People infected with HIV are still at risk of dying from opportunistic diseases despite dramatic gains in survival
The risk of death due to Opportunistic Infections (IO)* has declined dramatically since the advent of combined antiretroviral therapy (ART) (cocktail, as some say) in the mid-90s, but even in the era of effective ART about a third of people diagnosed with a first OI died within 5 years, according to the analysis of more than 20.000 people living with HIV in San Francisco.
Untreated HIV INFECTION usually leads to severe immune dysfunction within a few years, leaving people susceptible to opportunistic infections and cancers that could normally be kept under control by a healthy immune system.
It is well known that ART development has led to a sharp drop in the occurrence of OIs and a general decline in mortality among people living with HIV / AIDS. Previous study showed that the incidence of AIDS-defining illnesses (OIs) in San Francisco decreased by approximately 99% from 1993 to 2008. However, the effect of the specific stabilizer on death rates has not been fully described.
As reported in early edition of the report infectious disease officer on June 3, Kpandja Djawe of the Centers for Disease Control and Prevention and his colleagues examined the question of whether better treatment of HIV infection was associated with better survival after the diagnosis of AIDS-Defining Diseases, opportunistic diseases , and how survival would differ.
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The researchers sought data collected by the San Francisco Department of Public Health from 20.858 adult people with AIDS in the city as of 1981. Most were white, gay men, with an average age of about 40, but with Over time, demography has shifted more towards blacks and Hispanics / Latinos among men and women who contracted HIV through injecting drug use or transmission among heterosexual people.
They calculate the probabilities of survival after a first AIDS-defining illness, an OI and post-diagnosis treatment for 3 ages: 1981-1986 (without effective treatment), 1987-1996 (ITRN monotherapy or dual therapy only), and 1997 -2012 (effective multi-class combination ART). The data included 3002 people diagnosed during the first period, 14.097 diagnosed during the second period, and 3759 who were diagnosed during the third period.
- A total of 17.099 people infected with HIV died during the observation period, including 2957 during the first period (98%), 12.569 during the second period (89%), and 1573 - during the third period (42%).
- After adjusting for error factors, the average 5-year probability of survival among people diagnosed with AIDS (IOS) increased from 7% in 1981-1986 to 18% in 1987-1996 and to 65% during the period between 1997 -2012.
- Put another way, mortality rates over a 5-year period decreased from 93% to 82% and 35%, respectively.
- The greatest survival was observed in the gain, referring to deaths related to pneumocystose, rising from just 1% during the first period to 69% during the third period.
- The most common AIDS-defining diseases were Pneumocystis pneumonia (8163 cases), Kaposi's sarcoma (4195 cases), wasting syndrome (1864 cases), esophageal candidiasis (1381 cases), Mycobacterium avium complex (1.069 cases), Bovine spongiform encephalopathy related to HIV (932 cases), the extrapulmonary cryptococcosis (883 cases), cryptosporidiosis (694 cases), immunoblastic lymphoma (676 cases), and the disease cytomegalovirus, excluding CMV retinitis (643 cases).
- The five less common AIDS-defining diseases, OIs, were isosporiasis (36 cases), disseminated coccidioidomycosis (32 cases), recurrent sepsis Salmonella (19 cases), and invasive cervical cancer (12 cases).
- During 1997-2012, adjusted mortality rates were higher for cerebral lymphoma (note from the editor of Soropositivo.Org; I lost a friend like this) e progressive multifocal leukoencephalopathy.
A limitation of this analysis is that the combination of the ART era is quite long and there have been substantial changes in treatment. The first regimens were more difficult to take, had the worst side effects, and did not control HIV replication like modern regimens, especially for people with resistance to antiretroviral drugs. Subdividing this period of time may show that the current OIs and current mortality rates are lower than in the mid-1990s and early 2000s.
"Survival after the diagnosis of the first AIDS-defining Opportunistic Infection has improved considerably since 1981," the study authors concluded. “Some AIDS-defining illnesses remain associated with a higher risk of mortality more substantially than others, even after adjusting for known errors. Better prevention and treatment strategies are still needed to prevent AIDS-defining illnesses from occurring in the current era of HIV treatment. ”
"While recent research suggests that many opportunistic infections in the United States are now less common and often less lethal, we cannot forget about them," said Djawe in a Press release Issued by the American Society of Infectious Diseases.
"We have to keep them in mind, even in the context of the evolving epidemiology of HIV."
"Better prevention and treatment strategies, including early diagnosis of HIV positive serology, are needed to lessen the heavy burden of AIDS with opportunistic infections, even today, in the era of the combination of antiretroviral therapy," added the co-author. Sandra Schwarcz, an HIV epidemiologist at the San Francisco Department of Public Health.Today in the USA severe immune deficiencies resulting from OIs are seen mainly among people who are not diagnosed with HIV before the final course of infection. People who start treatment but fail to achieve sustained viral suppression and a good CD4 T-cell count also remain at risk.
San Francisco is known for its good health services for people living with HIV, and areas with the least access to specialized care can have the highest mortality rates from IO. All over the country, The CDC estimates whereas 86% of people living with HIV in 2011 had been diagnosed, 37% were on ART, and only 30% had an undetectable viral load.
“The importance of the so-called cascade of care, comprising early diagnosis of HIV infection, Effective care articulation, long-term retention in care, and durable viral suppression, has long been recognized as fundamental to achieve control over the various aspects of the epidemic, including obtaining good clinical results in infected individuals, ”wrote Henry Masur and Sarah from the National Institute of Allergy and Infectious Diseases in a Follow-up comment.
"San Francisco may be a better scenario to reduce the risk of mortality associated with AIDS-related opportunistic infections," he continued. “However, even with more than 30 years of effort and commitment from all relevant and relevant stakeholders in San Francisco, the current report illustrates that HIV-related opportunistic infections continue to occur and that patients still die at alarming rates during first years after your first AIDS-related opportunistic infection is recognized… A 35% mortality rate in 5 years after the initial diagnosis of AIDS-defining opportunistic infection leaves much room for improvement. ”
Written by Liz Highleyman
Translated by Claudio Souza from the original in People with HIV Still at Risk for Opportunistic Illness Death Despite Dramatic Survival Gains
* Translator's note: Although the text always refers to the “IO” of Opportunistic Infections, the opportunistic disease does not always result from an “infection”. There are cases of cancers, such as Sarkoma's sarcoma, which are not caused by any infection and yet it is a Opportunistic Disease. I kept the expression on account of a scruple to remain faithful to the text and, nevertheless, I launch this observation here (…).
Editor's Note Soropositivo Web Site:
Although there is still the possibility of “going to death” within five years after the manifestation of an opportunistic disease, the prognosis for people who have just received an HIV-positive diagnosis has greatly improved. I dearly remember hearing, from the mouth of the health “professional” who gave me the result that I, in 1994, had six months to live (To be completed, on November 13, twenty-three years of serologically conscious life). Reading this text should lead you, who are reading this text right now and who think that you may be one of the over XNUMX people who are infected with HIV.
Do the test yourself and quickly as soon as possible, as this reduces the chances, in case you are HIV positive, of developing or installing an opportunistic disease. Having AIDS is not good! having and not knowing and not treating is much worse!
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