Factors influencing HIV progression in a seroconverter cohort in Madrid from 1985 to 1999

A low-cost, sustainable, second generation system for surveillance of people living with HIV in Spain: 10-year trends in behavioural and clinical indicators, 2002 to 2011

A second-generation surveillance system of people infected with human immunodeficiency virus (HIV) has been implemented in Spain. Behavioural and clinical data were collected between 2002 and 2011 through an annual one-day, cross-sectional survey in public hospitals, including all in- and outpatients receiving HIVrelated care on the survey day. Mean age increased over time (from 38.7 years in 2002 to 43.8 years in 2011) and 68.4% of the 7,205 subjects were male. The proportion of migrants increased from 6.1% to 15.9%, while people who inject or used to inject drugs (PWID and Ex-PWID) decreased and men who have sex with men (MSM) and heterosexuals increased. Unprotected intercourse at last sex increased among MSM and PWID/Ex-PWID. Patients receiving antiretroviral treatment increased significantly from 76.0% to 88.2% as did those with CD4 T-cell counts ≥350 (from 48.2% to 66.9%) and viral copies <200 (from 47.0% to 85.2%). HIV-infected people with hepatitis C virus RNA decreased from 36.0% in 2004 to 29.9% in 2011, while those with HBsAg remained stable at around 4.4%. Implementation of a low-cost, sustainable system for second-generation surveillance in people living with HIV is feasible. In Spain, the information obtained has helped to define and refine public health policy and document treatment effectiveness.

Recommendations for the follow-up of study participants with breakthrough HIV infections during HIV/AIDS biomedical prevention studies

OBJECTIVE

To facilitate collection of cumulative data on longitudinal HIV disease outcomes during HIV prevention studies by developing recommendations for follow-up of the relatively few study participants with breakthrough infections.

DESIGN

We formed a working group to compare and contrast the various approaches taken in recent HIV prevention trials, to summarize the advantages and disadvantages associated with each, and to explore the feasibility of developing protocols for the long-term follow-up of seroconverters.

METHODS

We reviewed study designs, objectives, and assessments in 15 interventional studies that followed HIV seroconverters. Protocol team members joined discussions of the various approaches and developed recommendations.

RESULTS

Most HIV prevention clinical trials share a core set of objectives, including the description/comparison of virological, immunological, and clinical course of HIV, and sometimes a comparison of preseroconversion and postseroconversion behavior. Long-term follow-up of seroconverters can be conducted in separate studies if the transition from parent protocol is effectively managed.

CONCLUSION

We recommend the development of harmonized seroconverter protocols. Although specific research questions in the postseroconversion period may differ depending on prevention modality, harmonizing key evaluations would create an opportunity to ask overarching questions that inform the prevention field with respect to design and implementation of future combination prevention studies. Follow-up immediately postseroconversion should be conducted in the parent protocol before roll over into a follow-up protocol. Development of specimen repositories with ample volumes for future assays, standardized definitions of infection, diagnosis and seroconversion dates, and harmonization of study objectives and sample collections at key time points are important.

Differences between HIV-positive and HIV-negative African American men who have sex with men in two major U.S. metropolitan areas

Alarmingly high HIV prevalence rates among African American men who have sex with men (AAMSM) require the development of effective prevention interventions. In this study of AAMSM conducted in two cities, we explored similarities and differences between HIV-positive and HIV-negative AAMSM on sociodemographic variables, HIV-related risk behaviors, and attitudinal constructs. Differences emerged in several major life areas: (1) poverty, employment, and use of mental health services, (2) sexual risk behaviors, and (3) self-identification with gay identity and culture. With regard to sociodemographic indicators, HIV-positive AAMSM were doing worse than HIV-negative AAMSM in that they were more likely to be disabled, to be living below the poverty level, and accessing mental health services. With regard to risk behaviors and partner characteristics, HIV-positive AAMSM were acting more responsibly than their HIV-negative counterparts, as they were more likely to have used a condom the last time they had sex. In addition, when compared to their HIV-negative counterparts, HIV-positive AAMSM were more likely to have either no casual partners at all or main or casual partners who were HIV-positive, thus preventing new HIV transmission by partnering with other HIV-positive men. Attitudinally, HIV-positive men were more accepting of their sexual attractions to men and were more likely to identify as gay than their HIV-negative peers. Although causality cannot be determined, the findings of this study can be used to strengthen HIV prevention efforts by improving the selection of targeted behaviors and prevention messages for HIV-positive and HIV-negative AAMSM.

