Trends of mortality and causes of death among HIV-infected patients in Taiwan, 1984-2005

Background

The aim of this study was to analyse the trends of mortality and causes of death among HIV‐infected patients in Taiwan from 1984 to 2005.

Methods

Registered data and death certificates for HIV‐infected patients from Taiwan Centers for Disease Control were reviewed. Mortality rate and causes of deaths were compared among patients whose HIV diagnosis was made in three different study periods: before the introduction of highly active antiretroviral therapy (HAART) (pre‐HAART: from 1 January 1984 to 31 March 1997), in the early HAART period (from 1 April 1997 to 31 December 2001), and in the late HAART period (from 1 January 2002 to 31 December 2005). A subgroup of 1161 HIV‐infected patients (11.4%) followed at a university hospital were analysed to investigate the trends of and risk factors for mortality.

Results

For 10 162 HIV‐infected patients with a mean follow‐up of 1.97 years, the mortality rate of HIV‐infected patients declined from 10.2 deaths per 100 person‐years (PY) in the pre‐HAART period to 6.5 deaths and 3.7 deaths per 100 PY in the early and late HAART periods, respectively (P<0.0001). For the 1161 patients followed at a university hospital (66.8% with CD4 count <200 cells/μL), HAART reduced mortality by 89% in multivariate analysis, and the adjusted hazard ratio for death was 0.28 (95% confidence interval 0.24, 0.33) in patients enrolled in the late HAART period compared with those in the pre‐HAART period. Seventy‐six per cent of the deaths in the pre‐HAART period were attributable to AIDS‐defining conditions, compared with 36% in the late HAART period (P<0.0001). The leading causes of non‐AIDS‐related deaths were sepsis (14.7%) and accidental death (8.3%), both of which increased significantly throughout the three study periods. Compared with patients acquiring HIV infection through sexual contact, injecting drug users were more likely to die from non‐AIDS‐related causes.

Conclusions

The mortality of HIV‐infected patients declined significantly after the introduction of HAART in Taiwan. In the HAART era, AIDS‐related deaths decreased significantly while deaths from non‐AIDS‐related conditions increased.     

Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada from 1984 to 2003

OBJECTIVES: To examine changes over a 2-year period in both the mortality rate and the causes of death in a geographically defined HIV-infected population. METHODS: A database search of primary care information for the dates and causes of death for all patients documented with HIV infection and living in Southern Alberta between 1984 and 2003 was undertaken. Sociodemographic and clinical characteristics were obtained. Causes of death were then individually confirmed by reviewing the patients' hospital charts, autopsy reports, or death certificates and coded using the International Classification of Diseases, 9th Revisions. AIDS deaths were reconciled with Public Health Reports. The time span was divided into pre-highly active antiretroviral therapy (HAART) (1984-1996) and current HAART (1997-2003) periods. RESULTS: Between 1984 and 2003, there were 560 deaths in the 1987 individuals living with HIV infection in Southern Alberta. Of these, 436 deaths (78%) occurred pre-HAART and 124 (22%) in the current HAART period. The crude mortality rate declined from 117 deaths per 1000 patient-years pre-HAART to 24 in the current HAART period. In the pre-HAART era, 90% of all deaths were AIDS related whereas only 67% were AIDS related in the current HAART era. The leading causes of AIDS deaths were AIDS multiple causes (31%), Mycobacterium avium complex (18%), Pneumocystis pneumonia (10%) and non-Hodgkin's lymphoma (7%). The proportion of non-AIDS related deaths increased from 7% pre-HAART to 32% in the current HAART era. Accidental deaths, including drug overdose (29%), suicide (7%) and violence (3%), hepatic disease (19%), non-AIDS related malignancies (19%), and cardiovascular disease (16%) accounted for the majority of non-AIDS related deaths. No deaths directly caused by drug toxicity were found. Overall, 21% of patients who died were antiretroviral (ARV)-naive. A total of 14% of patients dying from AIDS were ARV-naive in contrast to 35% dying from non-HIV related conditions. Of all those dying from AIDS, 23% died<3 months after their initial diagnosis, reflecting late presentation. In the current HAART era, 87% of patients who died from AIDS were extensively treated, reflecting HAART treatment failures due mostly to multiclass drug resistance (42%), inexorable disease progression despite ARV (32%), lack of ability or interest to be maintained on a lifelong HAART programme (21%) and, rarely, drug intolerance (<1%). CONCLUSIONS: Deaths from AIDS-related causes have decreased significantly, but deaths from non-AIDS related conditions have increased, both as an absolute number of deaths and as a proportion of all deaths in HIV-infected patients. The increasing age of the HIV population, and the increased mean CD4 count, increased proportion of intravenous drug users, increased hepatitis B virus and hepatitis C virus coinfection rate, and increased history of smoking seen in our population also influenced the mortality rate and causes of death. These factors must also be considered in projecting future trends in mortality of an HIV-infected population.     

