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Schäfer G, Hoffmann C, Arasteh K, Schürmann D, Stephan C, Jensen B, Stoll M, Bogner JR, Faetkenheuer G, Rockstroh J, Klinker H, Härter G, Stöhr A, Degen O, Freiwald E, Hüfner A, Jordan S, Schulze Zur Wiesch J, Addo M, Lohse AW, van Lunzen J, Schmiedel S. Immediate versus deferred antiretroviral therapy in HIV-infected patients presenting with acute AIDS-defining events (toxoplasmosis, Pneumocystis jirovecii-pneumonia): a prospective, randomized, open-label multicenter study (IDEAL-study). AIDS Res Ther 2019; 16:34. [PMID: 31729999 PMCID: PMC6857475 DOI: 10.1186/s12981-019-0250-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/26/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To evaluate clinical outcomes after either immediate or deferred initiation of antiretroviral therapy in HIV-1-infected patients, presenting late with pneumocystis pneumonia (PCP) or toxoplasma encephalitis (TE). METHODS Phase IV, multicenter, prospective, randomized open-label clinical trial. Patients were randomized into an immediate therapy arm (starting antiretroviral therapy (ART) within 7 days after initiation of OI treatment) versus a deferred arm (starting ART after completing the OI-therapy). All patients were followed for 24 weeks. The rates of clinical progression (death, new or relapsing opportunistic infections (OI) and other grade 4 clinical endpoints) were compared, using a combined primary endpoint. Secondary endpoints were hospitalization rates after completion of OI treatment, incidence of immune reconstitution inflammatory syndrome (IRIS), virologic and immunological outcome, adherence to proteinase-inhibitor based antiretroviral therapy (ART) protocol and quality of life. RESULTS 61 patients (11 patients suffering TE, 50 with PCP) were enrolled. No differences between the two therapy groups in all examined primary and secondary endpoints could be identified: immunological and virologic outcome was similar in both groups, there was no significant difference in the incidence of IRIS (11 and 10 cases), furthermore 9 events (combined endpoint of death, new/relapsing OI and grade 4 events) occurred in each group. CONCLUSIONS In summary, this study supports the notion that immediate initiation of ART with a ritonavir-boosted proteinase-inhibitor and two nucleoside reverse transcriptase inhibitors is safe and has no negative effects on incidence of disease progression or IRIS, nor on immunological and virologic outcomes or on quality of life.
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Affiliation(s)
- Guido Schäfer
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | - Keikawus Arasteh
- Department for Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
| | - Dirk Schürmann
- Department for Pneumology and Infectious Diseases, Charité Universitätsmedizin, Berlin, Germany
| | - Christoph Stephan
- 2nd Medical Department, Section Infectious Diseases, University Medical Center, Frankfurt am Main, Germany
| | - Björn Jensen
- Department for Gastroenterology, Hepatology, Infectious Diseases, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Matthias Stoll
- Department for Immunology and Rheumatology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Johannes R Bogner
- Department for Infectious Diseases, Mediznische Klinik und Poliklinik IV der Universität München, Munich, Germany
| | - Gerd Faetkenheuer
- 1st Medical Department, Section Infectious Diseases, Universitätsklinikum Köln, Cologne, Germany
| | - Jürgen Rockstroh
- Medical Department, Section Infectious Diseases, Universitätsklinikum Bonn, Bonn, Germany
| | - Hartwig Klinker
- Department for Infectious Diseases, Julius Maximilians University, Würzburg, Germany
| | - Georg Härter
- Department for Infectious Diseases, University Hospital, Ulm, Germany
| | - Albrecht Stöhr
- ifi-Institute for Interdisciplinary Medicine, Hamburg, Germany
| | - Olaf Degen
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eric Freiwald
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anja Hüfner
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Jordan
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Schulze Zur Wiesch
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marylyn Addo
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Stefan Schmiedel
- Infectious Diseases Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- 1st Medical Department, Section Infectious Diseases & Tropical Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Karaosmanoğlu HK, Mete B, Gündüz A, Aydin ÖA, Sargin F, Sevgi DY, Durdu B, Dökmetaş İ, Tabak F. Late presentation among patients with human immunodeficiency virus infection in Turkey. Cent Eur J Public Health 2019; 27:229-234. [PMID: 31580559 DOI: 10.21101/cejph.a5416] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/30/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Late presentation of the patients with human immunodeficiency virus (HIV) infection is associated with less favourable treatment responses, more accelerated clinical progression, and a higher mortality risk. Although HIV prevalence is low in Turkey, it is steadily increasing and the information about late presentation among HIV-positives is limited. We aimed to analyze the status of late presentation among HIV-positive patients in Turkey. METHODS All newly diagnosed HIV/AIDS patients from 2003 to 2016 were enrolled in this study by five dedicated centres in Istanbul, Turkey. Demographic data, CD4+ counts, and HIV RNA were collected from medical records and were transferred to a HIV database system. Late pre- sentation was defined as presentation for care with a CD4 count < 350 cells/mm3 or presentation with an AIDS-defining event, regardless of the CD4 cell count. A medical literature search was done for the analysis of late presentation in Turkey. RESULTS The cohort included 1,673 patients (1,440 males, median age 35 years). Among them, 847 (50.6%) had an early diagnosis, with a CD count of more than 350 cells/mm3. The remaining 826 were late presenters. Among late presenters, 427 (25.5% of all, 51.7% of late presenters) presented with advanced HIV disease. Late presenters were more elderly and less educated. The gender seemed comparable between groups. Late presentation was more likely among married patients. Early presenters were more likely among homosexuals, those diagnosed in screening studies, and in lower HIV-RNA viral load category. There has been a decreasing trend among late presenters in 2011-2016 when compared to 2003-2011 period. CONCLUSION Current data suggest that half of HIV-infected patients present late in Turkey. In our cohort, those presented late were more elderly, less educated, married and had heterosexual intercourse. On admission, late presenters had more HIV-related diseases and were more likely in higher HIV-RNA category. In the cohort, men having sex with men were less likely late presenters. Efforts to reduce the proportion of late presentation are essential for almost every country. The countries should identify the risk factors of late presentation and should improve early diagnosis and presentation for HIV care.
