AIDS-related and non-AIDS-related mortality in the Asia-Pacific region in the era of combination antiretroviral treatment

Association of cardio-ankle vascular index and future major adverse cardiovascular events in older adults living with HIV

ABSTRACTIncreased arterial stiffness is an indicator of cardiovascular disease (CVD) and death in the general population. The cardio-ankle vascular index (CAVI) is a novel method for measuring arterial stiffness. This study investigated the utility of CAVI as a prognostic indicator of CVD and death in older adults living with HIV(OALHIV). Patients aged ≥50 taking antiretroviral treatment with no history of cardiovascular events enrolled from multiple centers in Chiang Mai, Thailand. Participants (N = 347) who underwent CAVI were followed up for five years. The primary endpoint was major adverse cardiovascular events (MACE): a composite of total deaths and hospitalizations due to myocardial infarction, coronary revascularization, stroke, and heart failure. Cox regression analysis determined between normal (<8) and high (≥8) CAVI against the incidence of MACE. Forty-five participants (13.0%) were diagnosed with MACE. The risk of MACE was more significant in high CAVI than normal CAVI (adjusted HR =  2.11, 95% confidence interval 1.06-4.20, p = 0.033). In OALHIV, CAVI was an independent prognosis of MACE, in addition to conventional CVD risk factors. CAVI-assisted to help identify high-risk patients showed the benefit of further evaluation and more intensive therapy to prevent CVD and death.

Recovery of renal function after early versus late switching of tenofovir disoproxil fumarate in people living with HIV with renal insufficiency

BACKGROUND

Although many guidelines recommend switching tenofovir disoproxil fumarate (TDF) to other antiretroviral agents if there is a progressive decline in the estimated glomerular filtration rate (eGFR) not explained by other causes, a definite cut-point of the eGFR for TDF switching is not known.

METHODS

A cohort study was conducted among people living with HIV (PLHIV) who switched from TDF to other agents due to declined eGFR. Participants were categorized according to the eGFR at TDF switching: early-switch (eGFR ≥ 60 mL/min/1.73 m²) and late-switch (eGFR < 60 mL/min/1.73 m²) groups. Binary logistic regression was used to determine factors associated with complete recovery of renal function.

RESULTS

Of 141 participants, mean age was 54.2 ± 12.2 years and 74.5% were male. Median duration of TDF use was 5.2 years. Mean eGFR at the time of TDF switching was 72.4 ± 13.7 mL/min/1.73 m² in the early-switch group and 47.0 ± 14.8 mL/min/1.73 m² in the late-switch group. Six months after TDF switching, mean eGFR significantly increased to 84.2 ± 13.5 (p = .001) and 58.5 ± 13.2 mL/min/1.73 m² (p < .001) in early-switch and late-switch groups, respectively. At 12 months after TDF switching, 44.4% of participants in early-switch group and 2.3% of participants in late-switch group had eGFR recovery to ≥ 90 mL/min/1.73 m² (p < .001). Multivariate analysis showed that only early switching (vs late switching) of TDF was associated with complete recovery of renal function at 12 months after TDF switching [OR, 7.542; 95% CI, 2.441-11.119; p = .028].

CONCLUSIONS

In PLHIV with TDF-associated renal insufficiency, eGFR significantly recovers after switching TDF to other agents. Early TDF switching has a higher chance of complete recovery of renal function.

Managing cardiovascular risk in people living with HIV in Asia - where are we now?

As the life expectancy of people living with HIV (PLWH) approaches that of the general population, the burden of comorbidities such as cardiovascular disease (CVD) is increasing. Regardless of HIV status, about 50% of CVD deaths worldwide occur in Asia, and Asian PLWH have a high prevalence of conventional CVD risk factors, such as smoking, dyslipidaemia, hypertension and insulin resistance or diabetes. As well as conventional CVD risk factors, PLWH have HIV-specific risk factors such as chronic inflammation, immune activation and endothelial damage, as well as risk factors related to antiretroviral therapy. This review describes the current knowledge on the epidemiology and risk factors of CVD in Asian PLWH and provides an Asian perspective on the recommendations for managing CVD risk in PLWH.

Assessment of atherosclerotic cardiovascular disease risks between people living with HIV receiving first-line and second-line antiretroviral therapy in a resource-limited setting

Cardiovascular disease has become an important health problem in people living with HIV (PLHIV) who receive antiretroviral therapy (ART). Atherosclerotic cardiovascular disease (ASCVD) risk score is a non-invasive tool to estimate the 10-year risk for ASCVD. A cross-sectional study was conducted among PLHIV receiving ART in a resource-limited setting, in order to assess the 10-year ASCVD risk between PLHIV receiving first-line and second-line ART. Of 460 participants with a mean age of 51.2 years, 262 (57.0%) were men. The mean duration of HIV infection was 14.7 years and the mean CD4 cell count was 509 cells/μL. Of all, 345 participants were receiving first-line ART and 115 were receiving second-line ART. The median 10-year ASCVD risk was 3.0% and 5.1% in the first-line and second-line ART groups, respectively (p = 0.029). The prevalence of a high 10-year ASCVD risk (≥20%) was significantly higher in the second-line ART group (3.5% vs 0.9%, p = 0.048). In multivariate analysis, receiving second-line ART was significantly associated with intermediate to high 10-year ASCVD risk (OR = 2.952; 95% CI, 1.656-6.997; p = 0.015). Atherosclerotic cardiovascular disease risk should be assessed in PLHIV, particularly those who receive second-line ART.

