Positives for Positives

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Missed visits to the doctor in the first year of HIV care may double the risk of death, according to a study published in the January 15 issue of Clinical Infectious Diseases.

At least 25 percent of people living with HIV are tested for the virus after their CD4 counts have dropped below 200 or they have already become ill with an AIDS-related problem. This means that the first year of care after testing positive is a critical time, when many need to be followed closely, initiate antiretroviral therapy and learn to adhere to their regimens. Unfortunately, studies show that many who need the greatest level of HIV care during the first year frequently miss appointments. No studies, however, have documented how serious this issue can be.

To examine this, Michael Mugavero, MD, and his colleagues from the University of Alabama in Birmingham (UAB) looked at the medical records of 567 people being treated at the UAB HIV clinic. All of the patients included in the analysis were seen for the first time after testing HIV positive at the UAB clinic between January 2000 and December 2005 and had not previously received HIV care at any other clinic. Mugavero’s team found that 60 percent of the patients missed at least one visit during the first year of care and 40 percent kept all appointments. A missed visit was counted when a person failed to show up for a scheduled appointment and did not call the clinic in advance to cancel or reschedule.

Failing to show up for a scheduled appointment had serious consequences. Mugavero and his colleagues found that the rate of death was 1.3 times higher among people who missed a visit during the first year of care. The authors explained that the missed visits themselves did not cause the increased death rate, but that missed visits are associated with other factors that may influence survival, such as substance use, cultural issues and poverty. They write that further research should be conducted to better understand these factors.

CDC Releases Updated Estimates About HIV Prevalence in U.S.; Agency Says 1.1 Million People Living With Virus

CDC on Friday in its Morbidity and Mortality Weekly Report released updated estimates of HIV prevalence in the U.S., saying that 1.1 million people were living with the virus at the end of 2006, Bloomberg reports. According to the report, the increase in the number of people living with HIV/AIDS in the U.S. in part is because of more effective antiretroviral drugs that have prolonged the lives of those living with the disease. Based on 2006 data, the study supports previous findings that HIV/AIDS disproportionately affects blacks and men who have sex with men. The estimate takes into account improved methodology and CDC's recent finding that the number of annual new HIV/AIDS infections in the U.S. is 40% higher than previously suspected (Lauerman, Bloomberg, 10/2).

Richard Wolitski, acting chief of CDC's Division of HIV/AIDS Prevention, said, "These data really show the continued impact that the epidemic is having on Americans, and they really reinforce the severe toll that is experienced in multiple communities" (Dunham, Reuters, 10/2). He added that CDC expects HIV prevalence "to keep increasing over time as treatment prolongs the lives of infected people and new infections outpace deaths" (Bloomberg, 10/2).

According to the report, in 2006, 48% of prevalent cases were attributable to male-to-male sexual contact, 28% to heterosexual contact and 19% to injection use. Overall, men accounted for almost 75% of HIV prevalent cases.

In terms of demographics, blacks made up 12% of the overall U.S. population but accounted for 46% of people living with HIV/AIDS in 2006. About 35% of people living with HIV/AIDS were white, and about 18% were Hispanic. In addition, the HIV prevalence rate among black women was almost 18 times higher than the rate among white women, while the prevalence rate was six times higher among black men than among white men (Reuters, 10/2). In addition, the report also found that HIV/AIDS prevalence rate among Hispanic men was more than twice that of white men, while the prevalence rate among Hispanic women was more than four times that of white women (MMWR, 10/3).

Wolitski said, "CDC has recognized and reported data on the disproportionate impact of the disease on blacks in the U.S. since the early years of the epidemic," adding, "This disparity is not one that is new, but it's one that remains and requires a heightened level of response" (Bloomberg, 10/2).

According to CDC, one in five -- or 232,700 of the 1.1 million people living with HIV/AIDS estimated in 2006 -- were not aware of their HIV-positive status in 2006 (Reuters, 10/2). The agency has called for bolstered HIV testing to enable access to appropriate medical care and ensure those infected understand the risk of spreading HIV. However, a majority of new infections are transmitted by who people who do not know they have the virus, CDC said. The study said, "Expanding the number and reach of effective HIV prevention services for at-risk populations -- including blacks, Hispanics and MSM of all races -- can contribute to reducing the disproportionate numbers of infections in these groups" (Bloomberg, 10/2).

Wolitski said that the increasing number of HIV/AIDS cases and the cost of treating them place a burden on the country's health care system. The study found that 14,000 Americans died of HIV/AIDS-related illnesses in 2006. According to the report, the previous estimate that one million people in the U.S. were HIV-positive in 2003 has been revised to 994,000 people living with HIV that year (Reuters, 10/2).