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Affiliation(s)
- Hayat Kumbasar Karaosmanoğlu
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Bilgül Mete
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Alper Gündüz
- Department of Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özlem Altuntaş Aydin
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Dr Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fatma Sargin
- Department of Infectious Diseases and Clinical Microbiology, Goztepe Training and Research Hospital, Medeniyet University, Istanbul, Turkey
| | - Dilek Yildiz Sevgi
- Department of Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Bülent Durdu
- Department of Infectious Diseases and Clinical Microbiology, Medical Faculty, Bezmi Alem University, Istanbul, Turkey
| | - İlyas Dökmetaş
- Department of Infectious Diseases and Clinical Microbiology, Sisli Hamidiye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fehmi Tabak
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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Brown AE, Attawell K, Hales D, Rice BD, Pharris A, Supervie V, Van Beckhoven D, Delpech VC, An der Heiden M, Marcus U, Maly M, Noori T. Monitoring the HIV continuum of care in key populations across Europe and Central Asia. HIV Med 2018; 19:431-439. [PMID: 29737610 DOI: 10.1111/hiv.12603] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the study was to measure and compare national continuum of HIV care estimates in Europe and Central Asia in three key subpopulations: men who have sex with men (MSM), people who inject drugs (PWID) and migrants. METHODS Responses to a 2016 European Centre for Disease Prevention and Control (ECDC) survey of 55 European and Central Asian countries were used to describe continuums of HIV care for the subpopulations. Data were analysed using three frameworks: Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; breakpoint analysis identifying reductions between adjacent continuum stages; quadrant analysis categorizing countries using 90% cut-offs for continuum stages. RESULTS Overall, 29 of 48 countries reported national data for all HIV continuum stages (numbers living with HIV, diagnosed, receiving treatment and virally suppressed). Six countries reported all stages for MSM, seven for PWID and two for migrants. Thirty-one countries did not report data for MSM (34 for PWID and 41 for migrants). In countries that provided key-population data, overall, 63%, 40% and 41% of MSM, PWID and migrants living with HIV were virally suppressed, respectively (compared with 68%, 65% and 68% nationally, for countries reporting key-population data). Variation was observed between countries, with higher outcomes in subpopulations in Western Europe compared with Eastern Europe and Central Asia. CONCLUSIONS Few reporting countries can produce the continuum of HIV care for the three key populations. Where data are available, differences exist in outcomes between the general and key populations. While MSM broadly mirror national outcomes (in the West), PWID and migrants experience poorer treatment and viral suppression. Countries must develop continuum measures for key populations to identify and address inequalities.
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Affiliation(s)
- A E Brown
- Independent Consultant, London, UK
- Public Health England, London, UK
| | | | - D Hales
- Independent Consultant, New York, USA
| | - B D Rice
- London School of Hygiene and Tropical Medicine, London, UK
| | - A Pharris
- European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - V Supervie
- INSERM French Institute of Health and Medical Research, Paris, France
| | - D Van Beckhoven
- Belgian Scientific Institute for Public Health, Brussels, Belgium
| | | | | | - U Marcus
- Robert Koch Institute, Berlin, Germany
| | - M Maly
- National Institute for Public Health, Prague, Czech Republic
| | - T Noori
- European Centre for Disease Prevention and Control, Stockholm, Sweden
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Mao L, de Wit J, Adam P, Post JJ, Slavin S, Cogle A, Wright E, Kidd M. Beliefs in Antiretroviral Treatment and Self-Efficacy in HIV Management are Associated with Distinctive HIV Treatment Trajectories. AIDS Behav 2018; 22:887-895. [PMID: 27995435 DOI: 10.1007/s10461-016-1649-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
An online survey was conducted among people living with HIV (PLHIV) in Australia to discern key factors associated with distinctive ART use patterns. The sample (N = 358), was further divided into three groups: those on ART continuously since initiation (n = 208, 58.1%); those on ART intermittently (n = 117, 32.7%); and those not on ART at the time of survey (n = 33, 9.2%). ART non-users were the most likely to hold serious concerns about ART that outweighed perceived necessities (benefits) from ART (AOR = 0.13; 95% CI 0.06-0.29; p < 0.001). They were also the least self-efficacious in HIV disease management (AOR = 0.29; 95% CI 0.09-0.87; p = 0.028). Intermittent ART users were more likely to receive their HIV diagnosis prior to 2003 (AOR = 0.38; 95% CI 0.28-0.53; p < 0.001) and perceive lower HIV management self-efficacy (AOR = 0.50, 95% CI 0.28-0.87; p = 0.015) than continuous users. ART-related beliefs and perceived self-efficacy in HIV self-management play an important role in achieving universal treatment uptake and sustained high levels of adherence.
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Affiliation(s)
- Limin Mao
- Centre for Social Research in Health, UNSW Australia, Room 307, Level 3 John Goodsell Building, Sydney, NSW, 2052, Australia.
| | - John de Wit
- Centre for Social Research in Health, UNSW Australia, Room 307, Level 3 John Goodsell Building, Sydney, NSW, 2052, Australia
- Department of Interdisciplinary Social Science, Utrecht University, Utrecht, The Netherlands
| | - Philippe Adam
- Centre for Social Research in Health, UNSW Australia, Room 307, Level 3 John Goodsell Building, Sydney, NSW, 2052, Australia
| | - Jeffrey J Post
- Prince of Wales Clinical School, UNSW Australia, Sydney, Australia
| | - Sean Slavin
- Centre for Social Research in Health, UNSW Australia, Room 307, Level 3 John Goodsell Building, Sydney, NSW, 2052, Australia
| | - Aaron Cogle
- National Association of People With HIV Australia, Sydney, Australia
| | - Edwina Wright
- Department of Infectious Disease, The Alfred Hospital and Monash University, Melbourne, Australia
- The Burnet Institute, Melbourne, Australia
| | - Michael Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia
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Tran DA, Wilson DP, Shakeshaft A, Ngo AD, Reyes J, Doran C, Zhang L. Cost-effectiveness of antiretroviral therapy expansion strategies in Vietnam. AIDS Patient Care STDS 2014; 28:365-71. [PMID: 24983389 DOI: 10.1089/apc.2014.0016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
This study determines an optimal strategy for scaling up ART in Vietnam by examining three initiation thresholds [350 cells/mm(3), 500 cells/mm(3), and treat all people living with HIV (PLHIV) regardless of CD4 cell counts] and treatment commencement rates among treatment-eligible PLHIV ranging from 5% to 100% within 12 months of diagnosis. Incremental cost-effectiveness ratios (ICERs) were calculated using a Markov model, based on data from a cohort of 3449 patients who initiated ART between January 1, 2005 and December 31, 2009 in 13 outpatient clinics across six provinces in Vietnam. Our analyses indicated that raising treatment eligibility criteria, in line with WHO guidelines (CD4 ≤500 cells/mm(3)) or removing CD4-based criteria would both be cost-effective in Vietnam. However, the cost-effective strategy from an economic viewpoint is first to increase coverage substantially among those with lowest CD4 levels, and only when coverage increases towards saturation should initiation criteria be lifted. Universal coverage under current guidelines would cost an additional $85 million and $96 million per year if the treatment threshold was 500 cells/mm(3). These scenarios would avert 15,000 and 22,000 HIV-related deaths in 2010-2019, with ICERs of $500-$660 per QALY gained. It is imperative to increase treatment coverage for newly diagnosed PLHIV in Vietnam according to the current guidelines prior to increasing the CD4 threshold for ART initiation.
