 was associated with a 2.28-fold higher risk of ARVDILI (95%CI: 1.15, 4.50; p = 0.02). Collectively, GSTT1 wild type and a combination of GSTT1 wild type plus HLA-B*35:05 were associated with susceptibility to ARVDILI in the Thai population.

HCV cure: an appropriate moment to reduce cannabis use in people living with HIV? (ANRS CO13 HEPAVIH data)

BACKGROUND

Thanks to direct-acting antivirals, hepatitis C virus (HCV) infection can be cured, with similar rates in HCV-infected and HIV-HCV co-infected patients. HCV cure is likely to foster behavioral changes in psychoactive substance use, which is highly prevalent in people living with HIV (PLWH). Cannabis is one substance that is very commonly used by PLWH, sometimes for therapeutic purposes. We aimed to identify correlates of cannabis use reduction following HCV cure in HIV-HCV co-infected cannabis users and to characterize persons who reduced their use.

METHODS

We used data collected on HCV-cured cannabis users in a cross-sectional survey nested in the ANRS CO13 HEPAVIH cohort of HIV-HCV co-infected patients, to perform logistic regression, with post-HCV cure cannabis reduction as the outcome, and socio-behavioral characteristics as potential correlates. We also characterized the study sample by comparing post-cure substance use behaviors between those who reduced their cannabis use and those who did not.

RESULTS

Among 140 HIV-infected cannabis users, 50 and 5 had reduced and increased their use, respectively, while 85 had not changed their use since HCV cure. Cannabis use reduction was significantly associated with tobacco use reduction, a decrease in fatigue level, paying more attention to one's dietary habits since HCV cure, and pre-HCV cure alcohol abstinence (p = 0.063 for alcohol use reduction).

CONCLUSIONS

Among PLWH using cannabis, post-HCV cure cannabis reduction was associated with tobacco use reduction, improved well-being, and adoption of healthy behaviors. The management of addictive behaviors should therefore be encouraged during HCV treatment.

Analysis of Deaths among HIV-Infected Patients Hospitalized in 2009–2018 in Main Centre of Infectious Disease in Region of Lower Silesia in Poland, Detailing Lesions in the Central Nervous System

Background and Objectives: Patients living with HIV (PLWH), especially those diagnosed too late or not receiving treatment with antiretroviral drugs in the stage of advanced immunodeficiency AIDS for various reasons, develop additional opportunistic infections or AIDS-defining diseases that may contribute directly to the death of these patients. Material and Methods: In this work, we focused on disorders of the central nervous system (CNS) by retrospectively analyzing the symptoms, clinical and autopsy diagnoses of patients diagnosed with HIV infection who died in the provincial specialist hospital in the Lower Silesia region in Poland. Results: The autopsy was performed in 27.4% cases. The cause of death was determined to be HIV-related/AIDS-associated in 78% patients. The most common AIDS-defining CNS diseases in our cohort were toxoplasmosis and cryptococcosis. Conslusions: The presented results of the most common causes of changes in the central nervous system among deceased HIV-infected patients are comparable to the results of studies by other scientists cited in the publication.

A Systematic Review of Risk Factors for Suicide Among Persons Living with HIV (1996-2020)

Persons living with HIV (PWH) are at elevated risk for suicide. We conducted a systematic literature review following PRISMA-P guidelines to examine risk factors associated with suicide as a cause of morbidity among PWH. We searched six electronic databases using search terms (suicide, suicide attempt, self-harm, self-injurious behavior, HIV, AIDS, PWH). We focused on factors that were specific to HIV infection (CD4 count, HIV-1 RNA, and antiretroviral therapy [ART]). The initial search yielded N = 2657 studies. Eligible studies included suicide as an outcome, quantitative study design, and publication in peer-reviewed journals from 1996 through 2020. Fourteen studies met inclusion criteria. PWH share risk factors for suicide found in the general population: psychiatric illness, previous suicide attempt, drug and alcohol misuse. PWH also have HIV-specific risk factors for suicide. HIV diagnosis in the past two years and transmission related to injection drug use were associated with increased risk; HIV-1 RNA, ART, and AIDS-defining illness were not.