The clinical outcome of HIV infection at a tertiary care center in Riyadh, Saudi Arabia

Objectives:

To investigate clinical characteristics and the outcome of people living with HIV (PLWHIV) at tertiary care center in Riyadh, Saudi Arabia.

Methods:

The present retrospective, observational study was carried between 2000-2019 at Prince Sultan Military Medical City (PSMMC), Riyadh, Saudi Arabia. The demographic and clinical characteristics of 137 PLWHIV patients were collected by reviewing the medical data record.

Results:

Of the total 137 PLWHIV, 78.8% were male and 21.2% were female. At care entry, the most opportunistic infections found were the cytomegalovirus infections. cytomegalovirus (CMV) infections in 13.8% of patients, tuberculosis (8%), AIDS associated malignancy (10.9%), hepatitis B (5.8%), NTM (3.6%), hepatitis C (2.2%). In the present study, more than half of the patients received integrase based combination therapy. The highest number (n=20) of patients were diagnosed in 2018.

Conclusions:

Our findings describe the clinical characteristics and outcomes of PLWHIV at a major tertiary referral hospital in Saudi Arabia. The non AIDS related disease is the major cause of death in HIV infected patients. Early diagnosis and initiation of antiretroviral therapy resulted in a significant decrease in morbidity and mortality.

Immunological and Virological Responses in Older HIV-Infected Adults Receiving Antiretroviral Therapy: An Evidence-Based Meta-Analysis

BACKGROUND

Millions of people living with the HIV have received antiretroviral therapy (ART). Older adults make up a significant portion of these individuals; however, the immunological and virological responses to ART for older patients still need to be clarified.

DESIGN

Meta-analysis.

METHODS

In this article, we systematically reviewed research articles published between 2001 and 2018 that reported immunological and virological responses and AIDS-related mortality among HIV- infected adults (including individuals aged 50 years and older) receiving ART, using meta-analysis. ART efficiency was measured using 3 outcomes: (1) immunological response, (2) virological response, and (3) mortality.

RESULTS

We identified 4937 citations, and 40 studies were eventually selected to investigate ART efficiency in older HIV-infected patients, comprising more than 888,151 patients initiating ART. We report that older patients showed poor immunological responses, with CD4 counts and the restoration of CD4 counts after ART initiation being significantly lower than seen in younger patients. However, older patients exhibited better viral suppression rates (risk ratio: 1.04; 95% confidence intervals: 1.01 to 1.08) after 36 months following ART initiation. In addition, older adults had a higher risk of AIDS-related death (adjusted hazard ratio: 1.44, 95% confidence interval: 1.30 to 1.60).

CONCLUSIONS

Older age after ART initiation was associated with a poorer immunological response and a higher risk of mortality, suggesting the need to increase early diagnosis and treatment among older HIV patients.

Cardiovascular disease-related mortality and factors associated with cardiovascular events in the TREAT Asia HIV Observational Database (TAHOD)

OBJECTIVES

With aging of the HIV-positive population, cardiovascular disease (CVD) increasingly contributes to morbidity and mortality. We investigated CVD-related and other causes of death (CODs) and factors associated with CVD in a multi-country Asian HIV-positive cohort.

METHODS

Patient data from 2003-2017 were obtained from the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD). We included patients on antiretroviral therapy (ART) with > 1 day of follow-up. Cumulative incidences were plotted for CVD-related, AIDS-related, non-AIDS-related, and unknown CODs, and any CVD (i.e. fatal and nonfatal). Competing risk regression was used to assess risk factors of any CVD.

RESULTS

Of 8069 patients with a median follow-up of 7.3 years [interquartile range (IQR) 4.4-10.7 years], 378 patients died [incidence rate (IR) 6.2 per 1000 person-years (PY)], and this total included 22 CVD-related deaths (IR 0.36 per 1000 PY). Factors significantly associated with any CVD event (IR 2.2 per 1000 PY) were older age [sub-hazard ratio (sHR) 2.21; 95% confidence interval (CI) 1.36-3.58 for age 41-50 years; sHR 5.52; 95% CI 3.43-8.91 for ≥ 51 years, compared with < 40 years], high blood pressure (sHR 1.62; 95% CI 1.04-2.52), high total cholesterol (sHR 1.89; 95% CI 1.27-2.82), high triglycerides (sHR 1.55; 95% CI 1.02-2.37) and high body mass index (BMI) (sHR 1.66; 95% CI 1.12-2.46). CVD crude IRs were lower in the later ART initiation period and in lower middle- and upper middle-income countries.

CONCLUSIONS

The development of fatal and nonfatal CVD events in our cohort was associated with older age, and treatable risk factors such as high blood pressure, triglycerides, total cholesterol and BMI. Lower CVD event rates in middle-income countries may indicate under-diagnosis of CVD in Asian-Pacific resource-limited settings.

Trends in mortality among ART-treated HIV-infected adults in the Asia-Pacific region between 1999 and 2017: results from the TREAT Asia HIV Observational Database (TAHOD) and Australian HIV Observational Database (AHOD) of IeDEA Asia-Pacific

INTRODUCTION

AIDS-related deaths in people living with HIV/AIDS have been decreasing in number since the introduction of combination antiretroviral treatment (cART). However, data on recent causes of death in the Asia-Pacific region are limited. Hence, we analysed and compared AIDS-related and non-AIDS-related mortality in high- and low-income settings in the region.