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Affiliation(s)
- Dam Anh Tran
- Kirby Institute, The University of New South Wales, Sydney, New South Wales, Australia
- National Drug Alcohol Research Centre, The University of New South Wales, Sydney, New South Wales, Australia
| | - David P Wilson
- Kirby Institute, The University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Shakeshaft
- National Drug Alcohol Research Centre, The University of New South Wales, Sydney, New South Wales, Australia
| | - Anh Duc Ngo
- The University of South Australia, Adelaide, Australia
| | - Josephine Reyes
- Kirby Institute, The University of New South Wales, Sydney, New South Wales, Australia
| | - Christopher Doran
- Hunter Medical Research Centre, The University of Newcastle, Newcastle, Australia
| | - Lei Zhang
- Kirby Institute, The University of New South Wales, Sydney, New South Wales, Australia
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Tran DA, Shakeshaft A, Ngo AD, Mallitt KA, Wilson D, Doran C, Zhang L. Determinants of antiretroviral therapy initiation and treatment outcomes for people living with HIV in Vietnam. HIV CLINICAL TRIALS 2014; 14:21-33. [PMID: 23372112 DOI: 10.1310/hct1401-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study explores patient characteristics that are significantly associated with very late combination antiretroviral therapy (cART) initiation (CD4 count ≤100 cells/mm³) and examines the association between patient characteristics and treatment outcomes, CD4 recovery, and mortality. DESIGN Data were obtained from the clinical records of 2,198 HIV/AIDS patients in 13 outpatient clinics across 6 provinces in Vietnam. METHODS Multivariate logistic regression and Cox proportional hazards regression were used to identify patient characteristics that are significantly associated with very late cART initiation and to measure relationships between patient characteristics and treatment outcomes. RESULTS Very late cART initiation was significantly associated with being male compared with female (odds ratio [OR], 0.36; 95% CI, 0.23-0.58), becoming HIV infected through injecting drugs (OR, 2.13; 95% CI, 1.09-4.14), and having opportunistic infections at cART initiation (OR, 1.69; 95% CI, 1.02-2.86). Being male (female vs male: hazard ratio [HR], 0.45; 95% CI, 0.20-0.98), very late cART initiation (timely vs late: HR, 0.18; 95% CI, 0.04-0.72), low baseline body mass index (BMI) (HR, 0.95; 95% CI, 0.92-0.98), and later baseline WHO clinical stage (WHO clinical stage IV vs combined group of stage I and II: HR, 5.70; 95% CI, 3.90-7.80) were significantly associated with death, whereas being female compared with male (HR, 1.51; 95% CI, 1.14-1.99) and timely cART initiation (HR, 35.45; 95% CI, 13.67-91.91) were significant predictors of CD4 recovery. CONCLUSIONS Timely testing of patients for HIV, increasing use of CD4 count testing services, and starting cART earlier are essential to reduce mortality and improve treatment outcomes.
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Affiliation(s)
- Dam Anh Tran
- National Drug Alcohol Research Centre, The University of New South Wales, Sydney, Australia Kirby Institute, Sydney, Australia. d.tran@
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Assessing the predictive value of HIV indicator conditions in general practice: a case-control study using the THIN database. Br J Gen Pract 2014; 63:e370-7. [PMID: 23735407 DOI: 10.3399/bjgp13x668159] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND UK HIV guidelines identify 37 clinical indicator conditions for adult HIV infection that should prompt an HIV test. However, few data currently exist to show their predictive value in identifying undiagnosed HIV. AIM To identify symptoms and clinical diagnoses associated with HIV infection and assess their relative importance in identifying HIV cases, using data from The Health Improvement Network (THIN) general practice database. DESIGN AND SETTING A case-control study in primary care. METHOD Cases (HIV-positive patients) were matched to controls (not known to have HIV). Data from 939 cases and 2576 controls were included (n = 3515). Statistical analysis assessed the incidence of the 37 clinical conditions in cases and controls, and their predictive value in indicating HIV infection, and derived odds ratios (ORs) for each indicator condition. RESULTS Twelve indicator conditions were significantly associated with HIV infection; 74.2% of HIV cases (n = 697) presented with none of the HIV indicator conditions prior to diagnosis. The conditions most strongly associated with HIV infection were bacterial pneumonia (OR = 47.7; 95% confidence interval [CI] = 5.6 to 404.2) and oral candidiasis (OR = 29.4; 95% CI = 6.9 to 125.5). The signs and symptoms most associated with HIV were weight loss (OR = 13.4; 95% CI = 5.0 to 36.0), pyrexia of unknown origin (OR = 7.2; 95% CI = 2.8 to 18.7), and diarrhoea (one or two consultations). CONCLUSION This is the first study to quantify the predictive value of clinical diagnoses related to HIV infection in primary care. In identifying the conditions most strongly associated with HIV, this study could aid GPs in offering targeted HIV testing to those at highest risk.
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Suárez-García I, Sobrino-Vegas P, Tejada A, Viciana P, Ribas MA, Iribarren JA, Díaz Menéndez M, Rivero M, Arazo P, del Amo J, Moreno S. Compliance with national guidelines for HIV treatment and its association with mortality and treatment outcome: a study in a Spanish cohort. HIV Med 2013; 15:86-97. [DOI: 10.1111/hiv.12078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2013] [Indexed: 11/29/2022]
Affiliation(s)
- I Suárez-García
- Infectious Diseases Unit; Infanta Sofía Hospital; Madrid Spain
| | | | - A Tejada
- Ramón y Cajal Hospital; Madrid Spain
| | - P Viciana
- Virgen del Rocío Hospital; Sevilla Spain
| | - MA Ribas
- Son Espases Hospital; Palma de Mallorca; Spain
| | | | | | - M Rivero
- Navarra Hospital; Pamplona Spain
| | - P Arazo
- Miguel Servet Hospital; Zaragoza Spain
| | - J del Amo
- National Epidemiology Center; Madrid Spain
| | - S Moreno
- Ramón y Cajal Hospital; Madrid Spain
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9
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Life expectancy living with HIV: recent estimates and future implications. Curr Opin Infect Dis 2013; 26:17-25. [PMID: 23221765 DOI: 10.1097/qco.0b013e32835ba6b1] [Citation(s) in RCA: 267] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE OF REVIEW The life expectancy of people living with HIV has dramatically increased since effective antiretroviral therapy has been available, and still continues to improve. Here, we review the latest literature on estimates of life expectancy and consider the implications for future research. RECENT FINDINGS With timely diagnosis, access to a variety of current drugs and good lifelong adherence, people with recently acquired infections can expect to have a life expectancy which is nearly the same as that of HIV-negative individuals. Modelling studies suggest that life expectancy could improve further if there were increased uptake of HIV testing, better antiretroviral regimens and treatment strategies, and the adoption of healthier lifestyles by those living with HIV. In particular, earlier diagnosis is one of the most important factors associated with better life expectancy. A consequence of improved survival is the increasing number of people with HIV who are aged over 50 years old, and further research into the impact of ageing on HIV-positive people will therefore become crucial. The development of age-specific HIV treatment and management guidelines is now called for. SUMMARY Analyses on cohort studies and mathematical modelling studies have been used to estimate life expectancy of those with HIV, providing useful insights of importance to individuals and healthcare planning.
