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Causes of Severe Illness at High CD4 Counts in French Cohort
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Mark Mascolini
XVI International AIDS Conference, Toronto
August 14, 2006
Heart disease, psychological problems, non-HIV viral infections, and endocrine disease put French Aquitaine cohort members in the hospital--and sometimes killed them--at CD4 counts some do not consider a starting point for antiretroviral therapy [1]. While hospital admission rates for AIDS and most serious non-AIDS illnesses dropped significantly in these antiretroviral-treated people from 2000 to 2004, rates for cardiovascular disease and non-AIDS cancers did not.
French clinicians in the Bordeaux region began enrolling Aquitaine cohort members in 1987. Since then, they have kept scrupulous records not only on response to antiretrovirals and AIDS diagnoses, but also on other illnesses.
Defining a "severe morbid event" as a clinical diagnosis that sent a person to the hospital or resulted in death, Aquitaine researchers counted 1854 hospital admissions for severe morbidity among 3863 cohort members. The yearly rate of such admissions per 1000 patients dropped 46% from 173 in 2000 to 92 in 2004. The yearly rate of hospitalized patients per 1000 patients sunk 41% from 132 in 2000 to 78 in 2004.
Bacterial infections, psychiatric setbacks, heart disease, digestive disease (mainly liver cirrhosis), non-HIV viral infections, and non-AIDS cancers accounted for nearly 60% of all severe morbidities. Most of the bacterial infections were pneumonias or skin infections in injecting drug users.
Heart disease put people in the hospital at a relatively high median CD4 count of 383 cells/mm3 (interquartile range [IQR] 225 to 575 cells/mm3), as did psychiatric problems (median 347 cells/mm3, IQR 196 to 521 cells/mm3), viral infections (median 333 cells/mm3, IQR 141 to 538 cells/mm3), and endocrine disorders (327 cells/mm3, IQR 296 to 620 cells/mm3). In contrast, AIDS diagnoses sent people in the hospital at a median of 57 cells/mm3 (IQR 14 to 180 cells/mm3).
The Aquitaine researchers suggested that even moderate drops in CD4 counts with HIV infection could allow the emergence of some non-AIDS illnesses.
Over the 5 years of follow-up, these clinicians saw significant drops in hospital admissions for AIDS (P < 0.0001), bacterial infections (P < 0.0001), psychiatric disorders (P = 0.003), and digestive disease (P = 0.0005). But hospitalization rates for cardiovascular disease and non-AIDS cancers stayed relatively stable.
Several variables raised the risk of severe morbidity: male gender, older age, injecting drug use, later AIDS stage, lower median CD4 count, higher median viral load, and lower hemoglobin (P < 0.001 for all). But coinfection with hepatitis C virus (HCV) did not heighten the risk of severe morbidity, even though 90% of the people with cirrhosis had HCV.
Reference
1. Bonnet F, Chene G, Lawson-Ayayi S, et al. Causes of severe morbidity in HIV-infected patients. Aquitaine cohorts 2000-20004: the importance of bacterial infections, cardiovascular, digestive, and psychiatric morbidity. XVI International AIDS Conference. August 13-18. Toronto. Abstract MOPDB02.
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