广西HIV/AIDS病人死亡影响因素的回顾性调查

目的了解广西壮族自治区（广西）艾滋病病毒（HIV）感染者和艾滋病（AIDS）病人（HIV/AIDS病人）中,与AIDS相关死亡病例和非AIDS相关死亡病例的分布情况,以及接受AIDS抗病毒治疗病例死亡的主要影响因素。方法采用AIDS综合防治数据信息系统中的HIV/AIDS死亡病例信息数据进行分析。结果对2010年1月-2011年7月死亡的5 265例有效个案进行分析,临床诊断为AIDS相关疾病死亡2 647例（50.3%）,意外伤害410例（7.8%）,其他疾病或难以确定与AIDS相关疾病的死亡1 973例（37.5%）,不详235例（4.5%）。4 382例（83.2%）未接受抗病毒治疗的主要原因是,发现较晚（46.4%）和家庭经济困难（13.7%）。2004-2011年7月底,累计治疗AIDS病人21 761例,死亡1 718例。在有完整资料的1 694例死亡病例中,825例（48.7%）在治疗后3个月内死亡;1 065例（62.9%）治疗前最近1次检测CD4T淋巴细胞≤50个/μL。结论未能及时就医或诊断时间较晚,免疫功能低下,是HIV/AIDS病人死亡的主要影响因素。要进一步建立健全监测检测和治疗体系,提高覆盖面和可及性,争取HIV/AIDS病人早发现、早诊断,及时开展抗病毒治疗,降低病死率。     

Universal decline in mortality in patients with advanced HIV-1 disease in various demographic subpopulations after the introduction of HAART in Hong Kong, from 1993 to 2002

OBJECTIVE: Reductions in HIV/AIDS mortality associated with highly active antiretroviral therapy (HAART) have mainly been reported from Western countries. We studied the impact on survival of patients with advanced HIV disease after the introduction of HAART in Hong Kong. METHODS: The mortality pattern in a government clinic cohort of 511 adult HIV-1-infected patients with AIDS or CD4 count <200 cells/microL from 1993 to 2002 was examined. The number of deaths, the crude mortality rate (CMR) and the death rate per 1000 person-months were recorded. RESULTS: Despite an increase in the patient population, 36 deaths occurred in the HAART era (1997-2002) as compared with 56 deaths in the pre-HAART era (1993-1996). The overall annual CMR fell significantly from a high, fluctuating level of 10.8-30.4 per 100 mid-year patient population pre-HAART to a low, steady level of 0.8-6.9 per 100 mid-year population in the HAART era (P=0.004, 1996 vs 1998; P<0.001, 1996 vs 2000; P<0.001, 1996 versus 2002). A fall in CMR was observed in all demographic subpopulations, categorized by sex, ethnicity, HIV exposure risk and age (P ranged from 0.012 to<0.001). Longitudinal tracking until mid-2003 revealed a death rate of 9.2 events/1000 person-months (52 deaths with 5661.5 person-months follow up) among patients first diagnosed as having advanced disease during 1993-1996, and a lower death rate of 2.4 events/1000 person-months (25 deaths with 10551.8 person-months follow up) in patients first diagnosed as having advanced disease during 1997-2001 (rate ratio 3.9; 95% confidence interval 2.4-6.2). CONCLUSION: There was dramatic temporal decline in mortality in patients with advanced HIV disease in all demographic subpopulations with the advent of HAART. Notwithstanding confounding variables, one reason for the universal decline may be that there was no major disparity in access to HIV care across community groups.     