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Iwuji CC, Churchill D, Gilleece Y, Weiss HA, Fisher M. Older HIV-infected individuals present late and have a higher mortality: Brighton, UK cohort study. BMC Public Health 2013; 13:397. [PMID: 23622568 PMCID: PMC3651303 DOI: 10.1186/1471-2458-13-397] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 04/04/2013] [Indexed: 11/19/2022] Open
Abstract
Background Initiating therapy with a low CD4 cell count is associated with a substantially greater risk of disease progression and death than earlier initiation. We examined factors associated with late presentation of HIV using the new European consensus definition (CD4 cell count <350 cells/mm3) and mortality. Methods Patients newly diagnosed with HIV infection at a UK clinic were recruited from January 1996 to May 2010. Factors associated with late presentation were assessed using logistic regression. Factors associated with mortality rates were analysed using Poisson regression. Results Of the 1536 included in the analysis, 86% were male and 10% were aged 50 years and older. Half the cohort (49%) had a CD4 cell count below 350 cells/mm3 at presentation (“late presentation”). The frequency of late presentation was highest in those aged 50 years or older and remained unchanged over time (64.3% in 1996-1998 and 65.4% in 2008-2010). In contrast, among those aged less than 50 years, the proportion with late presentation decreased over time (57.1% in 1996-1998 and 38.5% in 2008-2010). Other factors associated with late presentation were African ethnicity and being a male heterosexual. The mortality rate was 15.47/1000 person-years (pyrs) (95%-CI: 13.00-18.41). When compared with younger adults, older individuals had a higher mortality, after adjusting for confounders (rate ratio (RR) = 2.87; 95%-CI: 1.88-4.40). Conclusions Older adults were more likely to present late and had a higher mortality. Initiatives to expand HIV testing in clinical and community setting should not neglect individuals aged over 50.
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Affiliation(s)
- Collins C Iwuji
- Lawson Unit, Department of HIV/Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton BN2 5BE, UK.
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11
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MacKenzie AI, Holme SA. HIV testing in Scottish dermatology, a national audit. Clin Exp Dermatol 2013; 38:313-4. [DOI: 10.1111/ced.12113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 12/01/2022]
Affiliation(s)
- A. I. MacKenzie
- Department of Dermatology; Royal Infirmary of Edinburgh; Lauriston Place; Edinburgh; EH3 9YW; UK
| | - S. A. Holme
- Department of Dermatology; Royal Infirmary of Edinburgh; Lauriston Place; Edinburgh; EH3 9YW; UK
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12
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Rayment M, Thornton A, Mandalia S, Elam G, Atkins M, Jones R, Nardone A, Roberts P, Tenant-Flowers M, Anderson J, Sullivan AK. HIV testing in non-traditional settings--the HINTS study: a multi-centre observational study of feasibility and acceptability. PLoS One 2012; 7:e39530. [PMID: 22745777 PMCID: PMC3382186 DOI: 10.1371/journal.pone.0039530] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 05/23/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND UK guidelines recommend routine HIV testing in healthcare settings if the local diagnosed HIV prevalence >2/1000 persons. This prospective study assessed the feasibility and acceptability, to patients and staff, of routinely offering HIV tests in four settings: Emergency Department, Acute Care Unit, Dermatology Outpatients and Primary Care. Modelling suggested the estimated prevalence of undiagnosed HIV infection in attendees would exceed 1/1000 persons. The prevalence identified prospectively was not a primary outcome. METHODS Permanent staff completed questionnaires assessing attitudes towards routine HIV testing in their workplace before testing began. Subsequently, over a three-month period, patients aged 16-65 were offered an HIV test by study staff. Demographics, uptake, results, and departmental activity were collected. Subsets of patients completed questionnaires. Analyses were conducted to identify factors associated with test uptake. FINDINGS Questionnaires were received from 144 staff. 96% supported the expansion of HIV testing, but only 54% stated that they would feel comfortable delivering testing themselves, with 72% identifying a need for training. Of 6194 patients offered a test, 4105 (66·8%) accepted (61·8-75·4% across sites). Eight individuals were diagnosed with HIV (0-10/1000 across sites) and all transferred to care. Younger people, and males, were more likely to accept an HIV test. No significant associations were found between uptake and ethnicity, or clinical site. Questionnaires were returned from 1003 patients. The offer of an HIV test was acceptable to 92%. Of respondents, individuals who had never tested for HIV before were more likely to accept a test, but no association was found between test uptake and sexual orientation. CONCLUSIONS HIV testing in these settings is acceptable, and operationally feasible. The strategy successfully identified, and transferred to care, HIV-positive individuals. However, if HIV testing is to be included as a routine part of patients' care, additional staff training and infrastructural resources will be required.
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Affiliation(s)
- Michael Rayment
- Directorate of HIV/GU Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom.