METHODS

Patients from the TREAT Asia HIV Observational Database (TAHOD) and Australian HIV Observational Database (AHOD) receiving cART between 1999 and 2017 were included. Causes of death verification were based on review of the standardized Cause of Death (CoDe) form designed by the D:A:D group. Cohorts were grouped as AHOD (all high-income sites), TAHOD-high (high/upper-middle income countries) and TAHOD-low (lower-middle income countries). TAHOD sites were split into high/upper-middle income and lower-middle income country settings based on World Bank classifications. Competing risk regression was used to analyse factors associated with AIDS and non-AIDS-related mortality.

RESULTS

Of 10,386 patients, 522 died; 187 from AIDS-related and 335 from non-AIDS-related causes. The overall incidence rate of deaths during follow-up was 0.28 per 100 person-years (/100 PYS) for AIDS and 0.51/100 PYS for non-AIDS. Analysis indicated that the incidence rate of non-AIDS mortality decreased from 0.78/100 PYS to 0.37/100 PYS from year groups 2003 to 2007 to 2013 to 2017 (p < 0.001). Similarly, incidence rates of AIDS-related deaths decreased from 0.51/100 PYS to 0.09/100 PYS from year groups 2003 to 2007 to 2013 to 2017 (p < 0.001). More recent years of follow-up were associated with reduced hazard for non-AIDS mortality (2008 to 2012: aSHR (adjusted sub-hazard ratio) 0.72, 95% confidence interval (CI) 0.54 to 0.96, p = 0.027; 2013 to 2017: aSHR 0.64, 95% CI 0.47 to 0.87, p = 0.004) compared to years 2003 to 2007. The AHOD cohort had almost twice the hazard of non-AIDS mortality compared to TAHOD-low (lower-middle income sites) (aSHR 1.72, 95% CI, 1.20 to 2.46, p = 0.003); there were no differences between cohorts for AIDS-related mortality (p = 0.834).

CONCLUSION

AIDS and non-AIDS-related mortality rates have decreased over the past years in the Asia-Pacific region. There is a greater risk for non-AIDS-associated deaths in the AHOD cohort compared to lower-middle income settings in TAHOD.

Polymorphisms in the CD14 and TLR4 genes independently predict CD4+ T-cell recovery in HIV-infected individuals on antiretroviral therapy

BACKGROUND

Chronic HIV infection leads to marked depletion of CD4 T cells in the gastrointestinal tract and increased microbial translocation measured by an increase in circulating lipopolysaccharide (LPS) levels. Here, we hypothesized that single-nucleotide polymorphisms (SNPs) in genes encoding the Toll-like receptor 4 (TLR4) and CD14, the principal receptors for LPS, were associated with CD4 T-cell recovery postantiretroviral therapy (ART).

METHODS

Prospective study of predominantly white HIV-infected participants receiving suppressive ART for at least 12 months. We analysed the CD14 SNPs C-260T and the TLR4 SNPs A+896G, C+1196T. We also determined the levels of LPS and soluble CD14 in plasma samples collected pre-ART and post-ART initiation. CD4 T-cell recovery was assessed by linear mixed models.

RESULTS

Following ART, individuals with a TT genotype compared with a CT or CC genotype for CD14 C-260T SNP showed higher levels of soluble CD14 (P = 0.008 and 0.003, respectively). The CC genotype for the CD14 C-260T SNP, compared with CT or TT, and the TLR4 SNP (AC/GT), compared with the homozygous genotype (AA/CC), were both independently associated with enhanced long-term CD4 T-cell recovery (>3 months; P < 0.001).

CONCLUSION

Polymorphisms in CD14 and TLR4 are independently associated with long-term CD4 T-cell recovery in HIV-infected individuals post-ART.

A Decade of Combination Antiretroviral Treatment in Asia: The TREAT Asia HIV Observational Database Cohort

Asian countries have seen the expansion of combination antiretroviral therapy (cART) over the past decade. The TREAT Asia HIV Observational Database (TAHOD) was established in 2003 comprising 23 urban referral sites in 13 countries across the region. We examined trends in treatment outcomes in patients who initiated cART between 2003 and 2013. Time of cART initiation was grouped into three periods: 2003-2005, 2006-2009, and 2010-2013. We analyzed trends in undetectable viral load (VL; defined as VL <400 copies/ml), CD4 changes from pre-cART levels, and overall survival. Of 6,521 patients included, the overall median CD4 count at cART initiation was 120 cells/μl (interquartile range: 38-218). Despite an increase over time, pre-cART CD4 counts remained <200 cells/μl. Adjusted analyses showed undetectable VL was more likely when starting cART in later years [2006-2009: odds ratio (OR) = 1.76, 95% confidence interval (CI) (1.45, 2.15); and 2010-2013: OR = 3.04, 95% CI (2.33, 3.97), all p < .001, compared to 2003-2005], and survival was improved [2006-2009: subdistribution hazard ratio (SHR) = 0.41, 95% CI (0.27, 0.61), 2010-2013: SHR = 0.29, 95% CI (0.17, 0.49), all p < .001, compared to 2003-2005]. No differences in CD4 response was observed over time. Age and CD4 levels prior to cART initiation were associated with all three treatment outcomes, with older age and higher CD4 counts being associated with undetectable VL. Survival and VL response on cART have improved over the past decade in TAHOD, although CD4 count at cART initiation remained low. Greater effort should be made to facilitate earlier HIV diagnosis and linkage to care and treatment, to achieve greater improvements in treatment outcomes.

Switching Lopinavir/Ritonavir to Atazanavir/Ritonavir vs Adding Atorvastatin in HIV-Infected Patients Receiving Second-Line Antiretroviral Therapy With Hypercholesterolemia: A Randomized Controlled Trial

A randomized controlled trial was conducted among human immunodeficiency virus-infected patients receiving lopinavir/ritonavir-based regimens with hypercholesterolemia. Reduction of total cholesterol and low-density lipoprotein was significantly greater in patients who were randomized to the addition of atorvastatin compared with those who were switched from lopinavir/ritonavir to atazanavir/ritonavir.