The shifting pattern of cause-specific mortality in a cohort of human immunodeficiency virus-infected and non-infected injecting drug users

AIMS: To monitor changes in cause-specific mortality before and after 1997 according to human immunodeficiency virus (HIV) serological status in a cohort of injecting drug users (IDUs) observed for a 17-year period (1987--2004). DESIGN: Community-based prospective cohort study of IDUs recruited in three acquired immunodeficiency virus (AIDS) prevention centres (1987--96) and followed-up until to 2004. METHODS: We obtained annual overall mortality rates and mortality rates by specific causes according to HIV status. Poisson regression models were adjusted to compare mortality rates between calendar periods. Significant changes in slope trends were evaluated by join-point regression. Disease-specific mortality rates were estimated using competing risk models. FINDINGS: From 7186 IDUs recruited (80677.218 person-years), 1589 deaths were observed with an overall mortality rate of 19.7 per 1000 person-years (95% CI, 18.8-20.7). This rate decreased from 22.9 per 1000 (95% CI, 21.4-24.7) before 1997 to 17.4 per 1000 (95% CI, 16.3-18.6) after 1997 [relative risk (RR) 0.83; 95% confidence interval (CI), 0.75-0.92]. Risk of death for HIV-positive was four times higher than for HIV-negative (RR 4.08; 95% CI, 3.63-4.58). Among HIV-positive individuals a significantly decreased change point in trend was found in 1997 for both total and AIDS mortality. HIV-negative individuals showed a similar pattern for drug overdose, suicide and accident mortality. Both groups showed an increase in proportional mortality by liver-related causes, cardiovascular diseases and cancer. Furthermore, a progressively increasing trend was observed for the three causes. However, there were no significant differences according to serological groups. CONCLUSIONS: Cardiovascular and cancer mortality are increasing among IDUs, but the increases are not related to HIV infection. We have not found a link between highly active antiretroviral therapy (HAART) introduction and increases in mortality for specific causes.     

Concurrent HIV/AIDS diagnosis increases the risk of short-term HIV-related death among persons newly diagnosed with AIDS, 2002-2005

Despite the overall effectiveness and availability of highly active antiretroviral therapy (HAART), 1500 HIV-related deaths still occur annually in New York City. In considering ways to further reduce deaths, we assessed the contribution of concurrent HIV/AIDS diagnosis to HIV-related mortality in New York City among persons newly diagnosed with AIDS. We used Cox regression to conduct a retrospective cohort analysis of HIV-related mortality among 15,211 residents age 13+ reported with AIDS to the population-based HIV/AIDS registry between January 2002 and June 2005. Concurrent HIV/AIDS diagnosis was defined as a diagnosis of AIDS occurring within 1 month of initial diagnosis of HIV. HIV-related mortality was 20.2% among persons diagnosed concurrently and 12.2% among those diagnosed nonconcurrently (p < 0.0001). Concurrent HIV/AIDS was associated with more than twice the risk of HIV-related death within the 4 months after diagnosis (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.94-2.65) but no increased risk thereafter (HR 1.12, 95% CI 0.77-1.61). Other significant predictors of death included injection drug use and birth in the Caribbean or Latin America. After 4 years 11.9% of all HIV-related deaths were attributable to a concurrent HIV/AIDS diagnosis. Public health initiatives that facilitate early diagnosis of HIV may reduce HIV-related mortality by giving people the opportunity to initiate care and begin treatment with HAART before immunosuppression places them at risk for opportunistic illness and death.     

Mortality in Brazilian children with HIV/AIDS: the role of non-AIDS-related conditions after highly active antiretroviral therapy introduction

AIDS-related mortality has been significantly reduced in areas that systematically adopted highly active antiretroviral therapy (HAART). In Brazil, despite advances in control policy, there is still a lack of evidence about trends in children on causes of death related or not related to HIV/AIDS. We evaluate temporal trends in mortality due to non-HIV-related causes of death in relation to HIV/AIDS-related conditions among children with and without HIV infection. This nationwide study included all deaths in children reported from 1999 to 2007. Mortality odds ratios (MOR) and rates were calculated to assess time trends of death in children with or without HIV/AIDS. These data were analyzed by calendar year, as obtained from official national database. A total of 680,763 deaths occurred in Brazilian children under 13 years of age; of these, 2191 (0.32%) had causes related to HIV/AIDS listed on the death certificate. The mortality rate from HIV/AIDS-related causes in Brazilian children ranged from 0.72 per 100,000 children in 1999 to 0.40 per 100,000 children in 2007, while for selected nonrelated causes the rate of death among HIV-infected children was stable at 0.08 per 100,000 Brazilian children. In children with HIV/AIDS, the MOR of having selected conditions unrelated to HIV/AIDS as a cause of death in 2007 (compared to 1999) was 1.85 (95% confidence interval [CI] = 1.11-3.08, p = 0.02), but without a significant temporal trend (p = 0.413) through the analyzed period. In Brazil, deaths related to HIV/AIDS mortality in children significantly decreased, while the unrelated causes in HIV-infected children maintained a stable trend. These data reinforce the success of national public health policies and the need to offer comprehensive care to children with HIV/AIDS.     

