Late diagnosis of HIV infection: trends, prevalence, and characteristics of persons whose HIV diagnosis occurred within 12 months of developing AIDS

BACKGROUND: Persons diagnosed late in the course of HIV infection may be unknowingly transmitting infection and once diagnosed may have worse outcomes and greater medical expenses. METHODS: Persons diagnosed with AIDS in San Francisco between 2001 and 2005 were included. Late testers were persons diagnosed with HIV 12 months or less before their AIDS diagnosis. Prevalence trends, demographic and risk correlates, and predictors of late testing were measured. RESULTS: Among 2139 persons included, 830 (38.8%) were late testers. The prevalence of late testing was stable between 2001 and 2005. Late testing was more likely among persons <30 years old (Odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.4, 2.8), heterosexuals (OR: 1.88, 95% CI: 1.1, 3.1), persons without a reported risk (OR: 2.88, 95% CI: 1.7, 5.0), persons with private insurance (OR: 1.82, 95% CI: 1.4, 2.4), no insurance (OR: 1.83, 95% CI: 1.4, 2.4), born outside of the United States (OR: 1.64, 95% CI: 1.2, 2.2), and whose initial AIDS diagnosis was an opportunistic infection (OR: 2.24, 95% CI: 1.8, 2.8). CONCLUSIONS: A large proportion of persons with AIDS have tested late in the course of HIV infection and this proportion has not declined in recent years. Routine testing in medical settings, and use of rapid oral-fluid testing in traditional and nontraditional settings may increase early HIV diagnosis.     

Incidence of AIDS-defining cancers after AIDS diagnosis among people with AIDS in Italy, 1986-1998

A record linkage was carried out between the Italian National Registry of AIDS and 19 cancer registries. The aim was to evaluate the 1986 through 1998 trends in incidence rate (IR) of AIDS-defining cancers (ADCs) among persons with AIDS (PWA) in Italy overall and according to various characteristics. A steady decrease in IRs was found for Kaposi sarcoma (KS) in men between 1986-1992 (2.5 per 100 person-years [py]) and 1997-1998 (1.0 per 100 py). Conversely, the first decrease in IRs of KS in women (from 0.9 to 0.6 per 100 py) and of non-Hodgkin lymphoma in both genders (from 1.7 to 0.7 per 100 py) was seen between 1993-1996 and 1997-1998, thus pointing to a favorable impact of highly active antiretroviral therapies. The decline was consistent across different age and HIV transmission groups, but it was more marked in PWA with a CD4 count >50 cells/microL than in PWA with more severe immune suppression. As a proportion of AIDS cases, invasive cervical cancer increased from 1.5% in 1993-1996 to 2.4% in 1997-1998, but IRs after AIDS could not be evaluated. On account of the marked decline of KS in men in 1997-1998, the overall burden of ADCs in Italy became similar in both genders.     

Declining HIV/AIDS mortality in New York City

BACKGROUND: New York City has only 3% of the U.S. population but has reported nearly 16% of all AIDS cases. METHODS: This is an observational study using the New York City vital events and AIDS case surveillance registries to describe trends in HIV/AIDS mortality from 1983 through June 30, 1998. RESULTS: Annual HIV/AIDS deaths increased steadily until stabilizing at 7046 in 1995, declined 29% to 4998 in 1996, and declined 47% to 2625 in 1997. Comparing data from 1997 with those from 1995, declines occurred in all demographic groups and in all major HIV transmission categories: 74% in men who have sex with men, 68% in injecting drug users, and 64% in heterosexuals. In the first 6 months of 1998, declines were smaller than they had been in previous 6-month intervals in all demographic groups except Hispanic males and those between 35 and 44 years of age. From 1995 to the first 6 months of 1998, the number of people living with AIDS in New York City increased 22% (from 32,692 to 39,976). CONCLUSIONS: The precipitous 63% decline in HIV/AIDS deaths from 1995 to 1997 occurred at the same time that more effective antiretroviral therapies became widely available. The slowing in the mortality decline observed in 1998, however, suggests that although these new therapies may have a profound effect at the population level, deaths due to AIDS will continue.     

