贵港市老年HIV/AIDS患者生存状况及其影响因素的回顾性队列研究

 

目的 了解贵港市老年人类免疫缺陷病毒感染者/艾滋病患者（HIV/AIDS）的生存状况及其影响因素,为制定有针对性的防治措施提供参考依据。方法 采用回顾性队列研究,在艾滋病综合防治信息系统中选择年龄≥50岁的HIV/AIDS患者作为研究对象,用寿命表法计算生存率,Kaplan-Meier法绘制生存曲线,Log-Rank检验比较不同组别生存时间的差异,Cox比例风险模型进行多因素分析。结果 5 397例研究对象中,死亡2 466例,其中艾滋病相关死亡931例。累计观察164 122.77人月,艾滋病相关死亡率为5.67/1 000人月。平均生存时间为129.680个月（95%CI：127.513~131.846）,确诊后第12、36、60、96个月的生存率分别为81%、78%、77%、76%。多因素Cox回归分析显示,男性、汉族、AIDS、以性接触为主的感染途径、低CD4⁺T细胞水平及未检测者、未接受抗病毒治疗（ART）均是影响老年HIV/AIDS生存时间的危险因素。结论 贵港市老年HIV/AIDS的生存率低,生存时间受多种因素的影响,故须针对该类人群的特点,采取有效的综合防治措施,降低死亡风险,延长生存时间。

     

Survival after AIDS diagnosis in Tuscany (Italy), 1985--1992

The study evaluated the overall survival after AIDS diagnosis of 1,014 patients reported to the Italian AIDS Registry as resident in Tuscany, stratified by age, gender, year of diagnosis, HIV transmission category, initial AIDS-defining disease and CD4+ cells count. The study was a population-based survival analysis, carried out through Kaplan-Meier method (mean survival times -- MST --, 1, 2 and 3-year observed survival) and Cox models (crude and adjusted relative risk -- RR). The MST was 12.4 months for all cases, increasing from 4--7 months in 1985-- 1987 to 14 months in 1991--1992. The observed survival was 51.4% at the first year of follow-up, 28.4% at the second year and 14.5% at the third year. The multivariate analysis showed an independent prognostic effect of age, year of diagnosis, initial AIDS-defining disease and CD4⁺ cells count. The prognosis was worse in cases aged over 44 (reference: 25--29), diagnosed before 1988 (reference: 1991) and with wasting syndrome, toxoplasmosis, HIV encephalopaty or multiple diseases (reference: PCP alone); and better in cases with more than 100 CD4⁺ cells/mm³ (reference: 50 cells/mm³). The differences in gender and among HIV transmission categories disappeared after age-adjustment. The study confirmed, in an European population-based series, the poor long-term AIDS prognosis and, once AIDS has became clinically manifest, the prognostic value of some clinical and demographic variables.     

Trends and Differences Among Three New Indicators of HIV Infection Progression

Objective

This study proposes three indicators of, and assesses the disparities and trends in, the risk of HIV infection progression among people living with diagnosed HIV infection in the United States.

Methods

Using data reported to national HIV surveillance through June 2012, we calculated the AIDS diagnosis hazard, HIV (including AIDS) death hazard, and AIDS death hazard for people living with diagnosed HIV infection for each calendar year from 1997 to 2010. We also calculated a stratified hazard in 2010 by age, race/ethnicity, mode of transmission, region of residence at diagnosis, and year of diagnosis.

Results

The risk of HIV infection progression among people living with diagnosed HIV infection decreased significantly from 1997 to 2010. The risks of progression to AIDS and death in 2010 were higher among African Americans and people of multiple races, males exposed through injection drug use (IDU) or heterosexual contact, females exposed through IDU, people residing in the South at diagnosis, and people diagnosed in 2009 compared with white individuals, men who have sex with men, females with infection attributed to heterosexual contact, those residing in the Northeast, and those diagnosed in previous years, respectively. People aged 15–29 years had the highest AIDS diagnosis hazard in 2010.