Influenza-related mortality among adults aged 25-54 years with AIDS in South Africa and the United States of america

Background.?Data are limited on human immunodeficiency virus (HIV)-associated influenza burden in sub-Saharan Africa and the impact of highly active antiretroviral therapy (HAART). We compared influenza-related mortality in adults with AIDS in South Africa and the United States in the pre-HAART era and evaluated mortality trends after HAART introduction in the United States. Methods.?Monthly all-cause and pneumonia and influenza (P&I) mortality rates were compiled for adults with AIDS aged 25-54 years in South Africa (1998-2005) and the United States (pre-HAART era, 1987-1994; HAART era, 1997-2005). We estimated influenza-related deaths as excess mortality above a model baseline during influenza epidemic periods. Influenza-related mortality rates in adults with AIDS were compared with rates for age peers in the general population and adults ≥65 years old. Results.?In the United States before HAART, influenza-related mortality rates in adults with AIDS were 150 (95% confidence interval [CI], 49-460) and 208 (95% CI, 74-583) times greater than in the general population for all-cause and P&I deaths, respectively, and 2.5 (95% CI, 0.9-7.2) and 4.1 (95% CI, 1.4-13) times higher than in elderly adults. After HAART introduction , influenza-related mortality in adults with AIDS dropped 3-6-fold but remained elevated compared with the general population (all-cause relative risk [RR], 44 [95% CI, 16-121]); P&I RR, 73 [95% CI, 47-113]). Influenza-related mortality in South African adults with AIDS in recent years was similar to that in the United States in the pre-HAART era. Conclusions.?Adults with AIDS experience substantially elevated influenza-associated mortality, which declines with widespread HAART introduction but does not disappear. These data support increased access to HAART and influenza vaccination for HIV-infected adults.     

Declining incidence of invasive Streptococcus pneumoniae infections among persons with AIDS in an era of highly active antiretroviral therapy, 1995-2000

BACKGROUND: Our goal was to describe trends in invasive pneumococcal disease incidence among persons with acquired immunodeficiency syndrome (AIDS) since the introduction of highly active antiretroviral therapy (HAART). METHODS: We used time-trend analysis of annual invasive pneumococcal disease incidence rates from a population-based, active surveillance system. Annual incidence rates were calculated for 5 July-June periods by use of data from San Francisco county, the 6-county Baltimore metropolitan area, and Connecticut. The numerators were the numbers of invasive Streptococcus pneumoniae infections among persons 18-64 years of age with AIDS; the denominators were the numbers of persons living with AIDS, estimated on the basis of AIDS surveillance data. RESULTS: The annual incidence of invasive pneumococcal disease declined from 1094 cases/100,000 persons with AIDS (July 1995-June 1996) to 467 cases/100,000 persons living with AIDS (July 1999-June 2000). The annual percentage changes in incidence were -34%, -29%, -8%, and -1%. Declines were similar by surveillance area, sex, and race/ethnicity. During the final year of the study, the invasive pneumococcal disease incidence in persons with AIDS was half that of the pre-HAART era but was still 35 times higher than that in similarly aged non-HIV-infected adults. CONCLUSIONS: In the United States, invasive pneumococcal disease incidence declined sharply across a range of subgroups living with AIDS during the period after widespread introduction of HAART. Despite these gains, persons with AIDS remain at high risk for invasive pneumococcal disease.     

