 |
|
|
| |
Almost Half of Pneumocystis Patients in France Already in HIV Care at PCP Diagnosis
|
| |
| |
53rd ICAAC, September 10-13, 2013, Denver
"PCP remains an important threat for HIV-infected patients in the modern combination antiretroviral therapy era, with no improvement in mortality over the last decade."
Mark Mascolini
Almost half of HIV-positive people with newly diagnosed Pneumocystis pneumonia (PCP) in a large French cohort had already begun care for HIV, and three quarters of that group had started antiretroviral therapy [1]. French Hospital Database on HIV (FHDH) investigators blamed late HIV diagnosis or poor clinic attendance for persistently high PCP rates in this cohort. Mortality in cohort members diagnosed with PCP has not dropped in the last decade.
Pneumocystis jiroveci pneumonia in seemingly low-risk people emerged as an early signal that an acquired immunodeficiency epidemic had begun. Although PCP-related mortality waned after the arrival of combination antiretroviral therapy, FHDH investigators found that 3-year mortality after PCP diagnosis remained near 13% in 2001-2003 [2]. Because of high virologic response rates to current antiretroviral regimens, clinicians and people with HIV may forget that AIDS-defining diseases still kill high proportions of people in large HIV cohort studies. To further understanding of PCP rates and mortality in the current treatment era, FHDH researchers conducted this study.
The analysis involved 1259 people enrolled in the FHDH and diagnosed with PCP for the first time from 2004 to 2011. The investigators divided them into 666 people (53%) whose "inaugural PCP" (IPCP) diagnosis preceded HIV diagnosis and 593 people (47%) previously enrolled in the FHDH (PEPCP) and in care for HIV before PCP diagnosis. When diagnosed with PCP, the groups did not differ in median CD4 count (a low 38) or viral load (5.2 log or about 158,000 copies). Almost two thirds of these people with PCP (72%) were men, 27% were men who have sex with men, and 12% were from sub-Saharan Africa. Median age was 42.
Among the 593 PEPCP patients, 27% had an AIDS-defining diagnosis before PCP diagnosis and 74% had started combination antiretroviral therapy. These people had been receiving HIV care for a long time: Median time from FHDH enrollment to PCP diagnosis was 8 years. But they did not keep appointments faithfully: Only 45% had at least one CD4 count every 6 months, compared with an average 90% for the whole FHDH cohort.
One year after PCP diagnosis, 68% of cohort members had a viral load at or below 50 copies. The viral suppression rate was highest in people with IPCP (76%), lower in people with PEPCP but no prior AIDS diagnosis (64%), and lowest in people with PEPCP plus a prior AIDS diagnosis (49%, P < 0.0001).
Overall mortality stood at 7% 1 year after PCP diagnosis and 11% 3 years after PCP diagnosis. Three years after PCP diagnosis, mortality was equivalent in people with IPCP (9%) and PEPCP without a prior AIDS diagnosis (8%) but significantly higher in people with PEPCP and a prior AIDS diagnosis (25%, P < 0.0001). Despite continuing improvements in antiretroviral therapy, 3-year PCP-related mortality hardly dropped from the rate recorded in 2001-2003 [2].
Multivariate analysis adjusted for viral suppression, age, HIV transmission group, country of origin, and viral load and CDC count at PCP diagnosis determined that people with IPCP had a 40% higher chance of attaining a CD4 count of 200 or more after PCP diagnosis than did people with PEPCP without a prior AIDS diagnosis (adjusted hazard ratio [aHR] 1.4, 95% confidence interval [CI] 1.2 to 1.7). People with PEPCP with a prior AIDS diagnosis did not have a significantly different chance of reaching a CD4 count of 200 compared with PEPCP participants without a prior AIDS diagnosis (aHR 0.8, 95% CI 0.6 to 1.1).
A mortality analysis adjusted for viral suppression, immune reconstitution, age, HIV transmission group, and country of origin. In this analysis, PEPCP with a prior AIDS diagnosis almost tripled the risk of death compared with PEPCP without a prior AIDS diagnosis (aHR 2.9, 95% CI 1.8 to 4.8). IPCP did not have a significant impact on mortality compared with PEPCP without a prior AIDS diagnosis (aHR 1.2, 95% CI 0.8 to 2.0).
The FHDH investigators stressed that PCP patients in care and with a history of AIDS have a much worse prognosis than people without a prior AIDS diagnosis or people whose PCP diagnosis led to their HIV diagnosis. They concluded that "PCP remains an important threat for HIV-infected patients in the modern combination antiretroviral therapy era, with no improvement in mortality over the last decade."
References
1. Denis B, Guiguet M, Gregoire G, et al. Pneumocystis jirovecii pneumonia (PCP) in HIV infected patients in France in the combined antiretroviral therapy (cART) era is associated with late presentation or poor adherence. 53rd ICAAC. September 10-13, 2013. Denver. Abstract H-1260.
2. Grabar S, Lanoy E, Allavena C, et al. Causes of the first AIDS-defining illness and subsequent survival before and after the advent of combined antiretroviral therapy. HIV Med. 2008;9:246-256.
|
| |
|
|
|
|
|