Conclusion

Continued efforts are needed to ensure early HIV diagnosis as well as initial linkage to and continued engagement in HIV medical care among all people living with HIV. Targeted interventions are needed to improve health-care and supportive services for those with worse health outcomes.In the United States, the number of people aged 13 years and older living with human immunodeficiency virus (HIV) infection was estimated to be more than 1.1 million as of December 2010, a 9% increase from 2006.¹ For people living with HIV, increasing their access to care and eliminating disparities are primary goals of the National HIV/AIDS Strategy (NHAS) and the Healthy People 2020 objectives.^2,3 Assuring that all people with HIV are diagnosed early, promptly linked to care, retained in care, and offered antiretroviral treatment is essential to achieve the ultimate goal of the continuum of care,⁴ leading to viral suppression, improved health, survival, and prevention of HIV transmission.Several studies have used national HIV surveillance data to examine the disparities and determinants of progression to acquired immunodeficiency syndrome (AIDS; i.e., stage 3 HIV infection⁵) and death after HIV diagnosis. These studies have focused on individuals diagnosed in a certain time period and have examined the differences in time from HIV diagnoses to AIDS and death (i.e., the number of months/years from HIV diagnosis to AIDS or death) using survival analyses, including Kaplan-Meier survival curves, the Cox proportional hazard model, or the standardized relative risk.^6–8 However, previous studies have not assessed the risks of progression to AIDS and death among all people living with HIV, and have not reported the trends in these outcomes.To fill this gap, we propose in this study three cross-sectional indicators to estimate the risks of progression to AIDS and death in a calendar year after HIV diagnoses among people living with diagnosed HIV infection, regardless of their time of diagnosis (i.e., the year when an HIV infection was first diagnosed). The results allow for an annual assessment of the risks of HIV infection progression and can be used to monitor the trends in these outcomes among people living with HIV.Specifically, this study (1) examined the disparities in the risk of progression to AIDS in 2010 among people living with diagnosed HIV (not AIDS) infection at year-end 2009 (AIDS diagnosis hazard), the risk of death in 2010 among those living with diagnosed HIV (including AIDS) infection at year-end 2009 (HIV death hazard), and the risk of death in 2010 among individuals living with AIDS at year-end 2009 (AIDS death hazard); and (2) assessed the trends in the risks of HIV infection progression among people living with diagnosed HIV infection from 1997 to 2010 using the three indicators.     

Anthropometric indices as predictors of survival in AIDS adults. Aquitaine Cohort,France, 1985–1997

The aim of the study was to assess the performance of weight related nutritional markers [reported involuntary weight loss (WL) greater than 10%, measured WL and body mass index (BMI)] in predicting survival at AIDS stage. The three anthropometric indices were used as time dependant variables in Cox models to predict survival at AIDS stage. The studied sample included 630 HIV1-infected individuals of a prospective cohort of those 421 died (median survival at AIDS stage: 19.9 months). After adjustment for usual prognostic factors of survival, the reported WL greater than 10% was a pejorative predictor of survival (hazard ratio (HR) 2.4; 95% confidence interval (CI): 1.9–3.0). For measured WL <5%, between 5 and 10% and 10% of baseline weight compared with no WL, HR were respectively, 1.9 (CI: 1.4–2.6), 3.3 (CI: 2.4–4.4) and 6.7 (CI: 5.2–8.6). The HR of death were 2.2 (CI: 1.6–3.0) for BMI between 16 and 18.4 kg/m²and 4.4 (CI: 3.1–6.3) for BMI <16 compared to normal BMI (18.5). Even a limited WL measured at a given point in time during follow up increases the risk of death at the AIDS stage. Simple cross-sectional measures of BMI have a good predictive value of survival.     

浙江省台州市1998-2022年HIV/AIDS死因分析

目的 了解台州市1998-2022年HIV/AIDS的死亡情况和死因。方法 资料来源于中国疾病预防控制信息系统的艾滋病综合防治信息系统和台州市慢性病信息管理系统,以1998-2022年现住址为台州市的5 126例HIV/AIDS为研究对象,用SAS 9.4软件进行秩和检验、χ²检验及趋势分析。结果 1998-2022年HIV/AIDS死亡796例,病死率为15.53%（796/5 126）,病例在确证后1年内死亡占52.26%（416/796）。年初尚存活病例在年内死亡的构成比呈下降趋势（趋势χ²=5.60,P<0.001）。在死因构成上,艾滋病140例（17.59%）、恶性肿瘤237例（29.77%）、心血管病99例（12.44%）、伤害58例（7.29%）、其他160例（20.10%）和不详102例（12.81%）。恶性肿瘤、心血管病和其他死因的死亡病例构成比随时间变化均呈上升趋势（趋势χ²=1.92,P=0.028;趋势χ²=2.81,P=0.003;趋势χ²=2.07,P=0.020）。在HIV/AIDS不同死因中,确证年龄、职业、婚姻状况、民族、文化程度和感染途径的差异有统计学意义（均P<0.05）。死因为心血管病者死亡年龄最大,死因为艾滋病的死亡距确证间隔时间最短且首次检测CD4⁺T淋巴细胞计数最低,死因不详者的确证至抗病毒治疗的时间间隔最长（均P<0.05）。结论 1998-2022年台州市HIV/AIDS的非艾滋病相关死亡的构成比较高,随时间变化呈上升趋势,要进一步加强HIV/AIDS慢性非传染性疾病的早期筛查、干预和治疗。     