Declining Incidence of AIDS and Increasing Prevalence of AIDS Presenters Among AIDS Patients in Italy

Presented here are the results of a cohort study conducted on 3,483 consecutive HIV/AIDS patients between January 1993 and December 2000 to determine trends in AIDS incidence and presentation. The incidence of AIDS was calculated in the general population and examined further according to gender, age ( or >49 years), and heterosexual behaviour as a risk factor for HIV. Multivariate analysis was used to identify variables associated with AIDS presenters (defined as patients diagnosed with AIDS within 1 month of the first HIV-positive test). The numbers of patients with AIDS classified as (i) AIDS presenters, (ii) known HIV-positive patients on antiretroviral treatment, and (iii) known HIV-positive patients not receiving antiretroviral treatment were calculated. The overall incidence of AIDS decreased over time, mainly due to the lower number of patients on antiretroviral treatment developing AIDS. Factors associated with a higher risk of being an AIDS presenter were male gender and year of HIV diagnosis. Among patients with AIDS, the proportion of AIDS presenters increased from 13.8% prior to 1997 (when protease inhibitors were introduced in Italy) to 32.5% after 1997. Variables predictive of being an AIDS presenter were male gender, age at diagnosis, and AIDS diagnosis in the years 1997–2000. Heterosexuals had a higher risk of being AIDS presenters and a lower risk of being HIV-positive and not receiving antiretroviral treatment than intravenous drug users. In Italy, AIDS occurs mainly in subjects unaware of their HIV status (especially males, the elderly, and those infected heterosexually) or in patients refusing antiretroviral therapy (mainly intravenous drug users who do not refer to specialised centres).     

HIV/AIDS epidemic in French Guiana: 1979-1997. Groupe d'Etude Clinique de l'Infection VIH en Guyane Française

The incidence of AIDS in French Guiana remains one of the highest in Latin America and the Caribbean. The annual AIDS incidence rate increased continually from the start of the epidemic until 1995, when it reached 59.3/100,000 population declining thereafter to 26.6 in 1997. The prevalence of HIV in pregnant women was 0.9% in 1993, increasing to 1.3% in 1995, and that in individuals attending sexually transmitted disease (STD) clinics was 2.1% in 1996. We included 224 patients in a study of survival after AIDS diagnosis. The principal AIDS-defining diagnosis was tuberculosis in 20.5% of reported cases. The median duration of survival was 10.2 months. Multivariate analysis showed that, patients > or = 45 years at entry progressed more rapidly to AIDS than younger patients. HIV prevention and access to health care should be developed in the various ethnic communities and adapted to cultural status. The progressive implementation of multiple antiretroviral therapies since 1996 may further reduce progression of the disease but early HIV diagnosis is required to improve the overall prognosis of HIV-infected patients.     

Impact of highly active antiretroviral therapy on individual AIDS-defining illness incidence and survival in Australia

OBJECTIVE: To determine the effect of highly active antiretroviral therapy (HAART) on incidence of initial AIDS-defining illnesses (ADIs) and survival after individual ADIs. METHODS: Australian AIDS notification data over the period 1993 to 2000 were examined. Analyses were based on all initial ADIs. To examine the impact of HAART, two periods of AIDS diagnosis were chosen: pre-HAART (1993-1995) and HAART (1996-2000). Comparisons between these two periods included proportion of individual ADIs, median CD4 lymphocyte counts at and survival following AIDS and individual ADIs. Median survival was based on Kaplan-Meier estimates, with examination of factors influencing survival in a Cox proportional hazards model. RESULTS: Over the period 1993 to 2000 in Australia, 5017 initial ADIs were diagnosed among 4351 AIDS cases. At AIDS diagnosis, changes from the pre-HAART (1993-1995) to HAART (1996-2000) periods included an increased proportion of Pneumocystis carinii pneumonia (PCP) (25.9% to 30.4%; p =.001), AIDS dementia complex (5.2% to 6.8%; p = 0.029), non-Hodgkin lymphoma (NHL) (4.4% to 6.3%; p =.005), and tuberculosis (0.5% to 2.7%; p <.0005). Median survival following AIDS increased from 19.6 months for AIDS cases diagnosed in 1993 to 1995 to 39.6 months for AIDS cases diagnosed in 1996 to 2000 (p <.0005). Median survival was stable for NHL (7.5-8.8 months; p =.26), but increased significantly for almost all other ADIs. CONCLUSIONS: An increased proportion of PCP relative to other ADIs suggests an increasing proportion of AIDS patients not receiving specific prophylaxis, presumably because of "late" HIV diagnosis. Survival following almost all ADIs has increased in the era of HAART, although the prognosis after NHL remains extremely poor.     

