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Complications of HIV; HIV+ Not in Care or Being Tested
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Mitchell Wolfe from the CDC reported how since HAART became available in 1996 deaths among HIV+ people due to opportunistic infections have declined. The proportions of death due to many AIDS-related conditions have decreased since the availability of HAART therapy. But there is concern that deaths from somenon-AIDS-related causes such as liver and kidney disease are increasing as adverse outcomes from therapy or because people are living longer with HIV infection. In this study Mitchell examined diagnoses present at death to determine trends in causes of death since the advent of HAART therapy. Overall, he found the death rate among HIV-infected patients is lower since HAART became available. Deaths due to certain opportunistic infections is much lower but deaths due to liver disease, kidney disease, wasting, and non-Hodgkins lymphoma are increasing. The decrease in deaths and decrease due to opportunistic infections is due to improved treatment for HIV and improved prophylaxis for opportunistic infections. However, the bad news is that patients are still dying from PCP and other opportunistic infections. This is in part due to patients presenting themselves late for HIV diagnosis and care. It is in part due to individuals being afraid to test for HIV because they are afraid to enter care and take HIV drugs. They are afraid of the medical system. Perhaps, better outreach, education, and prevention programs can teach individuals that testing and entering care can help them and is not so foreign. In addition, the medical sysatem needs to improve itıs care for IVDUs and individuals threatened by them. Oftentimes, IVDUs with HIV have never entered the care system; they have used only the emergency room. They may have taken an HIV test but often do not return for results. They are often not welcome or feel threatened by the care system. Upon entering the care system they have no experience on how to navigate the system and negotiate with doctors and providers.
Data were obtained from the Adult and Adolescent Spectrum of HIV Disease (ASD) study, an ongoing medical record-review observational cohort study in 11 U.S. cities that has followed over 54,000 HIV-infected persons since 1990. They analyzed data from persons who died in 1992-2000, comparing diagnosis rates during 1992-1995 (pre-HAART) with those in 1996-2000 (HAART). We
restricted analysis to 6 sites that collected death certificate cause-of-death data.
From 1992 through 2000, we observed a total of 7188 deaths, 4870 (68%) during the pre-HAART period, and 2318 (32%) during the HAART period. Compared with the pre-HAART period, proportions of deaths with the following conditions decreased for tuberculosis (reduced by over 50%), non-TB mycobacterial infections (reduced by 30%), pneumocystis pneumonia (reduced by 30%), and toxoplasmosis (reduced by 30%). Proportions of deaths increased for liver disease (increased by 60% from 5% to 8%), non-Hodgkins lymphoma (increased by 50%), cachexia/wasting (increased by 30%), kidney disease (increased by 30%), and sepsis (increased by 20%). Although not reaching statistical significance, the trend for ischemic heart disease (increased by almost 100%) was suggestive of an increase in proportion of deaths. Itıs important to bear in mind that although the increases in percentages look scary 30%, 100%, etc. the overall number of deaths due to these causes is low- usually a few percentage points. For example, another study at this Conference looked at a patient group of 3000 and found rate of grade 4 or worse liver conditions including death was 6%, and for kidney related events it was less than 2%.
Although the authors concluded these results may be partially explained simply by the declines in AIDS-related causes, data from this analysis should be used to guide research into the question of whether some of these increases may be due to adverse outcomes from HAART or due to the aging population of persons infected with HIV, it is clear to me that liver related problems are increasing not just because people are getting older. The increase in liver related problems is due to patients being infected with hepatitis. Itıs also due to the late diagnosis of hepatitis. Many patients have had HIV for years but were never diagnosed with hepatitis so this condition remained unattended to. This allowed the hepatitis to progress. Over the years HAART or ART may have aggravated the liver, but without proper treatment for hepatitis, the liver condition will generally worsen. If diagnosis and proper treatment for hepatitis were considered hepatitis progression can often be slowed, stopped, or may regress with successful therapy. I presume that in many parts of the USA, testing HIV-infected patients for hepatitis C is not mandated and often does not occur. In many instances, doctors are not comfortable with treating HCV/HIV coinfected patients, so the patients may go untreated for their HIV; or, they may receive HIV treatment but doctors may not feel comfortable treating HCV. Itıs estimated that about 30% of HIV-infected patients have HCV. Among persons infected with HIV by IVDU, itıs estimated 50-90% have HCV. But, I think the prevalence rate for HCV is low because we do not have universal HCV testing. So, the testing and care systems for HCV among HIV-infected patients needs attention and funding.
25% May Not Know They Have HIV; 33% May Not Be In Care
Patsy Fleming from the CDC reported HIV prevalence data in the US which received a lot of discussion and newspaper articles. She reports the number of people with HIV in the USA appears to have increased in the last few years from about 800,000 or 900,000 people to 1 million. Of course, this is in part due to people living longer due to improved treatment for HIV. It is also probably due to in part increased HIV transmission. It is due to increases in risky lifestyles by at-risk individuals. It is in part due to increases in risky sexual behavior. It appears the rates for STDS are increasing and the presence of an STD can increase the risk for sexual transmission of HIV. In the last 2 years Fleming reported that the number of people diagnosed with AIDS was stable at about 40,000 per year. And the number of patients dying from AIDS is about stable: 17,000 in 1999 and 15,000 in 2000. Based on her estimates there are about 1 million people with HIV in the USA; about 75% know their HIV status, meaning about 25% do not know they have HIV. Based on the availability of CD4 counts for these patients, she reported that among the approximate 340,000 people with AIDS (who know their status) 7% did not have a reported CD4 count. Of the 330,00 people with HIV, who know their status, about 40% had no reported CD4 count. Fleming concluded that based on this information about 33% of people diagnosed with HIV/AIDS may not be receiving care; and in total 40%-60% of HIV-infected people may be untested for HIV, untreated, or both. She also estimated that if current trends continue the number of people with HIV should increase about 3% per year.
Of 1000 Men With Syphillis 27% Not Tested For HIV
Of 1000 men reported with syphillis in Chicago through the Department of Health, 19% were men who have sex with men and 81% were heterosexual men. HIV infection status was known for 111/194 (57.2%) of the MSM and 325/830 (39.1%) of the heterosexual men. Of the 111 MSM, 54 (48.6%) were HIV-infected (HIV+), as were 23 (7.1%) of the 325 heterosexual men. The data suggests that people having > 5 sex partners within the past year were 3 times more likely to be HIV+. Of the 1024 men, 296 (28.9%) had never been HIV tested, including 50 (25.7%) of the MSM and 246 (29.6%) of the heterosexual men. MSM were more likely to have been HIV tested than heterosexual men. Whether or not people got tested for HIV was unknown for 260 men, including 29 (14.9%) MSM and 231 (27.8%) heterosexual men.
The authors concluded that MSM with infectious syphilis were 1.6 times more likely to have been tested for HIV infection and 10 times more likely to be HIV+ than heterosexual men. The high proportion of HIV infection
among these men is concerning, suggesting a high level of unsafe sexual activity among persons with known HIV infection. As about a third of these men have not been tested for HIV infection, these data also
demonstrate that a significant proportion of very high-risk men are not being tested for HIV and highlight the critical need to increase HIV testing and educational efforts among both MSM and high-risk
heterosexual men.
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