Early prediction of median survival among a large AIDS surveillance cohort

Background  

For individuals with AIDS, data exist relatively soon after diagnosis to allow estimation of "early" survival quantiles (e.g., the 0.10, 0.15, 0.20 and 0.30 quantiles, etc.). Many years of additional observation must elapse before median survival, a summary measure of survival, can be estimated accurately. In this study, a new approach to predict AIDS median survival is presented and its accuracy tested using AIDS surveillance data.     

Section on AIDS: the politics of survival. Introduction

In one short decade, the politics of AIDS has become the politics of survival. In a world whose social order is changing before our eyes, AIDS insistently brings new meaning to the age-old question of what it is we must do to survive--as individuals, as families, as communities, as nations, as members of an interdependent world. The goal of this Special Section is to promote frank discussion, from an explicitly progressive perspective, of what it will take to stop the AIDS epidemic and deal with the devastation it has already wrought. Articles by AIDS researchers, service providers, and activists from around the world will address the numerous social, political, economic, and cultural factors that affect both the spread of AIDS and the social response to the epidemic. Topics to be considered in this and future issues of the Journal include: AIDS and community survival in the United States; women and AIDS, particularly in economically underdeveloped countries; the politics and economics of AIDS interventions in Latin America and the Caribbean; and the growing international AIDS industry.     

中国既往不安全有偿供血感染HIV者自然史双向性队列研究

目的探讨中国既往不安全有偿供血员HIV感染自然史及其影响因素。方法采用双向性队列研究方法，从国家艾滋病综合防治示范区中抽取6个省的10个县（区），选择所有2006年7月24日前发现并确认既往不安全有偿采血（浆）者HIV／AIDS病例，收集其感染、发病、死亡信息及影响因素。采用SPSS12.0统计软件分析。结果（1）在7551例HIV感染者中，典型进展者6533例（86．52％，其中AIDS患者4757例），快速进展者108例（1．43％），长期不进展者910例（12．05％）。（2）目前已经进展为AIDS者4865例（64．43％），AIDS中位潜伏期为9年（95％ CI：8．96-9．04）；至今累计未应用抗病毒药物治疗者1157例（占AIDS23．78％），其中死亡283例，这些未治疗的AIDS死亡者中位生存时间为6个月（95％CI：4-7），2、3年病死率分别为95％、99％。（3）AIDS潜伏期长短与性别、感染HIV时年龄无关（P〉0．05）；未治疗的AIDS患者生存时间长短与性别有关（P〈0．05），但与诊断AIDS时年龄、文化程度、婚姻无关（P〉0．05）。结论研究结果与UNAIDS提出的成年人慢速疾病进展规律比较，所得潜伏期略长而AIDS自然生存期较短，但与其他途径感染HIV人群潜伏期相近。     

Survival differences in Austrian patients with the acquired immunodeficiency syndrome

We investigated the association of clinical and demographic factors on survival of the 901 AIDS cases diagnosed until 31 December 1992 and reported to the Austrian Health Authorities up to 20 January 1994. The overall estimated median survival of patients with AIDS increased substantially from 8 months in 1987 to 16 months in 1988, although this increase was not significant by the log-rank test. However, the differences in hazard rates were larger at the beginning of the survival curve: between 1987 and 1988 the proportion surviving at 1 year increased from 41 to 62%, compared to an increase of the proportion surviving at 2 years from 30 to 35% (Breslow test,p value 0.008). AIDS patients diagnosed between 1988 and 1992 (n=755) were analyzed in more detail. Multivariate survival analysis revealed a shorter survival for those with residence in Eastern Austria, recipients of blood products, individuals with unknown transmission risk, those presenting with two AIDS indicator diseases and those with higher age at AIDS diagnosis. Candidal esophagitis as AIDS indicator disease was associated with longer survival. One hundred eighty-eight of the 755 AIDS patients (24.9%) died within the first 3 months after diagnosis of AIDS. We conclude that the survival time for AIDS patients has improved considerably after 1987, but survival is still very poor. Several factors have been shown to predict survival of patients with AIDS in Austria. Death within the first 3 months after the diagnosis of AIDS occurred at a relatively high frequency in Austrian AIDS patients. This may be caused by difficulties in the use of health care facilities or by the lack of awareness of HIV infection before diagnosis of AIDS either by patient or care provider.     