[Cohort studies and their contribution to the study of HIV infection: main characteristics and limitations]

In this paper, we provide a definition of cohort studies and reviews the main types of cohort studies used in the context of HIV infection. We discuss how the main sources of selection biases in cohort studies are those derived from the lack of observation of the event that determines the origin and/or of the event of interest due to losses to follow-up or development of a competing event, and how this bias must be appropriately taken into account following specific epidemiological methods. Although cohort studies play an essential role in the study of HIV infection, they are logistically complex and require considerable resources. Therefore, strategic planning on the quality and quantity of the information collected must always be accompanied by a resource allocation plan.

[Effect of distinct sociodemographic variables on progression of HIV infection in a cohort of drug users]

OBJECTIVE

To analyze whether the effectiveness of combined antiretroviral therapy in delaying progression to AIDS and death is affected by social inequities in a cohort of HIV-positive injecting drug users (IDUs).

METHODS

A cohort of 3,122 HIV-positive IDUs identified in the AIDS Information and Prevention Centers of the autonomous region of Valencia was analyzed, with further follow-up in 1,876. Progression to AIDS and death after seroconversion were calculated by Kaplan-Meier estimation according to sociodemographic variables (age, sex, education, marital status, length of addiction). Cox regression models were also fitted.

RESULTS

No significant differences were observed according to the variables considered when analyzing time to AIDS development. Evaluation of survival time revealed that individuals with further follow-up showed an excess of mortality (HR = 1.35; 95%CI: 0.20-1.54). For individuals without follow-up, mortality risk was reduced in those with secondary school education (HR = 0.51; 95%CI: 0.35-0.74) and with university education (HR = 0.41; 95%CI: 0.18-0.93) compared with those with no education. When individuals with follow-up were analyzed, the differences lost significance for those with secondary school education (HR = 0.92; 95%CI: 0.72-1.19) and university education (HR = 0.62; 95%CI: 0.35-1.11).

CONCLUSIONS

The mortality excess found in IDUs with lower educational levels, especially among those not seeking healthcare in the initial period after being identified as HIV-positive, highlights the need for interventions aimed at facilitating access to health systems, especially among the socially disadvantaged.

Factors associated with improvement in disability-adjusted life years in patients with HIV/AIDS

BACKGROUND

The epidemic of HIV/AIDS and treatments that have emerged to alleviate, have brought about a shift in the burden of disease from death to quality of life/disability. The aim was to determine which factors are associated with improvements in the level of health of male and female patients with HIV/AIDS in Andalusia, in terms of disability-adjusted life years.

METHODS

Descriptive study based on a sample group of 8800 people on the Andalusian AIDS register between 1983 and 2004.

DEPENDENT VARIABLES

Life lost due to premature mortality (YLL), years lost due to disability (YLD) and disability-adjusted life years (DALY).

INDEPENDENT VARIABLES

vital state, sex, age at the time of diagnosis, age at the time of death, transmission category, province of residence, AIDS-indicator disease and the period of diagnosis. A bivariate analysis was carried out to find out if the health level variables changed in accordance with the independent variables. Using the independent variables which had a statistically significant link with the level of health variables, a multivariate linear regression model, disaggregated by gender, was constructed.

RESULTS

Amongst the women, we found a model which explained the level of health of 64.9%: a link was found between a higher level of health (lower DALYs) and not intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis. Amongst the men, we found a model which explained the level of health of 64.4%: a link was found between a higher level of health (lower DALYs) and intravenous drug use, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.

CONCLUSION

A higher level of health (lower DALY) amongst both men and women was found to be linked to not be intravenous drug user, the province of residence, being diagnosed during the HAART era and older age at the time of diagnosis.