Estimated number of children left motherless by AIDS in the United States, 1978-1998

When a mother dies of AIDS, basic needs of her children may be left unmet. To estimate the number and characteristics of maternal AIDS orphans in the United States, demographic techniques were applied to data from several sources. From the national HIV/AIDS surveillance system, reporting delays were adjusted for the number of deaths among women aged 15-44 diagnosed with AIDS through 1998 and reported as deceased by December 1999. No fertility was assumed in the year preceding death. To the adjusted number of deaths the annual age- and race-specific cumulative fertility and infant mortality rates from national vital statistics were applied. A perinatal infection rate of 25% was assumed among children born through 1994, and 10% among children born after 1994. Through 1998, 51,473 women died leaving 97,376 children motherless. Of the estimated 76,661-87,0018 uninfected children, 83% were younger than 21 years when orphaned. After increasing each year, the annual number of orphaned children younger than 21 years peaked in 1995. In 1998, between 4252-4489 uninfected youth were added to 47,863-54,025 existing orphans younger than age 21. Due to declines in AIDS deaths, the annual number of children orphaned by AIDS has declined. Nevertheless, each year thousands of youth are orphaned.     

Delayed presentation and late testing for HIV: demographic and behavioral risk factors in a multicenter study in Italy

Ensuring timely access to care for persons with HIV is an important public health goal. To identify factors associated with delayed presentation to medical care after testing HIV-positive or with late HIV testing, we studied 968 patients at their first HIV care visit, enrolled in a multicenter study in Italy from 1997-2000. Patients completed a questionnaire on HIV-testing history, sexual behavior, and drug use behavior. Delayed presenters were patients with >6 months between their first HIV-positive test and presentation for HIV care; late testers were patients with CD4 count < 200 /mm or clinically defined AIDS at their first HIV-positive test. Among the study patients, 255 (26.3%) were delayed presenters, and 280 (28.9%) were late testers. In multinomial logistic regression analysis, injection drug use significantly increased (odds ratio [OR]= 5.04) the probability of delayed presentation but reduced (OR = 0.55) the chance of late testing. A previous HIV-negative test was associated with a reduced risk of both delayed presentation (OR = 0.39) and late testing (OR = 0.36). Unemployment was positively associated with delayed presentation and increasing age with late testing, whereas HIV counseling at the time of first positive HIV test strongly (OR = 0.42) reduced the odds of delayed presentation. Interventions aimed at promoting timely access to care of HIV-infected persons should consider differentiated programs for delayed presentation and late testing.     

Late presenters in an HIV surveillance system in Italy during the period 1992-2006

OBJECTIVES: The objectives of this study are to describe trends over time from 1992 to 2006 in the number of newly diagnosed HIV-infected individuals in Modena (Italy) and to describe their clinical and immunological characteristics. We also identify risk factors associated with presenting at late stages of HIV disease. METHODS: All new HIV diagnoses with at least 1 CD4 cell count and known stage of HIV disease were included. Using multivariate logistic regression models, we examined factors associated with being a late presenter, defined as individuals presenting with CD4 cell count <200 cells per microliter or AIDS within 3 months of their HIV-positive test. A quantile regression model was used to examine changes in CD4 cell count at presentation and trends over time. RESULTS: Of 844 newly diagnosed individuals included in analyses, 332 (39%) were late presenters, and this proportion remained constant over time (P = 0.106). Older age, male sex, and foreign born were the only determinants of being a late presenter. Persons newly diagnosed in 2002-2006 were less likely to present with an advanced clinical status. DISCUSSION: A substantial proportion of new HIV diagnoses are still at advanced stages of disease. In particular, foreign-born and heterosexual males still represent the largest part of AIDS presenters. Efforts are needed to encourage HIV testing and reduce the proportion who first seek HIV care at such a late stage.     