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Sherr L, Clucas C, Lampe F, Harding R, Johnson M, Fisher M, Anderson J, Edwards S, Team S. Gender and mental health aspects of living with HIV disease and its longer-term outcomes for UK heterosexual patients. Women Health 2012; 52:214-33. [PMID: 22533897 DOI: 10.1080/03630242.2012.665431] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Gender is important in the experience of illness generally and HIV specifically. In this study the authors compare 183 HIV positive women with 76 HIV positive heterosexual men attending United Kingdom HIV clinics on clinical, treatment, and mental health factors. Participants completed a questionnaire on mental health and HIV-related factors. Laboratory measures of HIV viral load and CD4 cell count were obtained at baseline and 6-18 months later. After adjusting for age, employment, and treatment status, men were significantly less likely than women to suffer from high psychological [adjusted odds ratio (OR) = 0.38, 95% confidence interval (CI): 0.17, 0.86] and global symptom distress (adjusted OR = 0.42, 95% CI: 0.19, 0.92). However, men were more likely than women to report having suicidal thoughts (adjusted OR = 1.85, 95% CI: 0.95, 3.58). Relational, sexual behavior, and quality of life factors were similar for men and women. Adherence levels did not differ by gender but were sub-optimal in 56% of patients. Men had significantly lower CD4 counts than women at baseline, but not at follow-up. No differences were observed in the proportions with viral suppression. The groups had generally similar HIV experiences with high psychological distress. Adherence monitoring and gender appropriate psychological support are needed for these groups.
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Affiliation(s)
- Lorraine Sherr
- Department of Infection and Population Health, University College London, London, UK.
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Affiliation(s)
- S Duncan
- Specialty Registrar Genitourinary Medicine, The Garden Clinic, Upton Hospital, Slough, UK.
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Uptake and outcome of combination antiretroviral therapy in men who have sex with men according to ethnic group: the UK CHIC Study. J Acquir Immune Defic Syndr 2012; 59:523-9. [PMID: 22205437 DOI: 10.1097/qai.0b013e318245c9ca] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We investigated differences in retention in HIV care and uptake of combination antiretroviral therapy (cART) and treatment outcomes between different ethnic men who have sex with men (MSM) groups. METHODS MSM subjects with known ethnicity and ≥1 day follow-up from 1996 to 2009 in the UK Collaborative HIV Cohort Study were included. Black and minority ethnic (BME) men were categorized as: black; Indian/Pakistani/Bangladeshi; other Asian/Oriental; and other/mixed. Logistic regression was used to identify factors associated with treatment initiation within the 6 months after each CD4 count. HIV viral load, CD4 counts, discontinuation/switch of a drug in the initial cART regimen, and development of a new AIDS event/death at 6 and 12 months were also analyzed. RESULTS Of 16,406 MSM, 1818 (11.0%) were BME; 892 (49.1%) black, 139 (7.6%) Indian/Pakistani/Bangladeshi, 254 (13.9%) other Asian/Oriental, 532 (29.2%) other/mixed. The proportion of MSM with no follow-up after HIV diagnosis was higher among BME than white MSM (3.4% vs. 2.2%, P = 0.002). Permanent loss to follow-up was highest in the other/mixed and lowest in Indian/Pakistani/Bangladeshi groups (P = 0.02). Six thousand three hundred thirty-eight MSM initiated first cART from January 1, 2000, to January 1, 2009. In multivariable analyses, BME MSM were 18% less likely to initiate cART than white MSM with similar CD4 counts [adjusted odds ratio 0.82 (95% confidence interval: 0.74 to 0.91), P = 0.0001]. However, once on cART, there were no differences in virological, immunological, and clinical outcomes. CONCLUSIONS This study demonstrates that despite BME MSM being a "minority within a minority" for those HIV infected, there are few ethnic disparities in access to and treatment outcomes in our setting.
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Mercer RM, Olarinde O, Ryan C, Greig J, Yeeles H, Walker A, Walker H, Meardon NC. Initiation of antiretroviral therapy in patients with a CD4 count of less than 350 cells: a retrospective audit against key indicators from the CQUIN payment framework. Int J STD AIDS 2011; 22:755-6. [PMID: 22174062 DOI: 10.1258/ijsa.2011.011042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A proportion of funding for the South Yorkshire HIV Network is dependant on meeting the targets of the Commissioning for Quality and Innovation (CQUIN) payment framework. This states that 85% of patients with a CD4 count below 350 should be on antiretroviral therapy (ART). We also audited how many patients we started on treatment within six weeks. We found 88% of the 243 patients were on ART at the end of the audit, but significantly less had been started on treatment within six weeks of their CD4 count falling below 350. Although the target was achieved, there were patients who should be excluded as shown by other clinical guidelines, for example patients on treatment for tuberculosis. If these patients were excluded and the threshold level increased, it would help emphasize the at-risk patient group and lead to a fairer allocation of funding.
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Affiliation(s)
- R M Mercer
- Sheffield Teaching Hospitals, Sheffield; Rotherham General Hospital, Rotherham; Doncaster Royal Infirmary, Doncaster, UK.
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Kober C, Johnson M, Fisher M, Hill T, Anderson J, Bansi L, Gompels M, Palfreeman A, Dunn D, Gazzard B, Gilson R, Post F, Phillips AN, Walsh J, Orkin C, Delpech V, Ainsworth J, Leen C, Sabin CA. Non-uptake of highly active antiretroviral therapy among patients with a CD4 count < 350 cells/μL in the UK. HIV Med 2011; 13:73-8. [PMID: 22106827 DOI: 10.1111/j.1468-1293.2011.00956.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2011] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Current British HIV Association (BHIVA) guidelines recommend that all patients with a CD4 count <350 cells/μL are offered highly active antiretroviral therapy (HAART). We identified risk factors for delayed initiation of HAART following a CD4 count <350 cells/μL. METHODS All adults under follow-up in 2008 who had a first confirmed CD4 count <350 cells/μL from 2004 to 2008, who had not initiated treatment and who had >6 months of follow-up were included in the study. Characteristics at the time of the low CD4 cell count and over follow-up were compared to identify factors associated with delayed HAART uptake. Analyses used proportional hazards regression with fixed (sex/risk group, age, ethnicity, AIDS, baseline CD4 cell count and calendar year) and time-updated (frequency of CD4 cell count measurement, proportion of CD4 counts <350 cells/μL, latest CD4 cell count, CD4 percentage and viral load) covariates. RESULTS Of 4871 patients with a confirmed low CD4 cell count, 436 (8.9%) remained untreated. In multivariable analyses, those starting HAART were older [adjusted relative hazard (aRH)/10 years 1.15], were more likely to be female heterosexual (aRH 1.13), were more likely to have had AIDS (aRH 1.14), had a greater number of CD4 measurements < 350 cells/μL (aRH/additional count 1.18), had a lower CD4 count over follow-up (aRH/50 cells/μL higher 0.57), had a lower CD4 percentage (aRH/5% higher 0.90) and had a higher viral load (aRH/log(10) HIV-1 RNA copies/ml higher 1.06). Injecting drug users (aRH 0.53), women infected with HIV via nonsexual or injecting drug use routes (aRH 0.75) and those of unknown ethnicity (aRH 0.69) were less likely to commence HAART. CONCLUSION A substantial minority of patients with a CD4 count < 350 cells/μL remain untreated despite its indication.