Improvement in survival among symptomatic AIDS patients by exposure category in Sao Paulo

OBJECTIVE

The study assesses AIDS survival time per AIDS-case definition and exposure category in Sao Paulo State, Brazil during the periods 1992 to 1995 and 1998 to 2001.

METHODS

Case-fatality rate per AIDS case, Cox proportional hazards analysis, and Kaplan-Meier survival time.

RESULTS

The case-fatality rate per AIDS case in 1998 to 2001 was 37.6% for symptomatic (Centers for Disease Control and Prevention/modified and/or Paho/Caracas) and 9.7% for the Brazilian asymptomatic CD4 count<350 cells/mm3 AIDS-case definitions. Heterosexual/female patients were diagnosed earlier and presented the lowest case-fatality rate, followed by homosexual/male patients, heterosexual/male patients, and injecting drug users. In the multivariate Cox proportional hazards model, the period of diagnosis (hazard ratio=2.66; 95% confidence interval [CI]: 2.58 to 2.74) and AIDS-case definition (hazard ratio=4.48; 95% CI: 4.53 to 5.16) were strong predictors of survival. For the total AIDS cases, excluding death definition and undetermined exposure category, the estimated first quarter survival time improved from 4 months in 1992 to 1995 to 50 months in 1998 to 2001. Considering only the symptomatic AIDS-case definition, however, the improvement was from 4 months in the period 1992 to 1995 to 14 months in the period 1998 to 2001.

CONCLUSION

The survival improvement in Sao Paulo State was attributable to the introduction of antiretroviral therapy with free universal access in 1996 and to earlier diagnosis associated with the introduction in 1998 of the Brazilian asymptomatic CD4 count<350 cells/mm3 AIDS-case definition with superior sensitivity compared with the symptomatic AIDS-case definitions.

Educational attainment and response to HAART during initial therapy for HIV-1 infection

OBJECTIVE

Previous research has demonstrated an association between educational attainment (EA) and negative physical and psychological outcomes. This study investigated whether EA is associated with regimen failure during initial therapy with highly active antiretroviral treatment (HAART) and whether adherence self-efficacy (ASE), a coping resource, moderates the relationship between EA and regimen failure.

METHODS

A secondary analysis of AIDS Clinical Trial Group Protocol 384, an international, multicenter, randomized, partially double-blinded trial, included 799 male and 181 female antiretroviral-naïve subjects (age, 37.0+/-9.5 years). Participants were recruited from 1998 to 1999 and followed for a median of 2.3 years across 81 centers. The dependent variable was "time to first regimen failure." Covariates include baseline HIV-1 log(10)RNA and CD4(+) counts, self-reported adherence, study site, ASE, age, sex, race, treatment assignment, and baseline use of nonantiretroviral medications.

RESULTS

ASE significantly moderated the relationship between EA and regimen failure. Results showed that for every 10-unit increase in ASE, individuals with "less than high school" education had a 17% reduction in regimen failure (hazard ratio=0.83; 95% confidence interval=0.70-0.98) when compared to the reference group "college/graduate," even after adjusting for baseline factors known to contribute to regimen failure. The time to first regimen failure was shorter with decreasing EA, trending toward significance (P=.08).

CONCLUSIONS

There is a social gradient in HAART effectiveness, and ASE reduces the deleterious effects of lower EA on regimen failure. We recommend designing controlled interventions to evaluate the effectiveness of programs that increase ASE prior to initiation with HAART, particularly for those with lower EA.

Impact of hepatitis C infection on long-term mortality of injecting drug users from 1990 to 2002: differences before and after HAART

OBJECTIVE

To assess the impact of HIV and hepatitis C virus (HCV) infection on long-term mortality in injecting drug users (IDU).

DESIGN

Community-based prospective cohort study.

METHODS

Mortality data from follow-up in clinical sites and the Mortality Registry by December 2002 were collected for 3247 IDU who attended three centres for voluntary counselling and testing for HIV/AIDS, HCV and hepatitis B virus (HBV) in 1990-1996. Mortality rates by Poisson regression were adjusting for age, sex, duration of drug use, education, HBV and calendar period (1990-1997 and 1998-2002).