Phylogenetic analysis of European encephalomyocarditis viruses: comparison of two genomic regions

Summary.  The phylogenetic relationships of encephalomyocarditis (EMC) viruses isolated from pigs and rodents in Europe were determined by comparison of nucleotide sequences from two different regions of the virus genome, the VP3/VP1 gene junction (part of the capsid-coding region) and part of the 3D polymerase-coding region. Thirty-five European EMC viruses could be divided into two genetic groups, one which contained viruses from Greece isolated between 1986 and 1997 and from Belgium in 1991 and the other which contained viruses from Italy (1986–1996), Cyprus (1994–1995), France (1995) and Belgium (1995–1996). Received August 26, 1998 Accepted December 18, 1998     

Differential impact of combined antiretroviral therapy on the survival of italian patients with specific AIDS-defining illnesses

BACKGROUND: A decrease in HIV-related mortality and morbidity has been observed since 1996 in most developed countries as a consequence of the extensive use of combined antiretroviral therapies. The purpose of this study was to investigate whether combined antiretroviral therapies had a differential impact on the survival of patients with different AIDS-defining illnesses (ADIs). METHODS: In total, 35,318 persons representing all the adults with AIDS (PWAs) diagnosed in Italy from January 1, 1990 to August 31, 1998 were studied. Actuarial life tables and the Kaplan-Meier method were used to estimate the cumulative probability of survival; the multivariate Cox proportional hazards model was used to estimate adjusted relative hazard of death (RH). RESULTS: Among PWAs diagnosed after 1995, the proportion of survivors 24 months after diagnosis was more than doubled (66%) compared with that of PWAs diagnosed before the end of 1995 (31%). Significantly decreased RHs for some ADIs were observed as early as 1996 (i.e., esophageal candidiasis, Pneumocystis carinii pneumonia, brain toxoplasmosis, HIV-wasting syndrome, and pulmonary tuberculosis). In the last period (1997-1998), the decrease was marked and significant for almost all the ADIs, ranging from 55% to 80% compared with the RHs of the reference year (1995). Conversely, primary lymphoma of the brain and Burkitt's lymphoma showed a low and not statistically significant decrease; these were the ADIs with the worst outcome. CONCLUSIONS: After 1995, there was a rather uniform increase in the survival of PWAs diagnosed with most specific ADIs but not for patients affected by primary brain lymphoma and Burkitt's lymphoma. The determinants of this differential effect need to be investigated.     

HIV / AIDS in China: migrant population,drug injection responsible for increased transmission

By 2000, China will have 1.2 million people infected with HIV and 33,000 people with AIDS. While HIV infection has been reported from almost all provinces and occupational groups in the country, HIV prevalence is highest among IV drug users in Yunnan province. The major source of infection elsewhere in China is through the receipt of tainted blood products and heterosexual intercourse. A National AIDS Committee was formed in October 1986 to advise the government on AIDS policy, and since 1990 to coordinate all AIDS prevention activities. The National Strategies Plan for AIDS/STD Prevention in China during 1996-2000 was prepared in 1995. China's in-country migrant labor population may become the most vulnerable to HIV infection. There are currently about 120 million migrant workers in China, of whom about half are registered, nonpermanent residents working in the fastest developing regions. The open nature of China's economy relative to recent past decades has made it difficult to monitor and control internal migration. Floating populations are the most difficult to reach with preventive health education and they tend to be deprived of access of health care. 61.4% of the migrant population is male and 40% are aged 20-24 years. China's traditional trade routes may be a factor in HIV infection. HIV/AIDS epidemiology, the synergy of STDs and AIDS in China, the international partnership in HIV/AIDS prevention in China, the role of international nongovernmental organizations in China, Hong Kong's contribution to AIDS prevention in China, awareness of the problems associated with HIV infection in China, and the challenges for AIDS-related work in China are discussed.     