Causes of Death in Hospitalized HIV Patients in the Early Anti-Retroviral Therapy Era

OBJECTIVE

To establish the cause(s) of death among persons with HIV and AIDS admitted to the Fevers Unit of the Korle-Bu Teaching Hospital (KBTH) in 2007 and to determine whether they were AIDS-related in the era of availability of HAART.

METHOD

Retrospective chart review of all deaths that occurred in the year 2007 among inpatients with HIV infection. Cause of Death (COD) was established with post mortem diagnosis, where not available ICD-10 was reviewed independently by two physicians experienced in HIV medicine and a consensus reached as to the most likely COD.

RESULTS

In the year under review, 215 (97%) of the 221 adult deaths studied were caused by AIDS and HIV-associated illnesses. Of these, 123 (55.7%) were due to an AIDS-defining illness as described in CDC Category 3 or WHO stage 4. Infections accounted for most of the deaths 158 (71.5%), many of them opportunistic 82 (51.8%). Tuberculosis was the commonest COD. Clinical diagnosis of TB was accurate in 54% of deaths, but was not validated by autopsy in 36% of deaths. There were few deaths (14.5%) in patients on HAART.

CONCLUSION

In a developing country like Ghana where HAART was still not fully accessible, AIDS-related events remained the major causes of death in persons living with HIV. Total scale-up of the ART programme with continuous availability of antiretrovirals is therefore imperative to reduce deaths from AIDS and HIV associated illnesses. There is need for interventions for early diagnosis as well as reduction in late presentation and also better diagnostic tools for tuberculosis.

Prevalence and mortality of cancer among HIV-infected inpatients in Beijing, China

Background

Cancer is responsible for elevated HIV-related morbidity and mortality. Research on HIV-infected patients with concurrent cancer is rare in China. The purpose of our study was to investigate the prevalence and risk factors associated with cancer among HIV-infected inpatients in Beijing, and to investigate the mortality and risk factors among HIV-infected inpatients with cancer.

Methods

Hospital records from a total of 1946 HIV-infected patients were collected from the Beijing Ditan Hospital. The data, from 2008 to 2013, were collected retrospectively. The cancer diagnoses included AIDS-defining cancers (ADC) and non-AIDS defining cancers (NADC). Logistic regression was used to identify risk factors predicting the concurrence of cancer with HIV. Mortality was examined using Kaplan-Meier estimates and Cox proportional hazards models.

Results

7.7 % (149 cases) of all HIV-infected inpatients had concurrent cancer at their first hospital admission; of those, 33.6 % (50 cases) had ADCs, and 66.4 % (99 cases) had NADCs. The most prevalent NADCs were Hodgkin’s lymphoma, gastrointestinal cancer, liver cancer, and lung cancer. Patients who did not accept antiretroviral therapy (ART) were more likely to suffer from cancer [AOR = 2.07 (1.42–3.01), p = 0.001]. Kaplan-Meier curves indicated that the survival probability of HIV-positive cancer patients was significantly lower than that of HIV-positive cancer-free patients (log-rank test, p < 0.001). For patients diagnosed with cancer, the mortality was also higher among those who did not receive ART [AHR = 2.19 (1.84–2.61), p < 0.001].

Conclusion

The prevalence of cancer concurrence among hospitalized HIV-infected patients was 7.7 %. Concurrent cancer also increased mortality among HIV-infected patients. ART was protective against concurrent cancer as well as mortality among HIV-infected cancer patients. These results highlight the importance of promoting cancer screening and early ART initiation among HIV-infected patients.

Prevalence and distribution of non-AIDS causes of death among HIV-infected individuals receiving antiretroviral therapy: a systematic review and meta-analysis

The advent of antiretroviral therapy has significantly improved AIDS-related morbidity and mortality. Yet, among people living with HIV, deaths due to non-AIDS-defining illnesses have been on the rise. The objective of this study was to provide information about the global prevalence and distribution of non-AIDS causes of death in the last ten years among people living with HIV receiving antiretroviral therapy, by income levels of countries. We used broad search terms in Google Scholar, PubMed, and EMBASE to identify all studies that investigated the cause of death among people living with HIV receiving antiretroviral therapy, published after January 1, 2005. References were also identified from review articles and reference lists. Inclusion criteria were English language, the study’s end date was after 2005, all patients were HIV-positive, at least two-thirds of the patients were receiving antiretroviral therapy, at least one patient died of non-AIDS causes of death. Titles, abstracts, and articles were reviewed by at least two independent readers. Of 2951 titles identified in our original search, 151 articles were selected for further screening. We identified 19 studies meeting our full criteria, with patients from 55 different nations. Pooled non-AIDS causes of death prevalence estimates in high-income countries were 53.0% (95% confidence interval, 43.6–62.3), in developing countries 34.0% (95% confidence interval, 20.3–49.1), and in sub-Saharan countries 18.5% (95% confidence interval, 13.8–23.7). Statistically significant variation was noted within and between categories. Our findings show that a significant number of people living with HIV across the world die from cardiovascular disease, non-AIDS malignancies, and liver disease. There is a global need for further scrutiny in all regions to improve preventive measures and early detection according to distinct causes of death patterns.