Trends in suicide mortality among people with HIV after diagnosis during 2012-18: a retrospective, national cohort study in China

BACKGROUND

Little is known about suicide mortality among people with HIV in low-income and middle-income countries. This study aimed to assess suicide mortality and its temporal change among people with HIV after diagnosis, then describe potential risk factors.

METHODS

This nationwide, population-based cohort study used data from the China Information System for Disease Control and Prevention (CISDCP), which continually enrolled people diagnosed with HIV in mainland China. We included all people with HIV diagnosed between Jan 1, 2012, and Dec 31, 2018, who were aged 15 years or older at diagnosis. Follow-up started from the date of HIV diagnosis to the date of death, date of last follow-up visit, or Dec 31, 2018, whichever came first. Crude suicide mortality was calculated as the number of suicide deaths divided by person-years at risk in 2012-18 and compared by time after HIV diagnosis. Standardised mortality ratios (SMRs) were used to compare the relative risk of suicide deaths in people with HIV with the general population. We compared the trends of suicide mortality across three diagnosis year groups (2012-13, 2014-15, and 2016-18) using cumulative incidence curve of suicide. Competing-risk models were used to explore the potential risk factors of suicide.

FINDINGS

770 656 people diagnosed with HIV were included in the CISDCP database, 763 287 of whom were aged 15 years or older at diagnosis and had follow-up information available. During follow-up, 2825 (2·0%) of 144 729 all-cause deaths were due to suicide, with a mortality of 142·8 deaths by suicide per 100 000 person-years (95% CI 137·7-148·2). People with HIV were at an increased risk of suicide compared with the general population (SMR 20·9 [95% CI 20·2-21·7]). The greatest risk was during the first 3 months after diagnosis (SMR 98·1 [93·1-103·4]), which then decreased but was still elevated after the first year (SMR 9·2 [8·5-9·8]). Late diagnosis and never on antiretroviral therapy were independent risk factors for suicide.

INTERPRETATION

Suicide mortality decreased during the study period, which coincided with improvement in access to care and treatment coverage. This study suggests the importance of targeted suicide prevention for people with HIV throughout the course of diagnosis and that the focus of efforts should be concentrated on the first 3 months after diagnosis. Our findings highlight the urgent need to integrate suicide screening and prevention in HIV care.

FUNDING

Young Scholar Scientific Research Foundation of National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Mortality in HIV and tuberculosis patients following implementation of integrated HIV-TB treatment: Results from an open-label cluster-randomized trial

BACKGROUND

HIV-TB treatment integration reduces mortality. Operational implementation of integrated services is challenging. This study assessed the impact of quality improvement (QI) for HIV-TB integration on mortality within primary healthcare (PHC) clinics in South Africa.

METHODS

An open-label cluster randomized controlled study was conducted between 2016 and 2018 in 40 rural clinics in South Africa. The study statistician randomized PHC nurse-supervisors 1:1 into 16 clusters (eight nurse-supervisors supporting 20 clinics per arm) to receive QI, supported HIV-TB integration intervention or standard of care (control). Nurse supervisors and clinics under their supervision, based in the study health districts were eligible for inclusion in this study. Nurse supervisors were excluded if their clinics were managed by municipal health (different resource allocation), did not offer co-located antiretroviral therapy (ART) and TB services, services were performed by a single nurse, did not receive non-governmental organisation (NGO) support, patient data was not available for > 50% of attendees. The analysis population consists of all patients newly diagnosed with (i) both TB and HIV (ii) HIV only (among patients previously treated for TB or those who never had TB before) and (iii) TB only (among patients already diagnosed with HIV or those who were never diagnosed with HIV) after QI implementation in the intervention arm, or enrolment in the control arm. Mortality rates was assessed 12 months post enrolment, using unpaired t-tests and cox-proportional hazards model. (Clinicaltrials.gov, NCT02654613, registered 01 June 2015, trial closed).