Pre-AIDS mortality and its association with HIV disease progression in haemophilic men, injecting drug users and homosexual men

OBJECTIVE: To study pre-AIDS mortality and its association with HIV disease progression in different exposure groups with known intervals of HIV seroconversion. DESIGN AND METHODS: The type and rate of pre-AIDS deaths were assessed in 111 HIV-infected haemophilic men followed in London, and 118 injecting drug users and 158 homosexual men followed in Amsterdam. In each group, the association between CD4+ T-cell count, HIV RNA and pre-AIDS mortality was studied using proportional hazards analysis. RESULTS: By 10 years after seroconversion 7.3% of the haemophilic men had died without AIDS and 38.2% had developed AIDS. These figures were 20.2 and 30.5% for injecting drug users, and 8.0 and 55.0% for homosexual men. The major causes of pre-AIDS mortality appear to differ in the three exposure groups. The risk of pre-AIDS death tended to increase with decreasing CD4 cell count and increasing HIV RNA levels in injecting drug users and homosexual men. In men with haemophilia the associations were less obvious, although the log-transformed CD4 cell count was predictive for pre-AIDS death. CONCLUSIONS: Pre-AIDS deaths occur and are at least partially related to HIV disease progression irrespective of how individuals became infected. Because of the longer life expectancy due to highly active antiretroviral therapy (HAART), pre-AIDS deaths are likely to show a further increase. Methods to incorporate these intermediate outcomes should be considered in the estimation of the size of the HIV epidemic and in the survival analysis of HIV-infected individuals. Prevention and treatment of non-AIDS infections, especially hepatitis C virus infection, and cancers will become increasingly important in HIV-infected individuals. The interaction between these therapies and HAART should be closely monitored.     

A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death.

SETTING: The Department of Obstetrics and Gynaecology, University Teaching Hospital, Lusaka, Zambia. OBJECTIVES: To ascertain 1) the non-obstetric causes of maternal mortality, 2) the importance of tuberculosis as a cause of maternal deaths, and 3) the trends in the aetiology of non-obstetric causes of maternal deaths during the past decade in the light of the human immunodeficiency virus epidemic. DESIGN: A 2-year retrospective study of the aetiology of all maternal deaths occurring at the University Teaching Hospital (UTH), Lusaka, Zambia between 1 January 1996 and 31 December 1997. Comparison of these data with available data published between 1974 and 1989. RESULTS: There were 251 maternal deaths recorded during the study period. Of these, 106 (42%) were due to direct (obstetric) causes and 145 (58%) were due to indirect (non-obstetric) causes. Malaria (30%), tuberculosis (25%) and unspecified chronic respiratory tract infections (22%) accounted for 77% of non-obstetric causes of maternal deaths and 44% of all causes of maternal deaths. The diagnosis of AIDS was closely linked with that of tuberculosis (92% of cases), and unspecified chronic respiratory illnesses (97%), but not with malaria (37%). The maternal mortality ratio for UTH was calculated at 921 per 100,000 live births, a significant increase from the 118 noted in 1982 and 667 in 1989. CONCLUSIONS: Despite improved obstetric services, the maternal mortality ratios at UTH, Lusaka, have increased eight-fold over the past two decades. This dramatic increase is mainly due to non-obstetric causes of death. Malaria and AIDS-associated tuberculosis and unspecified 'chronic respiratory illnesses' are now major causes of maternal death in Zambia. Greater emphasis is urgently required on early detection, accurate diagnosis, treatment and prevention of malaria and tuberculosis in pregnancy. Further definition of chronic 'unspecified' respiratory illnesses is also required.     

Acquired Immunodeficiency Syndrome—Related Malignancies in the Era of Highly Active Antiretroviral Therapy

Since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic, malignancies have been an important feature of this disease. Several cancers, including Kaposi sarcoma (KS), certain aggressive B-cell lymphomas, and cervical cancer, are considered AIDS-defining when they occur in patients infected with human immunodeficiency virus. Most AIDS-defining tumors are associated with one of 3 DNA viruses: KS-associated herpesvirus, Epstein-Barr virus, or human papillomavirus. With the introduction of highly active antiretroviral therapy (HAART), the incidence of KS and certain lymphomas has decreased, whereas that of other tumors, such as cervical cancer, has undergone little change. Several new drugs and therapies have been developed for KS and AIDS-related lymphomas, and these treatments, plus the development of HAART, have contributed to improvements in morbidity and mortality. At the same time, the improved overall survival of patients with HAART has contributed to an increase in the number of patients living with AIDS in developed countries such as the United States. With the development of HAART and improved prevention and treatment of opportunistic infections, an increasing percentage of the deaths in AIDS patients have been from malignancies. Strategies for prevention, screening, and therapy remain important areas of research in this developing field.     

