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After First Year of HAART in 1996, Mortality Stable With Advanced Disease
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11th European AIDS Conference
October 24-27, 2007
Madrid
Mark Mascolini
Ten years after Belgian adults with advanced HIV infection and nucleoside experience started highly active antiretroviral therapy (HAART), estimated survival stands at 63%, researchers reported at the 11th European AIDS Conference [1]. The highest death rate came in the first year of HAART, when clinicians and patients had no experience with the new regimens and many people had highly advanced infection. Since then, annual mortality in this prospective cohort study remained stable.
Several Belgian centers started this prospective cohort study when protease inhibitors (PIs) became available in 1996. With 395 members, the cohort is 74% white, 25% African, and primarily (72%) male. A large majority became infected heterosexually (46%) or through sex between men (40%). Injecting drug users make up only 7% of the cohort, and people infected by transfusion only 3%.
When these people entered the cohort, their age averaged 39 years and they had HIV infection for a median of 69 months. Three quarters had CDC category C disease, the median CD4 count measured a meager 26 cells, and the median viral load stood at 5.16 log (about 145,000 copies). Almost everyone--97%--had tried one or two nucleosides by the time they took their first PI.
After 10 years of follow-up, 64 people (16%) stopped coming back for checkups. Of the remaining 331 people, 130 (39%) died and 201 (61%) are still alive and in follow-up. The death rate per 100 person-years measured 13 in the first year of follow-up. After that, mortality remained statistically stable, varying between 2 and 5 deaths per 100 person-years in each year of follow-up. Estimated survival after 10 years stood at 63%.
Among the 130 deaths, HIV played a role in 67 (52%), while 43 (33%) were not related to HIV and the cause was uncertain in 20 (15%). In the first year of HAART, HIV caused 34 of 47 deaths (72%), but in the following years HIV bore the blame for only 33 of 83 deaths (40%).
Of the total 67 HIV-related deaths, 27 (40%) involved the brain, including 9 deaths from toxoplasmosis, 7 from cerebral lymphoma, 6 from HIV encephalopathy, and 3 from progressive multifocal leukoencephalopathy. Twelve deaths (18%) were attributed to "HIV disease progression/wasting syndrome." Among the 43 non-HIV deaths, 14 (40%) had an infectious cause (including 7 pneumonias), 7 (16%) resulted from non-AIDS cancers, and 4 (9%) from progression of chronic viral hepatitis. Four people (9%) killed themselves.
Upon entering the cohort, 297 people (75%) had CDC-defined AIDS. Of the remaining 98, 22 (22%) had an AIDS diagnosis during follow-up. Of the 201 people still in follow-up, 70% have a viral load below 50 copies. Sub-50-copy rates are highest among people with a CD4 count over 350 (80%) and lower for people with 200 to 350 CD4s (61%) or fewer than 200 CD4s (46%).
At the end of 2005, 70% of cohort members in follow-up were still taking a PI regimen, while 18% were taking a nonnucleoside-based regimen and the rest were taking only nucleosides.
Reference
1. Libois A, De Wit S, Poll B, et al. Ten year follow-up of patients starting protease inhibitor (PI) with CD4 below 100/ul: the PICASSO cohort. European AIDS Conference. October 24-27, 2007. Madrid. Abstract PS1/1.
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