FINDINGS

Overall, 21 379 participants were enrolled between December 2016 and December 2018 in intervention and control arm clinics: 1329 and 841 HIV-TB co-infected (10·2%); 10 799 and 6 611 people living with Human Immunodeficiency Virus (HIV)/ acquired immunodeficiency syndrome (AIDS) (PLWHA) only (81·4%); 1 131 and 668 patients with TB only (8·4%), respectively. Average cluster sizes were 1657 (range 170-5782) and 1015 (range 33-2027) in intervention and control arms. By 12 months, 6529 (68·7%) and 4074 (70·4%) were alive and in care, 568 (6·0%) and 321 (5·6%) had completed TB treatment, 1078 (11·3%) and 694 (12·0%) were lost to follow-up, with 245 and 156 deaths occurring in intervention and control arms, respectively. Mortality rates overall [95% confidence interval (CI)] was 4·5 (3·4-5·9) in intervention arm, and 3·8 (2·6-5·4) per 100 person-years in control arm clusters [mortality rate ratio (MRR): 1·19 (95% CI 0·79-1·80)]. Mortality rates among HIV-TB co-infected patients was 10·1 (6·7-15·3) and 9·8 (5·0-18·9) per 100 person-years, [MRR: 1·04 (95% CI 0·51-2·10)], in intervention and control arm clusters, respectively.

INTERPRETATION

HIV-TB integration supported by a QI intervention did not reduce mortality in HIV-TB co-infected patients. Demonstrating mortality benefit from health systems process improvements in real-world operational settings remains challenging. Despite the study being potentially underpowered to demonstrate the effect size, integration interventions were implemented using existing facility staff and infrastructure reflecting the real-world context where most patients in similar settings access care, thereby improving generalizability and scalability of study findings.

FUNDING

Research reported in this publication was supported by South African Medical Research Council (SAMRC), and UK Government's Newton Fund through United Kingdom Medical Research Council (UKMRC).

Determinants of retention in HIV antiretroviral treatment (ART) in the Cameroon International epidemiology Database to Evaluate AIDS (IeDEA) study clinics: the context of the HIV treat all strategy in Cameroon

Introduction

retaining patients in antiretroviral treatment (ART) is essential for successful outcomes. Unfortunately, Cameroon continues to report suboptimal ART retention. This study focused on identifying determinants of ART retention in three HIV clinics in Cameroon within the HIV treat all context.

Methods

a medical chart review of 423 subjects who initiated ART between July and September 2016 in the Limbe, Bamenda and Jamot Hospitals. Patients' sociodemographic and clinical characteristics and ART retention data were abstracted using structured paper forms. Chi square test was used to assess bivariate associations. Logistic regression was used to adjust for confounders. P-value was set at <0.05 at 95% confidence interval.

Results

the mean age was 40±11 years, and 65.1% were females. Antiretroviral treatment retention after 24 months was 309/392 (78.83%) and 30/423 (7.1%) were transferred-out, 11/423 (2.6%) reported dead and 73/423 (17.3%) lost to follow-up. HIV status disclosure (AOR 0.16 95% CI: 0.05-0.51, p<0.01) and age group 31-50 years (AOR 3.63, 95% CI: 1.04-12.59, P= 0.04) were associated with lower and higher ART retention respectively.

Conclusion

about a quarter of the participants were not retained in ART after 24 months. Patient-level factors determined ART retention. These factors should be considered in designing strategies to improve ART retention. More research is needed to identify other determinants of ART retention under the HIV treat all strategy.

Impact of an enhanced screening program on the detection of non-AIDS neoplasias in patients with human immunodeficiency virus infection

BACKGROUND

The incidence of non-AIDS defining cancer (NADC) is higher in people living with HIV (PLWH) than in the general population, and it is already one of the leading causes of death in the HIV-infected population. It is estimated that the situation will be aggravated by the progressive aging of PLWH. Early diagnosis through intensive cancer screening may improve the ability for therapeutic interventions and could be critical in reducing mortality, but it might also increase expenditure and harms associated with adverse events. The aim of this study is to evaluate an enhanced screening program for early diagnosis of cancer in PLWH compared to standard practice. The specific objectives are (1) to compare the frequency of cancer diagnosed at an early stage, (2) to analyze safety of the enhanced program: adverse events and unnecessary interventions, (3) to analyze the cost-utility of the program, and (4) to estimate the overall and site-specific incidence of NADC in PLWH.