Comparison of deaths related to Hepatitis C and AIDS in Scotland

In resource-rich countries, the incidence of and mortality from AIDS has fallen dramatically since the introduction of combination antiretroviral therapy. In contrast, developed countries have observed increases in the public health burden associated with the hepatitis C virus (HCV). We compared past and current trends in mortality related to HCV sequelae and HIV/AIDS in Scotland by linking death records with national databases of persons diagnosed with HCV and HIV/AIDS. AIDS-related deaths increased rapidly during the late-1980s to mid-1990s and declined dramatically after 1996. Deaths related to HCV (i.e., viral hepatitis, liver cancer, alcoholic liver disease, or non-alcoholic liver disease) surpassed the number of AIDS-related deaths in 1998 and increased at an average annual rate of 10.5% (95% confidence interval = 7-14%) during 1996-2005. The leading underlying cause of HCV-related deaths was alcoholic liver disease (50% of deaths during 2001-2005). This study highlights the increasing public health burden, vis-à-vis mortality, of HCV, when compared with HIV/AIDS in developed countries. Increased diagnosis and treatment of eligible HCV-infected individuals will be required if we wish to mitigate the future impact of HCV morbidity and mortality.     

Trends in perimortal conditions and mortality rates among HIV-infected patients

OBJECTIVES: To describe trends in perimortal conditions (pathological conditions causing death or present at death but not necessarily the reported cause of death) during three periods related to the availability of HAART, pre-HAART (1992-1995), early HAART (1996-1999), and contemporary HAART (2000-2003); annual mortality rates; and antiretroviral therapy (ART) prevalence during 1992-2003. DESIGN: Multicenter observational clinical cohort in the United States (Adult/Adolescent Spectrum of HIV Disease [ASD] project). METHODS: Proportionate mortality for selected perimortal conditions, annual mortality rates, and ART prevalence were standardized by sex, race/ethnicity, age at death, HIV transmission category, and lowest CD4 cell count of ASD decedents. Multivariable generalized linear regression was used to estimate trends in proportionate mortality, as linear trends through all three HAART periods, mortality rates, and ART prevalence. RESULTS: Of 9225 deaths, 58.6% occurred during 1992-1995, 29.5% during 1996-1999, and 11.9% during 2000-2003. Linear trends in proportionate mortality for noninfectious diseases (e.g., liver disease, hypertension, and alcohol abuse) increased significantly; proportionate mortality for AIDS-defining infectious diseases (e.g., pneumocystosis, nontuberculous mycobacterial disease, and cytomegalovirus disease) decreased significantly. Mortality rates decreased from 487.5/1000 person-years in 1995 to 100.6 in 2002. Of 36 256 patients from ASD, 75.7% (standardized average) were prescribed ART annually. CONCLUSIONS: Among HIV-infected patients, the majority of whom were prescribed ART, the increasing trend in common noninfectious perimortal conditions support screening and treatment for these conditions in order to sustain the trend in declining mortality rates.     

Hepatitis B and HIV: prevalence, AIDS progression, response to highly active antiretroviral therapy and increased mortality in the EuroSIDA cohort

BACKGROUND: Whether hepatitis B (HBV) coinfection affects outcome in HIV-1-infected patients remains unclear. OBJECTIVE: To assess the prevalence of HBV (assessed as HBsAg) coinfection and its possible impact on progression to AIDS, all-cause deaths, liver-related deaths and response to highly active antiretroviral therapy (HAART) in the EuroSIDA cohort. METHODS: Data on 9802 patients in 72 European HIV centres were analysed. Incidence rates of AIDS, global mortality and liver-related mortality, time to 25% CD4 cell count increase and time to viral load < 400 copies/ml after starting HAART were calculated and compared between HBsAg-positive and HBsAg-negative patients. RESULTS: HBsAg was found in 498 (8.7%) patients. The incidence of new AIDS diagnosis was similar in HBsAg-positive and HBsAg-negative patients (3.3 and 3.4/100 person-years, respectively) even after adjustment for potential confounders: the incidence rate ratio (IRR) was 0.94 [95% confidence interval (CI), 0.74-1.19; P = 0.61]. The incidences of all-cause and liver-related mortalities were significantly higher in HBsAg-positive subjects (3.7 and 0.7/100 person-years, respectively) compared with HBsAg-negative subjects (2.6 and 0.2/100 person-years, respectively). The adjusted IRR values were 1.53 for global (95% CI, 1.23-1.90; P = 0.0001) and 3.58 for liver-related (95% CI, 2.09-6.16; P < 0.0001) mortality. HBsAg status did not influence viral or immunological responses among the 1679 patients starting HAART. CONCLUSIONS: The prevalence of HBV coinfection was 9% in the EuroSIDA cohort. Chronic HBV infection significantly increased liver-related mortality in HIV-1-infected patients but did not impact on progression to AIDS or on viral and immunological responses to HAART.     