RESULTS

Overall, 11.2% were HIV/HCV negative, 43.7% positive only for HCV and 45.1% positive for both. During 26 772 person-years of follow-up, 585 deaths were detected (2.19/100 person-years). Before 1997, HIV/HCV-positive subjects had a five-fold increase in risk of death [relative risk (RR), 5.4; 95% confidence interval (CI), 2.5-11.4] compared with those negative for both; after 1997, a three-fold increase was observed (RR, 2.7; 95% CI, 1.7-4.2). Being HCV positive/HIV negative was not associated with an increase in the risk of death either before (RR, 1.3; 95% CI, 0.6-2.9) or after (RR, 1.2; 95% CI, 0.8-1.9) 1997 compared with HCV/HIV negative. While increases in mortality were seen in those HCV/HIV negative (RR, 1.6; 95% CI, 0.7-3.7) and those only positive for HCV (RR, 1.5; 95% CI, 1.0-2.1), a 20% reduction among coinfected IDUs was observed after 1997 (interaction P = 0.033).

CONCLUSIONS

HCV/HIV coinfection has had a large impact on mortality in IDU. After 1997, mortality increased in HIV negative/HCV positive subjects and decreased in HIV positive/HCV positive.

Trends in predictors of death due to HIV-related causes among persons living with AIDS in New York City: 1993-2001

To examine trends in predictors of HIV-related mortality among cohorts of persons living with AIDS (PLWA) in New York City (NYC), nine calendar year-specific cohorts of PLWA were created from 1993 to 2001. Cohorts were defined as persons who had been alive at any time during that year and had been diagnosed with AIDS before the end of that year. Predictors of death because of HIV-related causes of death were assessed by examining year-specific, stratified death rates per 1,000 PLWA and adjusted relative risks (RRs) from proportional hazards models. We conducted an analysis of AIDS surveillance data PLWA in NYC between 1993 and 2001. Univariate and multivariate Cox proportional hazards models were constructed for each calendar year cohort to evaluate trends in the RR of HIV-related death over the subsequent 5 years, adjusting for sex, race/ethnicity, age, transmission risk, borough of residence, category of AIDS diagnosis [opportunistic illness (OI) or CD4 count <200 cells/microL], time since AIDS diagnosis, and CD4 count at time of AIDS diagnosis. Death rates due to all causes and HIV-related causes declined substantially during 1993-1997 and then stabilized in all subgroups of PLWA between 1998 and 2001. Beginning in 1995, differences in survival emerged in some subgroups, such that by 2001 (1) injecting drug users (IDUs) had poorer survival compared with men who have sex with men (MSM) [RR(2001) = 2.1, 95% confidence intervals (95% CI) = 1.8-2.4]; (2) black and Hispanic PLWA had a significantly higher risk of death than white PLWA (RR(2001) = 1.4, 95% CI = 1.2-1.6, RR(2001) = 1.2, 95% CI = 1.1-1.4, respectively, and (3) PLWA aged 60 and above had poorer survival compared with younger persons (RR(2001) = 2.4, 95% CI = 1.9-3.0), after adjustment for other factors. The observed disparities that began to emerge in 1995 may be attributable to differential effects of, access to, or usage of highly active antiretroviral therapy (HAART). More targeted studies are needed to determine why such disparities have emerged.

[Effects of HIV status and other variables on the outcome of tuberculosis treatment in Spain]

OBJECTIVE

To analyze the effect of human immunodeficiency virus (HIV) status and other variables on the outcome of tuberculosis treatment in Spain.

PATIENTS AND METHODS

Multicenter retrospective cohort study in 6 autonomous communities of Spain (from May 1996 to April 1997). Data on treatment outcome were collected for new cases of tuberculosis in accordance with European guidelines. Follow up of patients continued for 3 months after scheduled end of treatment.