METHODS

We will conduct a multicenter, non-blinded, randomized, controlled trial, comparing two parallel arms: conventional vs enhanced screening. Data will be recorded in an electronic data collection notebook. Conventional intervention group will follow the standard of care screening in the participating centers, according to the European AIDS Clinical Society recommendations, and the enhanced intervention group will follow an expanded screening aimed to early detection of lung, liver, anal, cervical, breast, prostate, colorectal, and skin cancer. The trial will be conducted within the framework of the Spanish AIDS Research Network Cohort (CoRIS).

DISCUSSION

The trial will evaluate the efficacy, safety, and efficiency of an enhanced screening program for the early diagnosis of cancer in HIV patients compared to standard of care practice. The information provided will be relevant since there are currently no studies on expanded cancer screening strategies in patients with HIV, and available data estimating cost effectiveness or cost-utility of such as programs are scarce. An enhanced program for NADC screening in patients with HIV could lead to early diagnosis and improve the prognosis of these patients, with an acceptable rate of unnecessary interventions, but it is critical to demonstrate that the benefits clearly outweigh the harms, before the strategy could be implemented.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04735445. Registered on 25 June 2019.

Influence of HLA-B*5701 on 20 year survival rate among patients living with HIV

BACKGROUND

The life expectancy of people living with HIV (PLWH) remains shorter than that of the general population, despite significant improvement in the recent years. Mortality in HIV-infected individuals may be associated with a higher viral load at of diagnosis, a lower CD4 count, or clinical variables such as sex or route of transmission. This article investigated the role of the HLA-B*5701 varian on mortality among PLWH.

METHODS

Material for the analysis consist of the data of 2,393 patients for whom the HLA-B*57 variant was known. Those patients were followed under the care of the Infectious Diseases Hospital in Warsaw (n = 1555) and the Clinic of Acquired Immunodeficiency of the Pomeranian Medical University in Szczecin (n = 838). Factors such as age, gender, date of HIV diagnosis, route of transmission, date of death, baseline HIV viral load and baseline CD4 counts, were collected, and end-point cross-sectional analyses were marked at 60, 120, 180 and 240 month of observation.

RESULTS

HLA-B*5701 allele was found in 133 (5.5%) analyzed cases. Median age was notably higher for HLA-B*5701 positive patients [32.7 (28.3-41.3) vs. 31.6 (26.8-38.3)years p = 0.02]. HLA-B*5701 was associated with lower baseline viral load [4.21 (3.5-4.8) vs. 4.79 (4.2-5.3)log copies/ml p<0.001] and higher CD4count [448 (294.5-662) vs. 352 (176-514) cells/μl p<0.001]. There were no association between HLA-B*5701 and survival for any given end-point. Higher mortality was associated to male gender, intravenous drug users, lower CD4 count at baseline and higher baseline viral load.

CONCLUSIONS

In our study, the presence of HLA-B*5701 allel was not associated with mortality rate of HIV infected patients, irrespective of being associated with both higher baseline CD4 + cell count and lower baseline HIV viral load.

Mortality predictive factors of people living with human immunodeficiency virus and bloodstream infection

INTRODUCTION

Portugal has one of the highest mortality rates for people living with HIV (PLWHIV) in Europe. After antiretroviral therapy introduction, HIV-associated mortality declined, included the one associated with bloodstream infection (BSI). However it is still high, and European data are scarce . Therefore, characterizing BSI and defining prognostic factors may improve our approach.

METHODS

This was a 10-year retrospective study of predictive factors for 30-day and 3-year mortality in PLWHIV with BSI in a tertiary infectious diseases ward.