Early Versus Delayed Mortality among HIV Infected Patients Initiating Highly Active Antiretroviral Therapy in Tanzania

Development of HAART in the mid-1990's and its continued scale up has revolutionized the treatment of HIV-infected patients and led to remarkable reductions in HIV associated morbidity and mortality. However, recent studies have suggested a higher risk for early mortality in adults receiving ART in low-income countries as compared to those in high-income countries. There is dearth of data from developing countries where the burden of disease is high. The objective is to describe the burden and correlation between early vs. delayed mortality associated with HIV/AIDS in resource poor settings using data from Tanzania in East Africa. We performed a cross-sectional evaluation of routinely collected program data for 991 HIV-positive deceased adult patients who were placed on ART treatment, and died between January 1, 2007 and December 31, 2012. Data used were abstracted from records of patients who were treated at six health facilities in the Lake-zone Region of Tanzania in the timeframe. Bivariate and multivariate regression models were used to identify independent predictors of mortality and to calculate odds ratios. From the population, early deaths (within 3 months of ART initiation) occurred in 359 of the 991 cases, which represented 36.2%; while delayed deaths (after 3 months of ART initiation) occurred in 632 of 991 (63.8%). The average time to death for those who died within 3 months was 1 month compared to 22 months among those who died at > 3 months since initiation of ARV. In multivariate analysis, patients who were on WHO stage IV, had fever and cough symptoms at 6 months prior to death and patients with 0-1, 2-3, and 4-6 clinic visits had a higher risk of death in the first 3 months. Mortality among patients started on ART seems to be high. Where possible, healthcare providers should do more to vigorously monitor patients before starting them on ART for better outcomes. Additionally, public health efforts to encourage early testing and entry into treatment must be scaled up in resource poor countries to gain some lead-time and to keep the virus under control, sustain immune function, and delay the onset of opportunistic infections.

Human Herpesviruses as Copathogens of HIV Infection, Their Role in HIV Transmission, and Disease Progression

Of eight human herpesviruses (HHVs), often, only herpes simplex virus types 1 (HSV-1) and 2 (HSV-2) find mention in medical literature as both of these viruses are commonly associated with genital lesions and oral ulcers, commonly known as cold sores. However, role of human herpesviruses as copathogens and in aggravation and in the transmission of other human diseases, especially the Acquired immunodeficiency syndrome (HIV/AIDS) has only very recently been recognized. Therefore, screening and treating subclinical HHV infections may offer slowing of HIV infection, disease progression, and its transmission. Beside HSV-1 and HSV-2, HHV-3 a causative agent of herpes zoster remained one of the first manifestations of HIV disease before the era of highly active antiretroviral therapy (HAART). HHV-5 also known as human Cytomegalovirus infection remains a significant risk factor for HIV-associated mortality and morbidity even in HAART era. It is proposed that Cytomegalovirus viremia could be a better predictor of HIV disease progression than CD4+ T-lymphocyte count. The role of HHV-4 or Epstein-Burr virus and HHV-6, HHV-7, and HHV-8 is still being investigated in HIV disease progression. This review provides insight into the current understanding about these 8 HHVs, their co-pathogenesis, and role in HIV/AIDS disease progression. The review also covers recent literature in favor and against administering anti-HHV treatment along with HAART for slower AIDS progression and interrupted sexual transmission.

Assessing the trend of HIV/AIDS mortality rate in Asia and North Africa: an application of latent growth models

Over the last 30 years, HIV/AIDS has emerged as a major global health challenge. This study evaluates the change of HIV/AIDS mortality rates in Asian and North African countries from 1990 to 2010 using the Global Burden of Disease (GBD) study. HIV/AIDS mortality rates were derived from the GBD database from 1990 to 2010, for 52 countries in Asia and North Africa. First, a Latent Growth Model was employed to assess the change in AIDS mortality rate over time in six different regions of Asia, and also the change in AIDS mortality rate over time for males and females in Asia and North Africa. Finally, Latent Growth Mixture Models (LGMMs) were applied to identify distinct groups in which countries within each group have similar trends over time. Our results showed that increase in mortality rate over time for males is about three times greater than for females. The highest and lowest trend of AIDS mortality rates were observed in South-East Asia and high-income Asia-Pacific regions, respectively. The LGMM allocated most countries in the South and South-East region into two classes with the highest trend of AIDS mortality rates. Although the HIV/AIDS mortality rates are decreasing in some countries and clusters, the general trend in the Asian continent is upwards. Therefore, it is necessary to provide programmes to achieve the goal of access to HIV prevention measures, treatment, care, and support for high-risk groups, especially in countries with a higher trend of AIDS mortality rates.

HIV and aging: insights from the Asia Pacific HIV Observational Database (APHOD)

OBJECTIVES

The proportion of people living with HIV/AIDS in the ageing population (>50 years old) is increasing. We aimed to explore the relationship between older age and treatment outcomes in HIV-positive persons from the Asia Pacific region.

METHODS

Patients from the Australian HIV Observational Database (AHOD) and the TREAT Asia HIV Observational Database (TAHOD) were included in the analysis. We used survival methods to assess the association between older age and all-cause mortality, as well as time to treatment modification. We used regression analyses to evaluate changes in CD4 counts after combination antiretroviral therapy (cART) initiation and determined the odds of detectable viral load, up to 24 months of treatment.

