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ART Begun at Higher CD4 Count Tied to Lower Mortality in Vancouver IDUs
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IAS 2015, July 19-22, 2015, Vancouver
Mark Mascolini
Starting antiretroviral therapy (ART) at or above a CD4 count of 200 and maintaining at least 95% adherence during the first year of treatment independently lowered the risk of all-cause mortality in HIV-positive injection drug users (IDUs) in Vancouver, Canada [1]. HIV-specific mortality dropped significantly in both men and women IDUs after Vancouver launched a treatment as prevention (TasP) initiative in 2010.
Because the impact of wider antiretroviral access on high mortality in IDUs remains poorly understood, researchers from the British Columbia Centre for Excellence in HIV/AIDS and collaborators assessed changes in mortality and related predictors in HIV-positive men and women who inject drugs in the Vancouver area. Study participants were members of the ACCESS cohort, which began enrollment in May 1996.
The mortality analysis focused on people who had a baseline visit and at least one follow-up visit between May 1996 and May 2013. The investigators divided causes of death into six groups--HIV-related, overdose, liver-related, other accidental, other nonaccidental, and unknown. They used multivariable Poisson regression models adjusted for age and gender to calculate relative risk of death from each of these causes in women versus men. They also used Poisson regression adjusted for age and calendar-year periods to compare mortality in women and men before and after wide-scale TasP implementation (1996-2009 versus 2010-2013). Multivariable Cox regression identified predictors of all-cause mortality after adjustment for a range of demographic, clinical, and social/structural variables.
The study focused on 353 women (36.7% of the study group) and 608 men (63.3%). Women had a younger median age (35.0 versus 41.3, P < 0.001), shorter IDU duration (13.5 versus 17.6 years, P < 0.001), and a lower proportion of Caucasians (45.0% versus 62.2%, P < 0.001). A higher proportion of women than men were enrolled in methadone maintenance therapy (35.4% versus 26.8%, P = 0.005). A lower proportion of women than men began ART at a CD4 count at or above 200 and had at least 95% adherence in the first year of ART (11.6% versus 18.6%), and a higher proportion of women started ART at a CD4 count below 200 and had less than 95% adherence in the first year (71.1% versus 65.8%, P = 0.042).
During the study period 264 people died, and mortality was similar in women (4.41 per 100 person-years, 95% confidence interval [CI 3.65 versus 5.32) and men (4.64 per 100 person-years, 95% CI 3.98 to 5.40). HIV-related mortality dropped significantly after 2010 in both women (adjusted rate ratio [aRR] 0.20, 95% CI 0.07 to 0.55) and men (aRR 0.11, 95% CI 0.04 to 0.28).
Statistical analysis disclosed no difference between women and men in age-adjusted all-cause mortality. Women had almost a 90% lower risk of liver-related death (aRR 0.12, 95% CI 0.02 to 0.96).
People who began ART with a CD4 count at or above 200 and had at least 95% adherence in the first year of therapy had a significantly lower risk of death from any cause than people who started therapy with a lower CD4 count and had less adherence among both women (adjusted hazard ratio [aHR] 0.35, 95% CI 0.17 to 0.72) and men (aHR 0.18, 95% CI 0.09 to 0.34). Daily illicit prescription opioid use independently doubled the risk of death in men (aHR 2.07, 95% CI 1.36 to 3.17) but did not affect death risk in women.
The Vancouver team concluded that "HIV-related mortality rates have significantly declined since the beginning of efforts to expand access and adherence to ART," and that finding suggests "TasP-based efforts to scale up ART" among IDUs "have been associated with sharp declines in HIV/AIDS-related mortality" in this population.
Reference
1. Hayashi K, Kerr T, Dong H, et al. Reductions in mortality rates among HIV-positive people who inject drugs in Vancouver, Canada, during a treatment-as-prevention-based HAART scale up initiative: a gender-based analysis. IAS 2015. 8th Conference on HIV Pathogenesis, Treatment and Prevention. July 19-22, 2015. Vancouver. Abstract MOPEB156.
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