RESULTS

Of 2134 PLWHIV admissions, 145 (6.8%) had a BSI, mostly respiratory and catheter-related bacteremia and globally community-acquired. Nosocomial infections occurred in 42 (36%) cases, mostly caused by Enterococcus spp, Staphylococcus aureus, and Candida spp. PLWHIV with a BSI had higher 30-day mortality (27%) compared to those without a BSI (14%). APACHE II score, corticotherapy, and current intravenous drug use (IDU) had a prognostic impact on 30-day mortality. Three-year survival was 54% in PLWHIV with a BSI; a CD4 <200 cells, vascular or chronic pulmonary disease, and lymphoma were prognostic factors.

CONCLUSIONS

Patients with a BSI were more likely to present advanced HIV disease, have more comorbidities, a longer length of stay, and higher 30-day mortality. IDU and severity of infection determined the short-term prognosis. Three-year mortality was primarily influenced by lower CD4 cell counts, hematological tumor, and cardiopulmonary comorbidities. Systemic corticotherapy may influence nosocomial BSI and short-term prognosis.

Risk for Non-AIDS-Defining and AIDS-Defining Cancer of Early Versus Delayed Initiation of Antiretroviral Therapy : A Multinational Prospective Cohort Study

BACKGROUND

Immediate initiation of antiretroviral therapy (ART) regardless of CD4 cell count reduces risk for AIDS and non-AIDS-related events in asymptomatic, HIV-positive persons and is the standard of care. However, most HIV-positive persons initiate ART when their CD4 count decreases below 500 × 10⁹ cells/L. Consequences of delayed ART on risk for non-AIDS-defining and AIDS-defining cancer, one of the most common reasons for death in HIV, are unclear.

OBJECTIVE

To estimate the long-term risk difference for cancer with the immediate ART strategy.

DESIGN

Multinational prospective cohort study.

SETTING

The D:A:D (Data collection on Adverse events of anti-HIV Drugs) study, which included HIV-positive persons from Europe, Australia, and the United States.

PARTICIPANTS

8318 HIV-positive persons with at least 1 measurement each of CD4 cell count and viral load while ART-naive (study period, 2006 to 2016).

MEASUREMENTS

The parametric g-formula was used, with adjustment for baseline and time-dependent confounders (CD4 cell count and viral load), to assess the 10-year risk for non-AIDS-defining and AIDS-defining cancer of immediate versus deferred (at CD4 counts <350 and <500 × 10⁹ cells/L) ART initiation strategies.

RESULTS

During 64 021 person-years of follow-up, 231 cases of non-AIDS-defining cancer and 272 of AIDS-defining cancer occurred among HIV-positive persons with a median age of 36 years (interquartile range, 29 to 43 years). With immediate ART, the 10-year risk for non-AIDS-defining cancer was 2.97% (95% CI, 2.37% to 3.50%) and that for AIDS-defining cancer was 2.50% (CI, 2.37% to 3.38%). Compared with immediate ART initiation, the 10-year absolute risk differences when deferring ART to CD4 counts less than 500 × 10⁹ cells/L and less than 350 × 10⁹ cells/L were 0.12 percentage point (CI, -0.01 to 0.26 percentage point) and 0.29 percentage point (CI, -0.03 to 0.73 percentage point), respectively, for non-AIDS-defining cancer and 0.32 percentage point (CI, 0.21 to 0.44 percentage point) and 1.00 percentage point (CI, 0.67 to 1.44 percentage points), respectively, for AIDS-defining cancer.

LIMITATION

Potential residual confounding due to observational study design.

CONCLUSION

In this young cohort, effects of immediate ART on 10-year risk for cancer were small, and further supportive data are needed for non-AIDS-defining cancer.

PRIMARY FUNDING SOURCE

Highly Active Antiretroviral Therapy Oversight Committee.