Home collection versus publicly funded HIV testing in San Francisco: who tests where?

We examined records of all HIV antibody tests performed at anonymous publicly funded (PF) sites and by home collection (HC) testing for residents of San Francisco from August 1996 to December 1997. Although far fewer tests were performed by HC testing than at PF sites (715 versus 8712, respectively), a higher proportion of HC testers reported no prior history of HIV testing (33.1% versus 17.9%). HIV seroprevalence was higher among PF tests (1.8%) than among HC tests (0.9%). Compared with PF testers, HC testers were less likely to be gay men, lesbian or bisexual women, heterosexual women, African American, or Latino. HC testers were more likely to report sex with a known HIV-positive partner. HC testers were also more likely to reside in affluent neighborhoods. HC testing reaches some high-risk persons who may not otherwise seek PF testing, although, overall, the risk profile of HC testers appeared lower than that of PF testers. HC testing reaches some individuals who can financially afford HC testing, thus saving public prevention resources for hard-to-reach, high-risk populations.     

Changing clinical presentation and survival in HIV-associated tuberculosis after highly active antiretroviral therapy

OBJECTIVE: To assess changes in clinical presentation and outcome of HIV-associated tuberculosis (TB) before and after widespread implementation of highly active antiretroviral therapy (HAART). METHODS: We reviewed clinical charts of HIV-infected patients with culture-confirmed pulmonary TB in two referral clinical centers in Rome, Italy. The 67 patients diagnosed in 1995 to 1996 were compared with 51 patients diagnosed in 1997 to 1998. To analyze factors associated with survival we used a Cox model including antiretroviral therapy as a time-dependent covariate. RESULTS: Patients diagnosed in 1997 to 1998 were more likely to have TB as the first AIDS-defining illness (78% versus 58%, p <.05), to have HIV diagnosed <2 months before TB (33% vs. 7%, p <.005) and to have typical chest radiograph pattern (45% vs. 25%, p <.05), and had a higher CD4(+) count (median 105 vs. 43, p <.005). Survival at 1 year was 80% for patients diagnosed in 1997 to 1998 vs. 65% for those diagnosed in 1995 to 1996 (p by log-rank =.02). After adjusting at multivariate analysis, time period of diagnosis was not confirmed as associated with survival (hazard ratio, 1.05; 95% confidence interval, 0.39--2.81). Age, CD4+ cell count <25/mm(3), and AIDS-defining illnesses before TB diagnosis were all associated with an higher risk of death, whereas a decreased risk of death was observed in patients starting a triple combination antiretroviral therapy after TB diagnosis (hazard ratio, 0.14; 95% confidence interval, 0.03--0.57). CONCLUSIONS: Cases of HIV-associated TB occurring in patients with advanced immunosuppression and presenting with atypical radiologic appearance tend to be relatively less common in the HAART era. HAART is a major factor in prolonging survival in these patients.     

Epidemiological characteristics and predictors of late presentation of HIV infection in Barcelona (Spain) during the period 2001-2009

Background

Early diagnosis of HIV infection can prevent morbidity and mortality as well as reduce HIV transmission. The aim of the present study was to assess prevalence, describe trends and identify factors associated with late presentation of HIV infection in Barcelona (Spain) during the period 2001-09.

Methods

Demographic and epidemiological characteristics of cases reported to the Barcelona HIV surveillance system were analysed. Late presentation was defined for individuals with a CD4 count below 350 cells/ml upon HIV diagnosis or diagnosis of AIDS within 3 months of HIV diagnosis. Multivariate logistic regression were used to identify predictors of late presentation.