RESULTS

Of the 4899 patients included, 3417 (69.7%) had a satisfactory outcome, 438 (8.9%) died before or during treatment, and 1044 (21.4%) had a potentially unsatisfactory outcome. On stratification by HIV status, satisfactory outcome, mortality, and potentially unsatisfactory outcome were reported for 43.4%, 21.5%, and 35.1%, respectively, of HIV-positive patients; 71%, 6.2%, and 22.8%, respectively, of HIV-negative patients; and 74.3%, 7.5%, and 18.2%, respectively, of patients with no HIV status available. HIV modified the effect of several variables on the outcome of treatment, and so separate logistic regression models for each HIV category were constructed. Among HIV-positive patients, mortality increased in patients with neoplastic disease and in users of drugs by nonintravenous routes of administration, whereas potentially unsatisfactory outcomes increased in intravenous drug users and in women.

CONCLUSIONS

In Spain, the outcome of tuberculosis treatment is much worse in HIV-positive patients. Drug use and presence of neoplastic disease substantially affect mortality.

Do HIV Disease Progression and HAART Response Vary among Injecting Drug Users in Europe?

Prior to HAART availability, there was no evidence of a geographical variation in HIV disease progression among injecting drug users (IDU) from different European regions. Nowadays, factors of importance regarding HIV disease progression in the face of HAART availability, such as HAART access, adherence, and the organization of care for IDU may differ across Europe. Therefore we studied HIV disease progression in a European study of IDU with known dates of HIV-seroconversion. Results show that with ongoing HAART availability, the risk of HIV disease progression has continued to decrease. When accounting for pre-AIDS death (in AIDS analyses) and non-natural deaths (suicide, overdose, accidents and homicide, in analyses of death) which are common among IDU, the risk of AIDS and death has decreased by as much as 65% and 75%, respectively, in 2000/2001. Results show little geographic variation in progression to AIDS. All-cause mortality was higher in IDU from Glasgow than elsewhere, while in the Valencian region (Spain) IDU were at a significantly lower risk of non-natural deaths. The timing of HAART initiation by treatment-naïve IDU likewise differed across Europe: IDU in Amsterdam, Innsbruck, and Edinburgh started at significantly lower CD4 counts than IDU in Paris, Geneva, Glasgow, and the Valencian region, but the subsequent short-term immune response was similar. In conclusion, the risk in progression to AIDS or natural death is similar across western Europe although IDU across Europe differ in other factors, such as the risk of non-natural death and the timing of HAART initiation.

Gender differences in progression to AIDS and death from HIV seroconversion in a cohort of injecting drug users from 1986 to 2001

BACKGROUND

Although the consensus is that gender does not influence HIV progression, its relevance may depend on the setting.

AIM

To study gender differences in HIV progression to AIDS and death from 1986 to 2001 in a cohort of injecting drug user (IDU) seroconverters in Spain.

METHODS

Risk of AIDS and death in persons infected for the same length of time were compared through Kaplan-Meier, allowing for late entry, and Cox regression adjusting for gender, age, and calendar period (before 1992, 1992-1995, 1996-1998, 1999-2001) fitted as time dependent covariates.

RESULTS

Of 929 IDU, 24.7% were women. Median seroconversion year was 1993.3 for men and women. 44% of women and 34% of men received antiretroviral therapy. Risk of AIDS was lower in women in univariate (hazard ratio (HR) 0.72; 95%CI:0.51 to 1.01) and multivariate analyses (HR 0.73 95%CI:0.52 to 1.03). A 46% reduction in risk of AIDS for period 1999-2001 compared with 1992-1995 was seen in both men and women (HR: 0.56 (95%CI:0.36 to 0.87). As for mortality, women's risk of death was lower univariately (HR 0.67 95%CI:0.45 to 0.99) although compared with 1992-95, men experienced a 34% reduction in mortality during 1999-2001 (HR 0.66 95%CI:0.40 to 1.01), which was not statistically significant in women.

CONCLUSIONS

HIV progression was lower in female IDU before and after 1997 and their uptake of antiretroviral therapy was higher than male IDU. The inability to detect a reduction in mortality for women during 1999-2001 is probably attributable to lack of power. Differences in severity of addiction, drug using patterns, and competing causes of death may explain these findings.