RESULTS

A total of 7142 patients were included in these analyses (60% in TAHOD and 40% in AHOD), of whom 25% were >50 years old. In multivariable analyses, those aged > 50 years were at least twice as likely to die as those aged 30-39 years [hazard ratio (HR) for 50-59 years: 2.27; 95% confidence interval (CI) 1.34-3.83; HR for > 60 years: 4.28; 95% CI 2.42-7.55]. The effect of older age on CD4 count changes was insignificant (p-trend=0.06). The odds of detectable viral load after cART initiation decreased with age (p-trend=< 0.0001). The effect of older age on time to first treatment modification was insignificant (p-trend=0.21). We found no statistically significant differences in outcomes between AHOD and TAHOD participants for all endpoints examined.

CONCLUSIONS

The associations between older age and typical patient outcomes in HIV-positive patients from the Asia Pacific region are similar in AHOD and TAHOD. Our data indicate that 'age effects' traverse the resource-rich and resource-limited divide and that future ageing-related findings might be applicable to each setting.

Determinants of suicide and accidental or violent death in the Australian HIV Observational Database

Background

Rates of suicide and accidental or violent death remain high in HIV-positive populations despite significantly improved prognosis since the introduction of cART.

Methods

We conducted a nested case-control study of suicide and accidental or violent death in the Australian HIV Observational Database (AHOD) between January 1999 and March 2012. For each case, 2 controls were matched by clinic, age, sex, mode of exposure and HIV-positive date to adjust for potential confounding by these covariates. Risk of suicide and accidental or violent death was estimated using conditional logistic regression.

Results

We included 27 cases (17 suicide and 10 violent/accidental death) and 54 controls. All cases were men who have sex with men (MSM) or MSM/ injecting drug use (IDU) mode of exposure. Increased risk was associated with unemployment (Odds Ratio (OR) 5.86, 95% CI: 1.69–20.37), living alone (OR 3.26, 95% CI: 1.06–10.07), suicidal ideation (OR 6.55, 95% CI: 1.70–25.21), and >2 psychiatric/cognitive risk factors (OR 4.99, 95% CI: 1.17–30.65). CD4 cell count of >500 cells/µL (OR 0.25, 95% CI: 0.07–0.87) and HIV-positive date ≥1990 (1990–1999 (OR 0.31, 95% CI: 0.11–0.89), post-2000 (OR 0.08, 95% CI: 0.01–0.84)) were associated with decreased risk. CD4 cell count ≥500 cells/µL remained a significant predictor of reduced risk (OR 0.15, 95% CI: 0.03–0.70) in a multivariate model adjusted for employment status, accommodation status and HIV-positive date.

Conclusions

After adjustment for psychosocial factors, the immunological status of HIV-positive patients contributed to the risk of suicide and accidental or violent death. The number of psychiatric/cognitive diagnoses contributed to the level of risk but many psychosocial factors were not individually significant. These findings indicate a complex interplay of factors associated with risk of suicide and accidental or violent death.

Causes of death and risk factors for mortality among HIV-infected patients receiving antiretroviral therapy in Korea

A retrospective study was conducted to determine the mortality, causes and risk factors for death among HIV-infected patients receiving antiretroviral therapy (ART) in Korea. The outcomes were determined by time periods, during the first year of ART and during 1-5 yr after ART initiation, respectively. Patients lost to follow-up were traced to ascertain survival status. Among 327 patients initiating ART during 1998-2006, 68 patients (20.8%) died during 5-yr follow-up periods. Mortality rate per 100 person-years was 8.69 (95% confidence interval, 5.68-12.73) during the first year of ART, which was higher than 4.13 (95% confidence interval, 2.98-5.59) during 1-5 yr after ART. Tuberculosis was the most common cause of death in both periods (30.8% within the first year of ART and 16.7% during 1-5 yr after ART). During the first year of ART, clinical category B and C at ART initiation, and underlying malignancy were significant risk factors for mortality. Between 1 and 5 yr after ART initiation, CD4 cell count ≤ 50 cells/µL at ART initiation, hepatitis B virus co-infection, and visit constancy ≤ 50% were significant risk factors for death. This suggests that different strategies to reduce mortality according to the time period after ART initiation are needed.

Rates and factors associated with major modifications to first-line combination antiretroviral therapy: results from the Asia-Pacific region

BACKGROUND

In the Asia-Pacific region many countries have adopted the WHO's public health approach to HIV care and treatment. We performed exploratory analyses of the factors associated with first major modification to first-line combination antiretroviral therapy (ART) in resource-rich and resource-limited countries in the region.

METHODS

We selected treatment naive HIV-positive adults from the Australian HIV Observational Database (AHOD) and the TREAT Asia HIV Observational Database (TAHOD). We dichotomised each country's per capita income into high/upper-middle (T-H) and lower-middle/low (T-L). Survival methods stratified by income were used to explore time to first major modification of first-line ART and associated factors. We defined a treatment modification as either initiation of a new class of antiretroviral (ARV) or a substitution of two or more ARV agents from within the same ARV class.

RESULTS

A total of 4250 patients had 961 major modifications to first-line ART in the first five years of therapy. The cumulative incidence (95% CI) of treatment modification was 0.48 (0.44-0.52), 0.33 (0.30-0.36) and 0.21 (0.18-0.23) for AHOD, T-H and T-L respectively. We found no strong associations between typical patient characteristic factors and rates of treatment modification. In AHOD, relative to sites that monitor twice-yearly (both CD4 and HIV RNA-VL), quarterly monitoring corresponded with a doubling of the rate of treatment modifications. In T-H, relative to sites that monitor once-yearly (both CD4 and HIV RNA-VL), monitoring twice-yearly corresponded to a 1.8 factor increase in treatment modifications. In T-L, no sites on average monitored both CD4 & HIV RNA-VL concurrently once-yearly. We found no differences in rates of modifications for once- or twice-yearly CD4 count monitoring.