Results

Of the 2,938 newly diagnosed HIV-infected individuals, 2,507 (85,3%) had either a CD4 cell count or an AIDS diagnosis available. A total of 1,139 (55.6%) of the 2,507 studied cases over these nine years were late presenters varying from 48% among men who have sex with men to 70% among heterosexual men. The proportion of late presentation was 62.7% in 2001-2003, 51.9% in 2004-2005, 52.6% in 2006-2007 and 52.1% in 2008-2009. A decrease over time only was observed between 2001-2003 and 2004-2005 (p = 0.001) but remained constant thereafter (p = 0.9). Independent risk factors for late presentation were older age at diagnosis (p < 0.0001), use of injected drugs by men (p < 0.0001), being a heterosexual men (p < 0.0001), and being born in South America (p < 0.0001) or sub-Saharan Africa (p = 0.002).

Conclusion

Late presentation of HIV is still too frequent in all transmission groups in spite of a strong commitment with HIV prevention in our city. It is necessary to develop interventions that increase HIV testing and facilitate earlier entry into HIV care.     

Prevalence and predictors of highly active antiretroviral therapy use in patients with HIV infection in the united states. HCSUS Consortium. HIV Cost and Services Utilization

BACKGROUND: Highly active antiretroviral therapy (HAART) became standard for HIV in 1996. Studies at that time showed that most people infected with HIV had initiated HAART, but that members of minority groups and poor people had lower HAART use. It is not known whether high levels of HAART use have been sustained or whether socioeconomic and racial disparities have diminished over time. OBJECTIVES: To determine the proportion of patients who had received and were receiving HAART by January 1998, and to evaluate predictors of HAART receipt. DESIGN AND PARTICIPANTS: Prospective cohort study of a national probability sample of 2267 adults receiving HIV care who completed baseline, first follow-up, and second follow-up interviews from January 1996 to January 1998. MAIN OUTCOME VARIABLES: Proportion currently using HAART at second follow-up (August 1997 to January 1998), contrasted with the cumulative proportions using HAART at any time before January 1998 and before December 1996. ANALYSES: Bivariate and multiple logistic regression analysis of population characteristics predicting current use of HAART at the time of the second follow-up interview. RESULTS: The proportion of patients ever having received HAART increased from 37% in December 1996 to 71% by January 1998, but only 53% of people were receiving HAART at the time of the second follow-up interview. Differences between sociodemographic groups in ever using HAART narrowed after 1996. In bivariate analysis, several groups remained significantly less likely to be using HAART at the time of the second follow-up interview: blacks, male and female drug users, female heterosexuals, people with less education, those uninsured and insured by Medicaid, those in the Northeast, and those with CD4 counts of >/=500 cells/microl (all p <.05). Using multiple logistic regression analysis, low CD4 count (for CD4 <50 cells/microl: odds ratio [OR], 3.20; p <.001) remained a significant predictor of current HAART use at the time of the second follow-up interview, but lack of insurance (OR, 0.71; p <.05) predicted not receiving HAART. CONCLUSIONS: The proportion of persons under HIV care in the United States who had ever received HAART increased to over 70% of the affected population by January 1998 and the disparities in use between groups narrowed but did not disappear. However, nearly half of those eligible for HAART according to the U.S. Department of Health and Human Services guidelines were not actually receiving it nearly 2 years after these medications were first introduced. Strategies to promote the initiation and continuation of HAART are needed for those without contraindications and those who can tolerate it.     

Trends in HIV prevalence among pregnant women in Italy, 1994 to 2002

OBJECTIVE: The aim of the study was to analyze the trends in HIV prevalence among childbearing women through unlinked anonymous testing of newborns. METHODS: Dried-blood specimens, residual to routine metabolic screening of newborns, were collected in Italy during the last quarter of each year, from 1994 to 2002. These samples were tested anonymously for HIV antibodies. RESULTS: Of 844,311 specimens tested, 703 (0.83/1000; 95% confidence interval, 0.76-0.88) resulted as HIV antibody-reactive. Prevalence was 1.05 per 1000 in 1994 and decreased significantly over the following 3 years, reaching 0.60 per 1000 in 1997. Thereafter, a seroprevalence increase was recorded with a figure of 1.01 per 1000 in 1999. A decrease was again observed in 2001 and in 2002, when the seroprevalence rate was significantly lower than that recorded in 1994. During the entire study period, higher prevalence rates were observed in northern Italian regions, where the highest AIDS incidence rates are recorded, and in metropolitan compared with nonmetropolitan areas. The estimated number of children born each year to an HIV-positive mother ranged from 313 to 546. CONCLUSION: The number of children born to an HIV-positive mother calls for continued efforts to prevent vertical transmission of the infection.     