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Affiliation(s)
- C Kober
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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May M, Gompels M, Delpech V, Porter K, Post F, Johnson M, Dunn D, Palfreeman A, Gilson R, Gazzard B, Hill T, Walsh J, Fisher M, Orkin C, Ainsworth J, Bansi L, Phillips A, Leen C, Nelson M, Anderson J, Sabin C. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 2011; 343:d6016. [PMID: 21990260 PMCID: PMC3191202 DOI: 10.1136/bmj.d6016] [Citation(s) in RCA: 236] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate life expectancy for people with HIV undergoing treatment compared with life expectancy in the general population and to assess the impact on life expectancy of late treatment, defined as CD4 count <200 cells/mm(3) at start of antiretroviral therapy. DESIGN Cohort study. SETTING Outpatient HIV clinics throughout the United Kingdom. Population Adult patients from the UK Collaborative HIV Cohort (UK CHIC) Study with CD4 count ≤ 350 cells/mm(3) at start of antiretroviral therapy in 1996-2008. MAIN OUTCOME MEASURES Life expectancy at the exact age of 20 (the average additional years that will be lived by a person after age 20), according to the cross sectional age specific mortality rates during the study period. RESULTS 1248 of 17,661 eligible patients died during 91,203 person years' follow-up. Life expectancy (standard error) at exact age 20 increased from 30.0 (1.2) to 45.8 (1.7) years from 1996-9 to 2006-8. Life expectancy was 39.5 (0.45) for male patients and 50.2 (0.45) years for female patients compared with 57.8 and 61.6 years for men and women in the general population (1996-2006). Starting antiretroviral therapy later than guidelines suggest resulted in up to 15 years' loss of life: at age 20, life expectancy was 37.9 (1.3), 41.0 (2.2), and 53.4 (1.2) years in those starting antiretroviral therapy with CD4 count <100, 100-199, and 200-350 cells/mm(3), respectively. CONCLUSIONS Life expectancy in people treated for HIV infection has increased by over 15 years during 1996-2008, but is still about 13 years less than that of the UK population. The higher life expectancy in women is magnified in those with HIV. Earlier diagnosis and subsequent timely treatment with antiretroviral therapy might increase life expectancy.
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Affiliation(s)
- Margaret May
- School of Social and Community Medicine, Bristol University, Bristol BS8 2PS, UK.
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Palfreeman A, Fisher M. Diagnosis and management of HIV infection. Br J Hosp Med (Lond) 2011; 72:146-50. [PMID: 21475094 DOI: 10.12968/hmed.2011.72.3.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Infection with human immunodeficiency virus (HIV) is now increasingly common in the UK, but the diagnosis is often missed or overlooked. This article summarizes who to test and how best to offer testing to patients in whom HIV testing is clinically indicated.
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Affiliation(s)
- Adrian Palfreeman
- Department of Genitourinary Medicine and Sexual Health, University Hospital Leicester, Leicester LEI 5WW
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Lower mortality and earlier start of combination antiretroviral therapy in patients tested repeatedly for HIV than in those with a positive first test. AIDS 2011; 25:813-8. [PMID: 21330906 DOI: 10.1097/qad.0b013e3283454cd7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early diagnosis of HIV-1 infection will probably beneficially impact onward transmission and life expectancy. We compared mortality rates and CD4 cell counts at start of combination antiretroviral therapy (cART) in patients with different frequencies of diagnostic testing for HIV. METHODS Patients infected with HIV-1 through sexual contact and in follow-up anytime from 2004 through 2008 were selected from the AIDS Therapy Evaluation in the Netherlands national observational HIV cohort and stratified into three groups: patients without a prior negative HIV antibody test (i.e., with a positive first-test result); patients with 1-2 years between the last negative and first positive test; and patients with less than 1 year between tests. Outcome measures were mortality from 2004 through 2008 and CD4 cell count at cART initiation. RESULTS Of 5494 patients, the mortality rate was highest among the 4067 patients with a positive first test (1.33/100 person-years) and the adjusted relative risk of mortality was 0.50 in 561 patients with tests 1-2 years apart (P = 0.04 compared to patients with a positive first test) and 0.49 (P = 0.02) when tests were less than 1 year apart (n = 866). In patients with a positive first test, 48% had CD4 cell counts less than 200 cells/μl at cART initiation; this proportion was 23-26% in the two groups of repeatedly tested patients (adjusted odds ratio compared to patients with a positive first test 0.43 and 0.37, respectively; both P < 0.0001). CONCLUSION Frequent repeated testing for HIV may improve the rate of timely diagnosis and treatment, thereby preventing disease progression.
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Shepherd BE, Yu C. Accounting for data errors discovered from an audit in multiple linear regression. Biometrics 2011; 67:1083-91. [PMID: 21281274 DOI: 10.1111/j.1541-0420.2010.01543.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A data coordinating team performed onsite audits and discovered discrepancies between the data sent to the coordinating center and that recorded at sites. We present statistical methods for incorporating audit results into analyses. This can be thought of as a measurement error problem, where the distribution of errors is a mixture with a point mass at 0. If the error rate is nonzero, then even if the mean of the discrepancy between the reported and correct values of a predictor is 0, naive estimates of the association between two continuous variables will be biased. We consider scenarios where there are (1) errors in the predictor, (2) errors in the outcome, and (3) possibly correlated errors in the predictor and outcome. We show how to incorporate the error rate and magnitude, estimated from a random subset (the audited records), to compute unbiased estimates of association and proper confidence intervals. We then extend these results to multiple linear regression where multiple covariates may be incorrect in the database and the rate and magnitude of the errors may depend on study site. We study the finite sample properties of our estimators using simulations, discuss some practical considerations, and illustrate our methods with data from 2815 HIV-infected patients in Latin America, of whom 234 had their data audited using a sequential auditing plan.
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Affiliation(s)
- Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, 1161 21st Avenue South, Nashville, Tennessee 37232, USA.