CONCLUSIONS

Low-income countries tended to have lower rates of major modifications made to first-line ART compared to higher-income countries. In higher-income countries, an increased rate of RNA-VL monitoring was associated with increased modifications to first-line ART.

Currently available medications in resource-rich settings may not be sufficient for lifelong treatment of HIV

OBJECTIVE

Combination antiretroviral therapy (cART) has greatly improved the life expectancy of people living with HIV (PLHIV). Our study aims to project the life expectancy of PLHIV in a resource-rich setting in the context of the currently available antiretroviral treatments.

METHODS

Patient antiretroviral treatment data were sourced from an observational cohort of 3434 predominantly male (94.2%) PLHIV in Australia over the period 1997-2010. These data were analyzed in a computer simulation model to calculate the distribution of time until exhaustion of all treatment options and expected effect on mortality. Standardized mortality ratios were used to simulate expected survival before and after treatment exhaustion.

RESULTS

We estimated that the median time until exhaustion of currently available treatment options is 45.5 years [interquartile range (IQR) 34.0-61.0 years]. However, 10% of PLHIV are expected to exhaust all currently available cART options after just 25.6 years. PLHIV who start currently available cART regimens at age 20 years are expected to live to a median age of 67.4 (IQR 53.2-77.7) years. This is a substantial improvement on no cART [27.7 (IQR 23.8-32.0) years] but is still substantially less than the median general population mortality age [82.2 (IQR 74.0-87.8) years]. The life expectancy gap between PLHIV and the general population is greatest for those infected at younger ages.

CONCLUSION

As treatment options are exhausted, a substantial difference in life expectancy between PLHIV and the general population could be expected even in resource-rich settings, particularly for people who acquire HIV at a younger age or who are currently highly treatment experienced.

Long-term survival in HIV positive patients with up to 15 Years of antiretroviral therapy

BACKGROUND

Life expectancy has increased for newly diagnosed HIV patients since the inception of combination antiretroviral treatment (cART), but there remains a need to better understand the characteristics of long-term survival in HIV-positive patients. We examined long-term survival in HIV-positive patients receiving cART in the Australian HIV Observational Database (AHOD), to describe changes in mortality compared to the general population and to develop longer-term survival models.

METHODS

Data were examined from 2,675 HIV-positive participants in AHOD who started cART. Standardised mortality ratios (SMR) were calculated by age, sex and calendar year across prognostic characteristics using Australian Bureau of Statistics national data as reference. SMRs were examined by years of duration of cART by CD4 and similarly by viral load. Survival was analysed using Cox-proportional hazards and parametric survival models.

RESULTS

The overall SMR for all-cause mortality was 3.5 (95% CI: 3.0-4.0). SMRs by CD4 count were 8.6 (95% CI: 7.2-10.2) for CD4<350 cells/µl; 2.1 (95% CI: 1.5-2.9) for CD4 = 350-499 cells/µl; and 1.5 (95% CI: 1.1-2.0) for CD4≥500 cells/µl. SMRs for patients with CD4 counts <350 cells/µL were much higher than for patients with higher CD4 counts across all durations of cART. SMRs for patients with viral loads greater than 400 copies/ml were much higher across all durations of cART. Multivariate models demonstrated improved survival associated with increased recent CD4, reduced recent viral load, younger patients, absence of HBVsAg-positive ever, year of HIV diagnosis and incidence of ADI. Parametric models showed a fairly constant mortality risk by year of cART up to 15 years of treatment.

CONCLUSION

Observed mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors. These rates did not vary much by duration of treatment. Changes in mortality with age were similar to those in the Australian general population.

Cost-effectiveness of integrating methadone maintenance and antiretroviral treatment for HIV-positive drug users in Vietnam's injection-driven HIV epidemics

Drug use negatively affects adherence to and outcomes of antiretroviral treatment (ART). This study evaluated the cost-effectiveness of integrating methadone maintenance treatment (MMT) with ART for HIV-positive drug users (DUs) in Vietnam. A decision analytical model was developed to compare the costs and consequences of 3 HIV/AIDS treatment strategies for DUs: (1) only ART, (2) providing ART and MMT in separated sites (ART-MMT), and (3) integrating ART and MMT with direct administration (DAART-MMT). The model was parameterized using empirical data of costs and outcomes extracted from the MMT and ART cohort studies in Vietnam, and international published sources. Probabilistic sensitivity analysis was conducted to examine the model's robustness. The base-case analysis showed that the cost-effectiveness ratio of ART, DAART-MMT, and ART-MMT strategies was USD 1358.9, 1118.0 and 1327.1 per 1 Quality-Adjusted Life Year (QALY), equivalent to 1.22, 1.00, and 1.19 times Gross Domestic Product per capita (GDPpc). The incremental cost-effectiveness ratio for DAART-MMT and ART-MMT versus ART strategy was 569.4 and 1227.8, approximately 0.51 and 1.10 times GDPpc/QALY. At the willingness to pay threshold of 3 times GDPpc, the probability of being cost-effective of DAART-MMT versus ART was 86.1%. These findings indicated that providing MMT along with ART for HIV-positive DUs is a cost-effective intervention in Vietnam. Integrating MMT and ART services could facilitate the use of directly observed therapy that supports treatment adherence and brings about clinically important improvements in health outcomes. This approach is also incrementally cost-effective in this large injection-driven HIV epidemic.

Laboratory and clinical predictors of disease progression following initiation of combination therapy in HIV-infected adults in Thailand

BACKGROUND

Data on determinants of long-term disease progression in HIV-infected patients on antiretroviral therapy (ART) are limited in low and middle-income settings.