Long-term survival,risk factors and causes of mortality in surgically treated chronic pancreatitis

Background/ObjectivesChronic pancreatitis (CP) is a complex disease with a high complications rate, poor quality of life and considerable mortality. Prospective investigations on long-term outcomes in chronic pancreatitis are scarce. Thus, we aimed to assess long-term survival, causes of death and impact of risk factors on survival in a cohort of surgically managed patients with chronic pancreatitis.MethodsAfter IRB approval, a prospective longitudinal cohort study with long-term follow-up (up to 19.6 years) was conducted. All consecutive single center patients operated between 1997 and 2019 were included. Data on health and social status, risk behavior, history of CP, indications for surgery, comorbidities and causes of death were collected. Survival analysis was performed using Kaplan-Meier analysis. Cox proportional multivariate hazard regression was used to assess the impact of risk factors on mortality. The results are reported as the hazard ratio (HR) with the 95% confidence interval (CI). The log-rank test was used to test for differences in survival between groups.ResultsA total of 161 patients with CP were subjected to operative management due to chronic pain or local complications of CP. Forty-eight patients (29.8%) died during the follow-up period. Mortality rate was 32.8 per 1000 patient-years (PY) since the diagnosis of CP. Standardized mortality ratio (SMR) was 1.8 (2.7 for the subgroup of continuous alcohol users). Median survival after surgical treatment was 13.3 years. Univariate analysis revealed the following risk factors on survival: preoperative and postoperative continuous moderate or heavy alcohol consumption, heavy smoking, age ≥50 years, Charlson’s comorbidity index (CCI) ≥4 and 2–3, unemployment, disability, insulin-dependent diabetes, pancreatic exocrine insufficiency (PEI), and low body mass index (BMI). In multivariate regression analysis lower survival was associated with continuous moderate/heavy alcohol consumption (hazard ratio (HR) 2.27), history of heavy smoking (HR 4.40), unemployment (HR 2.49), CCI 2–3 and ≥4 (HR 2.53 and HR 3.16, respectively), and BMI <18.5 (HR 4.01).Behavioral risk factors accounted for the vast majority of deaths due to chronic alcoholic liver disease (21 cases, 43.7%), smoking-related diseases (15 cases, 31.3%). CP-related mortality was 4.2%.ConclusionsLong-term outcomes of surgically treated chronic pancreatitis was associated with low CP-related mortality. Alcohol-related and smoking-related diseases caused the vast majority of deaths. Thus, surgery provides the best results in patients, preventing postsurgical relapse of original behavioral risks. For achieving this, ongoing postoperative support would be highly beneficial.     

Changing trends in hepatitis C-related mortality in the United States, 1995-2004

The disease burden and mortality from hepatitis C are predicted to increase in the United States as the number of persons with long-standing chronic infection grows. We analyzed hepatitis C mortality rates derived from US Census and multiple-cause-of-death data for 1995-2004. Deaths were considered hepatitis C-related if: (1) hepatitis C was the underlying cause of death, (2) chronic liver disease was the underlying cause and hepatitis C was a contributing cause, or (3) human immunodeficiency virus was the underlying cause and chronic liver disease and hepatitis C were contributing causes. A total of 56,409 hepatitis C-related deaths were identified. Mortality rates increased 123% during the study period (1.09 per 100,000 persons to 2.44 per 100,000), but average annual increases were smaller during 2000-2004 than 1995-1999. After peaking in 2002 (2.57 per 100,000), overall rates declined slightly, but continued to increase among persons aged 55-64 years. Overall increases were greater among males (144%) than females (81%) and among non-Hispanic blacks (170%) and Native Americans (241%) compared to non-Hispanic whites (124%) and Hispanics (84%). The 7,427 hepatitis C deaths in 2004 (mean age: 55 years), corresponded to 148,611 years of potential life lost. The highest mortality rates in 2004 were observed among males, persons aged 45-54 and 55-64 years, Hispanics, non-Hispanic blacks, and non-Hispanic Native American/Alaska Natives. Conclusion: Overall, hepatitis C mortality has increased substantially since 1995. Despite small declines in recent years, rates have continued to increase among persons aged 55-64 years. Hepatitis C is an important cause of premature mortality.     