Many patients taking HIV drugs can now expect to live into their 70s

Michael Carter, Friday, July 25, 2008

A large international study has provided evidence that people taking HIV treatment can now expect to live into their 60s and beyond. The study is published in the July 26th edition of The Lancet, and showed that an individual starting successful HIV treatment aged 20 would be expected to live to be 63, and that a patient initiating an anti-HIV drugs regimen aged 35 could live to the age of 67. It also provided evidence of the dramatic and continued decline in the risk of death amongst people with HIV since effective HIV treatment became available.

What is more, the researchers found that starting treatment with a CD4 cell count above 200 cells/mm3 would mean that a person aged 20 could expect to live to be 70, and that a 35 year-old could survive into their 72nd year.

Nevertheless, they still found that even in their most optimistic estimates, the life-expectancy of HIV-positive individuals was approximately ten years shorter than that of an HIV-negative individual. Furthermore injecting drug users and patients who started HIV treatment with lower CD4 cell counts had lower life-expectancies.

The author of an accompanying editorial calls these findings “exciting” and believes that they underline the importance of prompt diagnosis and treatment of HIV. He also suggests that the risk of death would be diminished and overall prognosis further improved by starting anti-HIV drugs with a CD4 cell count of 500 cells/mm3.

Almost immediately after multi-drug antiretroviral therapy became available in 1996, doctors observed dramatic reductions in rates of illness and death in HIV-positive patients treated with such drugs. A number of studies have shown that antiretroviral therapy has the potential to dramatically improve the prognosis of HIV-positive patients, but they have only considered patients in single cohorts or countries.

Therefore researchers from the Antiretroviral Cohort Collaboration which involves 14 large HIV cohort studies in Canada, Europe and the USA, looked at rates of mortality and the life-expectancy of over 43,000 patients who started HIV treatment for the first time between 1996 – 99, 2000 – 02 and 2002 – 05. They also looked at whether there were any patient characteristics which affected the risk of death or prognosis.

A total of 2056 (5%) patients died. The mortality rate fell from 16 deaths per 1000 person years between 1996- 99 to 10 per 1000 person years between 2002 – 05.

They also noted significant improvements in the prognosis for HIV-positive patients in the ten years of the study. Overall, a 20 year-old starting HIV treatment between 1996 and 2005 would be expected to live another 43 years. Between 1996 and 1999, they calculated that such a patient would live to be 56 years old, but in the period 2002 to 2005 this had improved to a little under 70 years.

There were also impressive improvements in the prognosis of 35 year-olds starting treatment, with an expectation of a further 32 years in life after HIV therapy was initiated. But, once more, prognosis improved over time from an expectation of a further 25 years of life in 1996 – 99, to 32 years by 2002- 05.

Patients who started HIV treatment with a low CD4 cell count (below 100 cells/mm3) had much higher mortality rates than patients initiating antiretroviral therapy with a CD4 cell count above 200 cells/mm3 (aged 20 – 44, 20 per 1000 person years vs. five per 1000 person years).

Furthermore a 20 year-old starting treatment with a CD4 cell count below 100 cells/mm3 would have a life-expectancy of 54 years compared to a life-expectancy of 70 years for a 20 year-old starting treatment with a CD4 cell count above 200 cells/mm3. The importance of CD4 cell count at the time of therapy initiation to prognosis was also seen in 35 year-olds, with patients with a CD4 cell count below 100 cells/mm3 expected to live until they were 62 compared to a prognosis of 72 years for patients with a CD4 cell count above 200 cells/mm3.

The investigators also found that women had a better prognosis than men, but that injecting drug users had a life-expectancy that was up to 20 years shorter than non-injecting drug users.

“There has been an improvement of outcomes with combination antiretroviral therapy between 1996 and 2005, characterised by a marked decrease in mortality rates” write the investigators. They attribute such reductions in mortality and improvements in life-expectancy to “improvements in therapy during the first decade of combination therapy.”

But they note that their study suggests that the prognosis of people taking antiretroviral therapy is still not normal. Picking up on this point, the author of the accompanying editorial highlights the findings of the SMART study which showed that patients with lower CD4 cell counts had a higher risk of serious non-HIV-related illnesses. The SMART study’s conclusions were one of the factors leading to HIV treatment guidelines recommending that antiretroviral therapy should be started at a CD4 cell count of 350 cells/mm3. The author notes the “clinical mischief of untreated HIV infection” and looks forward to the results of a clinical trial which could show if there is any benefit in starting HIV treatment at a CD4 cell count of 500 cells/mm3.

The Antiretroviral Cohort Collaboration. Life expectancy of individuals on combination therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet 372: 293 – 299, 2008.