METHODS

Effects of current CD4 count, viral load and haemoglobin and diagnosis of AIDS-defining events (ADEs) after start of combination ART (cART) on death and new ADEs were assessed using Poisson regression, in patient aged ≥ 18 years within a multi-centre cohort in Thailand.

RESULTS

Among 1,572 patients, median follow-up from cART initiation was 4.4 (IQR 3.6-6.3) years. The analysis of death was based on 60 events during 6,573 person-years; 30/50 (60%) deaths with underlying cause ascertained were attributable to infections. Analysis of new ADE included 192 events during 5,865 person-years; TB and Pneumocystis jiroveci pneumonia were the most commonly presented first new ADE (35% and 20% of cases, respectively). In multivariable analyses, low current CD4 count after starting cART was the strongest predictor of death and of new ADE. Even at CD4 above 200 cells/mm(3), survival improved steadily with CD4, with mortality rare at ≥ 500 cells/mm(3) (rate 1.1 per 1,000 person-years). Haemoglobin had a strong independent effect, while viral load was weakly predictive with poorer prognosis only observed at ≥ 100,000 copies/ml. Mortality risk increased following diagnosis of ADEs during cART. The decline in mortality rate with duration on cART (from 21.3 per 1,000 person-years within first 6 months to 4.7 per 1,000 person-years at ≥ 36 months) was accounted for by current CD4 count.

CONCLUSIONS

Patients with low CD4 count or haemoglobin require more intensive diagnostic and treatment of underlying causes. Maintaining CD4 ≥ 500 cells/mm(3) minimizes mortality. However, patient monitoring could potentially be relaxed at high CD4 count if resources are limited. Optimal ART monitoring strategies in low-income settings remain a research priority. Better understanding of the aetiology of anaemia in patients on ART could guide prevention and treatment.

Predictors of immune recovery and the association with late mortality while on antiretroviral treatment in Cambodia

The objectives of this study were to examine the association of the on-treatment CD4 cell count with late mortality (after >6 months of antiretroviral treatment [ART]) and to identify the determinants of the long-term CD4 cell count evolution after treatment initiation. We conducted a retrospective analysis including all antiretroviral (ARV)-naïve adults initiating ART in a tertiary hospital in Phnom Penh, Cambodia from 2003-2010. We used Cox proportional hazards modelling (mortality analysis), including time-updated CD4 counts, and mixed-effects modelling (CD4 response over time). Overall, 2840 patients were included (47% male, median age: 34 years, median baseline CD4 count: 78 cells/μL). The median time on ART was 2.5 years (IQR 1.1-4.3); 71 patients died after >6 months of ART. The baseline CD4 count was the main determinant of the on-treatment CD4 cell count. Time-updated CD4 cell counts was the strongest determinant of late mortality with a HR of 0.32 (95% CI 0.16-0.63) and 0.29 (95% CI 0.11-0.71) for CD4 values of 200-350 cells/μL and 350-500 cells/μL respectively. We conclude that baseline CD4 counts strongly determine the long-term immune recovery, which critically affects late mortality. This calls for increased efforts for early ART initiation and availability of CD4 count testing in low-income countries.

Universal definition of loss to follow-up in HIV treatment programs: a statistical analysis of 111 facilities in Africa, Asia, and Latin America

BACKGROUND

Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition.

METHODS AND FINDINGS

At a set "status classification" date, patients were categorized as either "active" or "LTFU" according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities-representing 180,718 patients from 19 countries-were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173-181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%-7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean=150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean=1.2%, 95% CI: 1.0%-1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean=19.9%, 95% CI: 19.1%-21.7%).

CONCLUSIONS

Based on this evaluation, we recommend the adoption of ≥180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide. Please see later in the article for the Editors' Summary.

Does use of antiretroviral therapy regimens with high central nervous system penetration improve survival in HIV-infected adults?

OBJECTIVES

The aim of the study was to determine whether combination antiretroviral therapy (cART) with high central nervous system penetration-effectiveness (CPE) rank (neurocART) is associated with increased survival benefit compared with non-neurocART.

METHODS

Prospective data were examined for HIV-positive patients in the Asia Pacific HIV Observational Database who had commenced cART. CPE rank was calculated using the 2010 rankings process. NeurocART status was assigned to regimens with a CPE rank of 8 or more. Survival was analysed using Cox proportional hazards models with covariates updated at changes in cART regimen and with deaths up to 90 days after regimen cessation attributed to that regimen. Sensitivity analyses were conducted to examine the robustness of analysis assumptions.

RESULTS

Among 5882 patients, 308 deaths occurred. The hazard ratio (HR) for neurocART use was 0.89 (P=0.35) when data were stratified by cohort and adjusted for age, mode of HIV exposure, hepatitis B virus coinfection, AIDS-defining illness, CD4 count (cells/μL) and regimen count. Sensitivity analyses showed similar nonsignificant results. We also examined a composite endpoint of AIDS-defining illness or death (HR=0.93; P=0.61), baseline regimen as neurocART (HR=0.95; P=0.69), CPE category (P=0.71) and prior neurocART duration (P=0.16). No association between CD4 cell count and neurocART use was observed (P=0.52).

CONCLUSIONS

Our findings do not show a significant overall survival benefit associated with neurocART compared with cART. The potential benefit associated with neurocART in terms of prevention of neurocognitive impairment did not translate into an improvement in overall survival in this population. These findings were limited by the low incidence of associated mortality. Further studies and more extensive data are needed to address these limitations.