Trends in non-Hodgkin lymphoma (NHL) and HIV-associated NHL deaths in the United States

Since a significant number of lymphomas have been associated with the human immunodeficiency virus (HIV), the purpose of this study was to describe the impact of HIV infection on non-Hodgkin's lymphoma (NHL) mortality trends and demographics. Multiple-cause-of-death data for the United States from 1979 through 1996 were obtained from the National Center for Health Statistics, Centers for Disease Control and Prevention. Annual NHL deaths rates for the United States were calculated as the number of NHL deaths per 100,000 persons, based on estimates of the U.S. resident population. The time periods 1979-1982, 1986-1989, and 1993-1996 were examined for changes over time. To describe NHL and HIV infection mortality, the characteristics of NHL deaths with HIV infection listed anywhere on the death records were examined beginning in 1987. This study found that despite reports of a lower incidence rate of NHL among blacks with HIV/AIDS, death rates from lymphomas associated with HIV/AIDS have markedly increased in black males and females over time. It was also noted that in agreement with other studies, this study documented a decrease in NHL/HIV mortality in 1996.     

Mortality among human immunodeficiency virus-infected patients with cirrhosis or hepatocellular carcinoma due to hepatitis C virus in French Departments of Internal Medicine/Infectious Diseases, in 1995 and 1997.

Several studies have suggested that the progression of hepatitis C virus (HCV) infection is more severe in patients infected by the human immunodeficiency virus (HIV). Two national retrospective multicenter cohort surveys were performed in France that included 17,487 HIV-infected patients during 1995 and 26,497 during 1997. The following data was evaluated: total number of deaths; number of deaths linked to AIDS, cirrhosis, or hepatocellular carcinoma (HCC); and number of deaths related to other (non-HCV--linked) causes. In 1995, the causes of death were as follows: AIDS, 1307 (7.47%); cirrhosis or HCC, 21 (0.12%); and other (non-HCV--linked) causes, 99 (0.56%). In 1997, the causes of deaths were as follows: AIDS, 459 (1.73%); cirrhosis or HCC 36 (0.13%); and other (non-HCV--linked) causes, 48 (0.18%). Comparative results between the 1995 and 1997 surveys showed a dramatic decrease in AIDS-related mortality rates (7.47% vs. 1.73%; P<.001) but not in HCV-related mortality rates (0.06% vs. 0.07%; P=.79). In France, despite the high prevalence of HCV infection in HIV-positive patients, the mortality rate in 1995 and 1997 caused by HCV-related cirrhosis or HCC was low.     

Effects of HIV infection on age and cause of death for persons with hemophilia A in the United States

Because of changes in factor replacement therapy and in treatment of human immunodeficiency virus (HIV) infection, we examined death record data for persons with hemophilia A in the United States to evaluate effects of HIV infection on age and causes of death. Multiple cause-of-death data from 1968 through 1998 were examined to assess death rates for persons with hemophilia A. ICD-9 coded causes of death from 1979 through 1998 were examined to assess long-term trends. From 1979 through 1998, 4,781 deaths among persons with hemophilia A were reported, of which 2,254 (47%) had HIV-related disease listed as a cause of death. In the late 1980s, mortality among persons with hemophilia A increased markedly, and the age-adjusted death rate peaked at 1.5 per 1,000,000 population in 1992. Median age at death decreased from 55 years in 1979-1982 to 40.5 years in 1987-1990, and increased to 46 years in 1995-1998. In the period 1995-1998, the median age of hemophilia A decedents with HIV-related disease was 33 years, compared to 72 years for those without HIV-related disease; the most frequently listed causes of death for those without HIV-related disease were hemorrhagic and circulatory phenomena; the most frequently listed for those with HIV-related disease were diseases of liver and the respiratory system. From 1995 to 1998, hemophilia A-associated deaths decreased by 41%, with a 78% decrease among those who had HIV-related disease. Although HIV infection has adversely effected mortality for persons with hemophilia A, the marked recent decrease in the death rate among persons with hemophilia A appears to reflect advances in care for those with HIV-related disease and is consistent with a decline in HIV mortality observed in the general population.