湖北省接受艾滋病抗病毒治疗的老年患者生存情况分析

目的 分析湖北省接受艾滋病抗病毒治疗的老年患者基本情况及生存情况。 方法 回顾性分析年龄≥50岁的艾滋病患者主要流行病学特征和生存情况,并以年龄＜50岁艾滋病患者为对照,进行相关分析,寿命表法计算累积生存率,Kaplan-Meier法绘制年龄≥50岁和＜50岁两组艾滋病患者的生存曲线,Cox比例风险模型分析影响死亡的主要危险因素。 结果 ≥50岁的艾滋病患者有2 643例,开始治疗的平均年龄为(58.49±7.1)岁,年龄＜50岁的艾滋病患者有7 725例,开始治疗的平均年龄为(34.43±8.68)岁。两组艾滋病患者主要以男性、已婚或同居、异性性传播、初中及以下文化、基线CD4值在0~200个/μl之间、WHO临床分期为Ⅰ期、初始治疗方案为齐多夫定/司他夫定 + 拉米夫定 + 依非韦伦/奈韦拉平为主;寿命表法显示年龄≥50岁组老年艾滋病患者累积生存率从第1年的82.06%下降到第10年的53.63%,年龄＜50岁组艾滋病患者累积生存率从第1年的97.48%下降到第10年的94.2%。Log-Rank检验显示年龄≥50岁组的死亡风险高于＜50岁组(χ²=209.74,P＜0.001)。多因素Cox比例风险模型分析显示,文化程度、WHO临床分期、基线CD4数、初始治疗方案是年龄≥50岁组艾滋病患者死亡的危险因素(P＜0.05);文化程度、婚姻状况、感染途径、WHO临床分期、基线CD4数、初始治疗方案是年龄＜50岁组艾滋病患者死亡的危险因素(P＜0.05)。 结论 湖北省接受艾滋病抗病毒治疗的老年艾滋病患者生存率低,应结合本省特点,根据老年人群的特征和死亡危险因素采取针对措施,降低老年艾滋病患者的死亡风险,提高生存率。     

Impact of housing on the survival of persons with AIDS

Background  

Homeless persons with HIV/AIDS have greater morbidity and mortality, more hospitalizations, less use of antiretroviral therapy, and worse medication adherence than HIV-infected persons who are stably housed. We examined the effect of homelessness on the mortality of persons with AIDS and measured the effect of supportive housing on AIDS survival.     

Who Are California's Late HIV Testers? An Analysis of State AIDS Surveillance Data, 2000–2006

Objectives

Late HIV testing leads to preventable, severe clinical and public health outcomes. California, lacking a mature HIV surveillance system, has been excluded from documented analyses of late HIV testers in the United States. We identified factors associated with late HIV testing in the California AIDS surveillance data to inform programs of HIV testing and access to treatment.

Methods

We analyzed data from California AIDS cases diagnosed between 2000 and 2006 and reported through November 1, 2007. Late testers were people diagnosed with HIV within 12 months before their AIDS diagnosis. We identified factors significantly associated with late HIV testing using multivariable logistic regression.

Results

Among 28,382 AIDS cases, 61.2% were late HIV testers. Late testing was significantly associated with those ≥35 years of age, heterosexual contact or unknown/other reported transmission risk, and being born outside of the U.S. When further classified by country of birth, people born in Mexico were most likely to be HIV late testers who progressed to AIDS.