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men,United States, 1990-1999

OBJECTIVES: We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM). METHODS: We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced. RESULTS: The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26,930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100,000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years. CONCLUSIONS: Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV-related morbidity in racial/ethnic minority MSM.     

Genetic sonography as the preferred option of prenatal diagnosis in patients with pregnancies following intracytoplasmic sperm injection.

The option of prenatal diagnosis with nuchal translucency measurement at 10-14 weeks of gestation and second trimester targeted ultrasound including fetal echocardiography (genetic sonography) is reported in patients after intracytoplasmic sperm injection (ICSI). From January 1995 to December 1998, 153 consecutive patients, with a mean age of 32.3 years (+/-4.1) and 29. 6% >/= 35 years, who had become pregnant after ICSI, were studied. They attended our unit for first and second trimester sonography. Of these, 67.8% of primigravid and 80.9% of nulliparous women were included. Multiple pregnancy rate was 19.7%; 189 fetuses were screened in total. Due to the introduction of genetic sonography in 1995, the rate of invasive prenatal diagnosis decreased from 74% in 1995, to 48, 36 and 19% in 1996, 1997, and 1998 respectively. Two inherited numerical and structural chromosomal anomalies in clinically healthy children at birth (1.0%) and four major malformations in all liveborn children and late abortions (2.1%) were recorded. The results demonstrate that especially in women of advanced reproductive age with a long history of infertility, detailed genetic sonography may be a reasonable and highly accepted alternative to avoid even the relatively low risks associated with invasive screening procedures.     

Trends in AIDS and mortality in HIV-infected subjects with hemophilia from 1985 to 2003: the competing risks for death between AIDS and liver disease

OBJECTIVE: To study trends in progression to AIDS, all-cause mortality, and cause-specific mortality (AIDS-related, liver disease, and hemorrhagic complications) over calendar periods with different exposure to highly active antiretroviral therapy (HAART) in a cohort of hemophiliacs in Spain, taking into account the competing risks of the causes of death. METHODS: Multicenter cohort of HIV-infected hemophiliacs. HIV seroconversion was estimated using mathematic techniques for interval-censored data from 1979 through 1985. Rates of AIDS and cause-specific death were calculated by Poisson regression, allowing for late entry, for the periods 1985 through 1992, 1993 through 1996, 1997 through 2000 (early HAART), and 2001 through 2003 (late HAART), also allowing for competing risks. RESULTS: Of 585 subjects, 44% were younger than 15 years of age, 82% had severe hemophilia, 86% had type A hemophilia, and the median seroconversion date was October 1982. Calendar period and age at HIV seroconversion strongly influenced AIDS and death rates. Compared with 1993 through 1996, decreases of 75% (relative risk [RR] = 0.25, 95% confidence interval [CI]: 0.14 to 0.43) and 72% (RR = 0.28, 95% CI: 0.12 to 0.63) in the RR of AIDS were observed in early and late HAART. For all-cause mortality, 72% (RR = 0.28, 95% CI: 0.18 to 0.42) and 83% (RR = 0.17, 95% CI: 0.09 to 0.33) decreases were observed by 1997 through 2000 and 2001 through 2003. For liver-related deaths, increases were observed in the late-HAART period (RR = 2.80, 95% CI: 0.94 to 8.36) compared with 1993 through 1996, but using competing risks, this RR was substantially reduced (RR = 1.70, 95% CI: 0.57 to 5.04). DISCUSSION: Major reductions in AIDS and death rates were observed from 1997 to 2003 in hemophiliacs. These survival improvements are largely attributable to decreases in AIDS-related deaths and have been accompanied by increases in liver disease death rates, which are overestimated if competing risks are not taken into account.