The Cost Effectiveness of Mental Health Treatment in the Lifetime of Older Adults with HIV in New York City: A Markov Approach

BACKGROUND

There are noticeable gaps in knowledge regarding the cost and effectiveness of integrated medical and behavioral services for older adults with HIV. Their lifespan is close to the population's level but their quality of life has sharply declined due to depression and substance use. Mental health disorders are widespread among an aging population with HIV.

OBJECTIVE

The aim of this study was to build a decision analytic model to evaluate medical interventions with and without mental health treatment using primary data of 139 older adults with HIV and health outcomes from the literature.

METHODS

We tracked the progression of depression and cumulative deaths among older adults with HIV using a Markov model with 50 annual cycles through three health states. Deterministic and probabilistic sensitivity analyses addressed uncertainty in estimating the parameters and around the model's assumptions.

RESULTS

An integrated medical and behavioral care system is cost effective at a willingness to pay of $50,000 per QALY compared with medical care only. The incremental cost was $516,452 and the incremental effectiveness was 38.8 quality-adjusted life-years (QALY), with an incremental cost-effectiveness ratio of $13,316 per QALY.

CONCLUSIONS

Appropriate and efficacious referrals to integrated medical + behavioral services, either in the same facility or connected to their primary care doctor, are instrumental to reverse loses in quality of life and avoid premature death. If mental health is left unattended, HIV would progress, causing declines in quality of life and ultimately triggering premature death. Reliable data on the cost and effectiveness of different types of HIV integrated services are needed.

Ventricular and atrial functions assessed by speckle-tracking echocardiography in patients with human immunodeficiency virus

PURPOSE

Antiretroviral therapy (ART) has dramatically changed the clinical manifestation of human immunodeficiency virus (HIV) associated cardiomyopathy from severe left ventricular (LV) systolic dysfunction to a pattern of subclinical cardiac dysfunction. The aim of this study was to evaluate by speckle tracking echocardiography (STE) LV, right ventricular (RV), and biatrial functions in HIV-infected patients under different ART combinations.

METHODS

We consecutively included 128 HIV-infected patients (mean age 44.2 ± 10.1 years, 110 males) and 100 controls (mean age 42.1 ± 9.4 years, 83 males). Ventricular and atrial functions were assessed by both conventional and STE.

RESULTS

Although there was not any significant difference in conventional echocardiographic variables, HIV-infected patients had significantly lower LV global longitudinal strain (GLS), RV GLS, left atrial (LA) reservoir and conduit strain, and right atrial conduit strain. HIV patients receiving integrase strand transfer inhibitors and protease inhibitors (PI) had significantly lower LV GLS and LA conduit strain, while patients receiving non-nucleoside reverse transcriptase inhibitors and PI had significantly lower RV GLS than controls. CD4 count at the time of echocardiography was strongly correlated with LV GLS (r = .619, P < .001) and RV GLS (r = .606, P < .001).

CONCLUSION

Biventricular and atrial functions are subclinically impaired in HIV-infected patients. ART regimen may also affect myocardial functions.

Changes in survival and causes of death among people living with HIV: Three decades of surveys from Tokyo, one of the Asian metropolitan cities

INTRODUCTION

Survival among people living with HIV (PLWH) has dramatically improved in the antiretroviral therapy (ART) era. This is the first study in Asia to describe three decades of surveys on survival and causes of death among PLWH.

METHODS

We included 1121 HIV-infected patients, categorized into three period groups according to date of first visit: 1986-1996 (Pre-ART); 1997-2007 (Early-ART); and 2008-2018 (Late-ART).

RESULTS

Ten-year all-cause mortality has reduced from Pre-ART (49.6/1000 person-years) to Late-ART (6.3/1000 person-years). Mortality for AIDS-defining illnesses (ADIs) has also reduced from Pre-ART (34.4/1000 person-years) to Late-ART (2.9/1000 person-years), and mortality for non-ADIs has reduced from Pre-ART (11.7/1000 person-years) to Late-ART (2.9/1000 person-years). In the ART-era, deaths from non-AIDS-defining malignancies and unnatural events including suicide represented the majority of non-ADI-related deaths and mortality rates of non-AIDS defining malignancies and unnatural cause event were not different between each group (3.4, 1.9 and 2.5/1000 person-years). Crude cumulative survival improved over the study period, and 10-year survival ratios of HIV-infected patients to the general Japanese population approached 1.00, from Pre-ART (0.66) to Late-ART (0.99). Even in the Late-ART period, survival remained lower in patients with a history of ADIs than in those without, but the difference in 5-year mortality between these groups has shrunk in the Late-ART compared to the Pre-ART.