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Impact of earlier HAART initiation on the immune status and clinical course of treated patients on the basis of cohort data of the German Competence Network for HIV/AIDS. Infection 2011; 39:3-12. [PMID: 21221704 DOI: 10.1007/s15010-010-0070-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 11/30/2010] [Indexed: 01/24/2023]
Abstract
PURPOSE Hitherto, studies on highly active antiretroviral therapy (HAART) initiation have shown partly inconsistent results. Our study investigated the clinical course and course of immune status after HAART initiation at CD4-cell-count/μl of treated patients between 250 and 349 (group 1), compared to 350-449 (group 2), on the basis of the cohort of the Competence Network for HIV/AIDS (KompNet cohort). METHODS Patients had to be HAART-naïve. Medication had to start at the earliest in 1996, being at least triple combination therapy. The primary endpoints of death, first AIDS-defining illness and first drop of CD4-cell-count/μl below 200 were evaluated as censored event times between the initiation of HAART (t (0)) and the date of the first event/date of last observation. Probabilities of event-free intervals since t (0) were calculated by Kaplan-Meier estimation, compared by logrank tests. The results were adjusted for confounders using Cox regression. Additionally, incidences were estimated. RESULTS A total of 822 patients met the inclusion criteria (group 1: 526, group 2: 296), covering 4,133 patient years (py) overall. In group 1, 0.64 death cases/100 py were found, with the corresponding vale being 0.17 in group 2. In group 1, 1.38 AIDS-defining events/100 py occurred, whereas it was 0.78 in group 2. In group 1, 2.64 events of first drop of CD4-cell-count/μl below 200 occurred per 100 py, compared to 0.77 in group 2. Kaplan-Meier estimations showed borderline significant differences regarding death (p = 0.063), no differences regarding first AIDS-defining illness (p = 0.148) and distinct differences regarding the first drop of CD4-cell-count/μl below 200 (p = 0.0004). CONCLUSIONS The results gave a strong hint for a therapy initiation at higher CD4-cell-count/μl regarding the outcome of death in treated patients. A distinct benefit was shown regarding the first decline of CD4-cell-count/μl below 200.
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Abstract
PURPOSE OF REVIEW This review examines situations in which information from cohort studies has proved to be useful for the development of treatment guidelines. RECENT FINDINGS Although there are several reasons why randomized controlled trials (RCTs) are felt to provide the most robust evidence for treatment guidelines, they may suffer from insufficient duration of follow-up, inadequate power to consider differences in important adverse events and highly selected patient populations. Furthermore, as most RCTs are performed for licensing purposes, strategic treatment decisions often lack supportive evidence from RCTs. Although data from cohort studies may be used to complement information from RCTs, cohort studies themselves are susceptible to several biases (most notably confounding) which may limit their findings. However, in the HIV field, information from such studies has been influential in guiding decisions relating to when to start highly active antiretroviral therapy, what drugs to use in the initial highly active antiretroviral therapy regimen and when to switch highly active antiretroviral therapy should virological failure occur. SUMMARY Given the biases that may be present, caution should be exercised when interpreting findings from cohort studies, particularly if comparisons are made of treatment strategies that involve some element of patient or clinician choice.
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Fernandes JRM, Acurcio FDA, Campos LN, Guimarães MDC. [Initiation of antiretroviral therapy in HIV-infected patients with severe immunodeficiency in Belo Horizonte, Minas Gerais State, Brazil]. CAD SAUDE PUBLICA 2010; 25:1369-80. [PMID: 19503967 DOI: 10.1590/s0102-311x2009000600019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 01/28/2009] [Indexed: 11/22/2022] Open
Abstract
The main objective was to assess the proportion of delayed initiation of antiretroviral therapy (ART) and associated factors. This was a cross-sectional study of 310 patients enrolled in two public health centers in Belo Horizonte, Minas Gerais State, Brazil. Delayed ART initiation was defined as starting treatment with a CD4 count lower than 200 cells/mm(3) or clinical symptoms of severe immunodepression at the time of first antiretroviral prescription. The majority of participants were males (63.9%), had no health insurance (76.1%), and started ART less than 120 days after the first medical visit (75.2%). The proportion of delayed ART initiation was 68.4%. Unemployment, referral by a health professional for HIV testing, fewer than two medical visits in the six months prior to ART initiation, and time between first medical visit and ART initiation less than 120 days were independently associated with the outcome. Our results suggest that every patient 13 to 64 years of age should be offered HIV testing, which could increase the rate of early HIV diagnosis, and thus patients that tested positive could benefit from timely follow-up and antiretroviral therapy.
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Harte D, Dosekun O, Sethi G, Chadborn T, de Ruiter A, Copas A, Edwards SG, Miller RF. Immunosuppression among HIV-1-positive patients attending for care: experience from two large HIV centres in the United Kingdom. HIV Med 2010; 11:114-20. [DOI: 10.1111/j.1468-1293.2009.00753.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Johnson M, Sabin C, Girardi E. Definition and epidemiology of late presentation in Europe. Antivir Ther 2010; 15 Suppl 1:3-8. [DOI: 10.3851/imp1522] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Suarez-Lozano I, Viciana P, Lacalle JR, Teira R, Lozano F, Lopez-Aldeguer J, Pedrol E, Domingo P, Cosin J, Roca B, Geijo P, Fuente B, Vergara A, Ribera E, Galindo MJ, Zapata A, Sanchez T, Vidal F, Munoz-Sanz A, Munoz-Sanchez J, Garrido M. The relationship between antiretroviral prescription patterns and treatment guidelines in treatment-naïve HIV-1-infected patients. HIV Med 2009; 10:573-9. [DOI: 10.1111/j.1468-1293.2009.00731.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Palfreeman A, Fisher M, Ong E, Wardrope J, Stewart E, Castro-Sanchez E, Peto T, Rogstad K, Sheather J, Gazzard B, Pillay D, O'Brien J, Delpech V, Lowbury R, Fleet R, Azad Y, Lyall H, Hardie J, Adegbite G, Rooney G, Whitehead R. Testing for HIV: concise guidance. Clin Med (Lond) 2009; 9:471-6. [PMID: 19886111 PMCID: PMC4953460 DOI: 10.7861/clinmedicine.9-5-471] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
HIV is now a treatable medical condition and the majority of those living with the virus remain fit and well on treatment. Despite this a significant number of people in the UK are unaware of their HIV infection and remain at risk to their own health and of passing their virus unwittingly on to others. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the U.K. Testing for HIV infection is often not performed due to misconceptions held by healthcare workers even when it is clinically indicated and this contributes to missed or late diagnosis. This article summarises the recommendations from the U.K. national guidelines for HIV testing 2008. The guidelines provide the information needed to enable any clinician to perform an HIV test within good clinical practice and encourage 'normalisation' of HIV testing. The full version is available at www.bhiva.org/cmsl 222621.asp.
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Hughes GJ, Fearnhill E, Dunn D, Lycett SJ, Rambaut A, Leigh Brown AJ. Molecular phylodynamics of the heterosexual HIV epidemic in the United Kingdom. PLoS Pathog 2009; 5:e1000590. [PMID: 19779560 PMCID: PMC2742734 DOI: 10.1371/journal.ppat.1000590] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 08/25/2009] [Indexed: 11/25/2022] Open
Abstract
The heterosexual risk group has become the largest HIV infected group in the United Kingdom during the last 10 years, but little is known of the network structure and dynamics of viral transmission in this group. The overwhelming majority of UK heterosexual infections are of non-B HIV subtypes, indicating viruses originating among immigrants from sub-Saharan Africa. The high rate of HIV evolution, combined with the availability of a very high density sample of viral sequences from routine clinical care has allowed the phylodynamics of the epidemic to be investigated for the first time. Sequences of the viral protease and partial reverse transcriptase coding regions from 11,071 patients infected with HIV of non-B subtypes were studied. Of these, 2774 were closely linked to at least one other sequence by nucleotide distance. Including the closest sequences from the global HIV database identified 296 individuals that were in UK-based groups of 3 or more individuals. There were a total of 8 UK-based clusters of 10 or more, comprising 143/2774 (5%) individuals, much lower than the figure of 25% obtained earlier for men who have sex with men (MSM). Sample dates were incorporated into relaxed clock phylogenetic analyses to estimate the dates of internal nodes. From the resulting time-resolved phylogenies, the internode lengths, used as estimates of maximum transmission intervals, had a median of 27 months overall, over twice as long as obtained for MSM (14 months), with only 2% of transmissions occurring in the first 6 months after infection. This phylodynamic analysis of non-B subtype HIV sequences representing over 40% of the estimated UK HIV-infected heterosexual population has revealed heterosexual HIV transmission in the UK is clustered, but on average in smaller groups and is transmitted with slower dynamics than among MSM. More effective intervention to restrict the epidemic may therefore be feasible, given effective diagnosis programmes. Since 1995, HIV among heterosexuals in the UK increased to the point where the total number of heterosexuals infected with HIV, predominantly of non-B subtypes, exceeds the number of HIV-positive homosexual men. To understand the dynamics of this epidemic, we have applied the novel technique of phylodynamics to the analysis of viral sequences taken in the course of routine clinical care from approximately 40% of the HIV-infected heterosexual population in the UK. Phylodynamics reconstructs the pattern of viral sequence divergence in time, revealing the size of transmission clusters and the dynamics of transmission within them. Of 11,071 patients studied, 296 were linked to at least two others in the UK. There were 8 clusters comprising 10 or more individuals among these, yielding a total of 143 or 5% of all individuals with links, much lower than seen earlier among homosexual men (25%). Viral transmissions within clusters also occurred less rapidly, only 2% being dated to the first 6 months of infection, compared to 25% among homosexual men. Overall, transmission clusters exist in the UK heterosexual HIV epidemic but they are generally smaller than among homosexuals; onward transmission occurs less rapidly and is not associated with acute HIV infection.
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Affiliation(s)
- Gareth J. Hughes
- Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Esther Fearnhill
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - David Dunn
- Medical Research Council Clinical Trials Unit, London, United Kingdom
| | - Samantha J. Lycett
- Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Andrew Rambaut
- Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Andrew J. Leigh Brown
- Institute of Evolutionary Biology, School of Biological Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
- * E-mail:
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Abstract
OBJECTIVE To assess whether immunodeficiency is associated with the most frequent non-AIDS-defining causes of death in the era of combination antiretroviral therapy (cART). DESIGN Observational multicentre cohorts. METHODS Twenty-three cohorts of adults with estimated dates of human immunodeficiency virus (HIV) seroconversion were considered. Patients were seroconverters followed within the cART era. Measurements were latest CD4, nadir CD4 and time spent with CD4 cell count less than 350 cells/microl. Outcomes were specific causes of death using a standardized classification. RESULTS Among 9858 patients (71 230 person-years follow-up), 597 died, 333 (55.7%) from non-AIDS-defining causes. Non-AIDS-defining infection, liver disease, non-AIDS-defining malignancy and cardiovascular disease accounted for 53% of non-AIDS deaths. For each 100 cells/microl increment in the latest CD4 cell count, we found a 64% (95% confidence interval 58-69%) reduction in risk of death from AIDS-defining causes and significant reductions in death from non-AIDS infections (32, 18-44%), end-stage liver disease (33, 18-46%) and non-AIDS malignancies (34, 21-45%). Non-AIDS-defining causes of death were also associated with nadir CD4 while being cART-naive or duration of exposure to immunosuppression. No relationship between risk of death from cardiovascular disease and CD4 cell count was found though there was a raised risk associated with elevated HIV RNA. CONCLUSION In the cART era, the most frequent non-AIDS-defining causes of death are associated with immunodeficiency, only cardiovascular disease was associated with high viral replication. Avoiding profound and mild immunodeficiency, through earlier initiation of cART, may impact on morbidity and mortality of HIV-infected patients.
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Street E, Curtis H, Sabin CA, Monteiro EF, Johnson MA. British HIV Association (BHIVA) national cohort outcomes audit of patients commencing antiretrovirals from naïve. HIV Med 2009; 10:337-42. [PMID: 19490183 DOI: 10.1111/j.1468-1293.2009.00692.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of this work was to audit the extent to which routine HIV care in the UK conforms with British HIV Association (BHIVA) guidelines and specifically the proportion of patients starting highly active antiretroviral therapy (HAART) who achieve the outcome of virological suppression below 50 HIV-1 RNA copies/mL within 6 months. METHODS A prospective cohort review of adults with HIV infection who started antiretroviral therapy (ART) for the first time between April and September 2006 was carried out using structured questionnaire forms. RESULTS A total of 1170 adults from 122 clinical sites participated in the review. Of these patients, 699 (59.7%) started ART at CD4 counts <200 cells/microL and 193 (16.5%) had not been tested for HIV drug resistance. Excluding patients with valid reasons for stopping short-term ART, 795 (73.5%) of 1081 patients had an undetectable viral load (VL) at follow-up. Detectable VL was strongly associated with pretreatment CD4 count below 50 cells/microL and pretreatment VL above 100 000 copies/mL, and was not associated with clinic location or case load. About a quarter of patients did not have a VL measurement during the first 6 weeks after starting ART. CONCLUSIONS The majority of patients who initiated ART at sites participating in this UK national audit were managed within the BHIVA guidelines and achieved virological suppression below 50 copies/mL around 6 months after commencing treatment. Poor VL outcomes were associated with very low CD4 cell count and/or high VL at baseline but not with clinic case load or location. There is an urgent need to diagnose patients at an earlier stage of their HIV disease.
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Affiliation(s)
- E Street
- Department of Genitourinary Medicine, Leeds General Infirmary, Leeds LS1 3EX, UK
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