CONCLUSIONS

Mortality for ADIs and non-ADIs in PLWH has reduced in the Early-ART and Late-ART. To improve survival for PLWH further, early HIV detection and treatment and good management of non-AIDS-defining malignancies and mental disorders are needed. (248/250).

HIV-1 Tat Activates Akt/mTORC1 Pathway and AICDA Expression by Downregulating Its Transcriptional Inhibitors in B Cells

HIV-1 infects T cells, but the most frequent AIDS-related lymphomas are of B-cell origin. Molecular mechanisms of HIV-1-induced oncogenic transformation of B cells remain largely unknown. HIV-1 Tat protein may participate in this process by penetrating and regulating gene expression in B cells. Both immune and cancer cells can reprogram communications between extracellular signals and intracellular signaling pathways via the Akt/mTORC1 pathway, which plays a key role in the cellular response to various stimuli including viral infection. Here, we investigated the role of HIV-1 Tat on the modulation of the Akt/mTORC1 pathway in B cells. We found that HIV-1 Tat activated the Akt/mTORC1 signaling pathway; this leads to aberrant activation of activation-induced cytidine deaminase (AICDA) due to inhibition of the AICDA transcriptional repressors c-Myb and E2F8. These perturbations may ultimately lead to an increased genomic instability and proliferation that might cause B cell malignancies.

Trends of Cause of Death among Human Immunodeficiency Virus Patients and the Impact of Low CD4 Counts on Diagnosis to Death: a Retrospective Cohort Study

BACKGROUND

Monitoring the full spectrum of causes of death among human immunodeficiency virus (HIV) patients has become increasingly important as survival improves because of highly active antiretroviral therapy. However, there are no recently published data regarding the changes in the causes of death among HIV patients based on year of HIV diagnosis, and the impact of low CD4 count at the time of HIV diagnosis on the clinical outcome is still unclear in Korea.

METHODS

A retrospective cohort study was conducted with 801 patients with HIV infection who were followed up at a tertiary university hospital and diagnosed with HIV between July 1984 and October 2019. The causes of death were analyzed by descriptive analysis based on CD4 count and the year of HIV diagnosis. Kaplan-Meier and log rank tests were performed to compare the prognosis between the CD4 < 200 cells/mm³ and CD4 ≥ 200 cells/mm³ groups.

RESULTS

Among 801 patients, 67 patients were eligible for the death cause analysis. Infection-related death accounted for 44 patients (65.7%) and non-infection related death accounted for 23 patients (32.4%). Pneumocystis pneumonia (29.9%) was the single most common cause of death in both past and present cases, and tuberculosis (19.4%) was the second leading cause of death from infections, but the frequency has declined in recent years. Causes of infection-related death have decreased, whereas non-infection related causes of death have increased remarkably. Malignancy-related death was the most common cause of non-infection related death. Acquired immunodeficiency syndrome (AIDS) non-related malignancy accounted for 11.9%, whereas AIDS-related malignancy accounted for 6.0% of the total death among HIV patients. No significant statistical differences were found in mortality rate (P = 0.228), causes of death (P = 0.771), or survival analysis (P = 0.089) between the CD4 < 200 cells/mm³ and CD4 ≥ 200 cells/mm³ groups.

CONCLUSION

Being diagnosed with CD4 < 200 cells/mm³ at the time of HIV diagnosis was not an indicator of greater risk of death compared with the CD4 ≥ 200 cells/mm³ group. Malignant tumors have become an important cause of death in recent years, and an increasing tendency of AIDS-non-related malignancy causes has been observed.