Conclusions

Our findings support wider implementation of opt-out HIV testing and HIV testing based in emergency departments. Services for HIV testing and treatment should be inclusive of all populations, but especially targeted to populations that may have more limited access.Among the more than one million people in the United States estimated to be infected with human immunodeficiency virus (HIV), nearly one-quarter remain undiagnosed.¹ Increasing evidence suggests that earlier antiretroviral therapy (ART) for HIV improves survival compared with deferred therapy.^2,3 The benefits of HIV diagnosis well before acquired immunodeficiency syndrome (AIDS) diagnosis are clearly documented and include survival benefit for asymptomatic HIV-infected people with early initiation as compared with deferred initiation of ART,² decreased viral transmission due to lower-serum HIV-1 ribonucleic acid levels⁴ as well as risk modification in people who know their HIV serostatus,⁵ and decreased health expenditures.⁶ In Canada, the estimated annual medical cost of a late presenter, after adjusting for patient characteristics, was more than twice that of a non-late presenter, with a difference of more than $8,000 per person. This discrepancy is mostly due to hospital care costs, which are 15 times higher for those diagnosed late.⁷Given that the period from primary HIV infection to AIDS is estimated at seven to eight years⁸ and the Centers for Disease Control and Prevention (CDC) guidelines advocate routine HIV testing for all U.S. adults,⁹ late HIV testing (defined as the first diagnosis of HIV within one year of an AIDS diagnosis)¹⁰ should be an unusual clinical outcome. However, national estimates from CDC reported that 45% of people with AIDS at 16 sites in the U.S. were late testers.¹⁰ Among AIDS surveillance cases in San Francisco and South Carolina, 39% and 41%, respectively, were late testers.^11,12 In the U.S., AIDS diagnoses can be arguably regarded as a measure of diagnostic or treatment failure.In California, approximately 85% of adult HIV cases are male, 28% are Hispanic, 20% are African American, and 50% are white. Men who have sex with men (MSM) comprise the main risk exposure for men (77%). For women, heterosexual contact is the main risk exposure (52%), followed by injection drug use (23%).¹³ California is home to about 4.4 million Mexican immigrants, about 40% of the total immigrant population in the U.S., and is a key destination for Mexican migrants.^11,14 Both the U.S. and Mexico have concentrated HIV epidemics, where prevention and testing campaigns prioritize traditionally high-risk groups such as MSM and injection drug users (IDUs).The role of migration on the vulnerability of immigrants in California, historically considered a low-risk group, is complex and poorly understood but may have a significant impact on the likelihood of becoming infected with HIV while in the U.S.¹⁵ The denominator of Mexican immigrants in California likely varies by structural factors such as agricultural season. The effect and extent of this varying denominator on HIV/AIDS estimates is not well characterized. In this analysis of California AIDS surveillance data, we identified factors that are significantly associated with late HIV testing in the state.     

Mobilizing a Medical Home to Improve HIV Care for the Homeless in Washington, DC

African Americans face a higher burden of HIV infection, morbidity, and mortality than other ethnic groups in the United States. As an organization that exists to serve the homeless and impoverished of Washington, DC, So Others Might Eat (SOME) works diligently to address this disparity. SOME''s clients are primarily African Americans who often face obstacles to HIV care because of low socioeconomic status, mistrust of the medical establishment, and fear of being identified as HIV positive. We relate the lessons we learned at SOME''s medical clinic while trying to better address the needs of our clients living with HIV/AIDS. Chief among those lessons was the need to shift from considering our patients “noncompliant” with their HIV-related care to recognizing they had needs we were not addressing.AFRICAN AMERICANS ARE disproportionately affected at all stages of HIV infection. Though comprising only 13% of the population, non-Hispanic Blacks account for 50% of AIDS cases in the United States.¹ About 41% of US men and 64% of US women living with HIV/AIDS are African American.¹ African Americans are more likely to die from HIV/AIDS and less likely to have access to highly active antiretroviral therapy than are infected persons of other ethnic groups.^2,3Research indicates that people infected with HIV/AIDS without accumulated financial assets have an 89% greater risk of death than do their counterparts, and those with less than a high school education have a 53% greater risk of death than do those with more education.⁴ Many of these grim predictors of HIV/AIDS survival are present in clients served by So Others Might Eat (SOME), a community-based organization that serves the homeless and impoverished of Washington, DC. SOME works to address the public health emergency that exists for poor HIV-infected African Americans. The organization faces considerable barriers despite the Healthy People 2010 call to address the disproportionate impact of HIV/AIDS among African American and Hispanic populations, because reductions in Medicare and Medicaid reimbursements for medical care and more strict Medicaid eligibility criteria make it difficult to expand care to the most needy.⁵

FACTS ABOUT SOME MEDICAL CLINIC

盐城市2005-2015年艾滋病抗病毒治疗患者生存分析

目的 探索盐城市2005-2015年首次接受抗病毒治疗的艾滋病病毒感染者(HIV)/艾滋病病人(AIDS)的生存时间及影响因素。 方法 利用中国疾病预防控制系统艾滋病综合防治信息系统收集盐城市2005-2015年HIV/AIDS的生存、死亡信息,采用寿命表法分析患者的生存率,采用Cox比例风险模型分析可能影响生存时间的因素。 结果 共有670例接受抗病毒治疗的病例纳入本次研究,截止到研究结束时,有48例病人死于艾滋病相关疾病,占7.16%。抗病毒治疗后患者1~5年的累积生存率分别为0.93、0.91、0.91、0.88和0.88。多因素Cox比例风险模型分析结果显示,首次确诊HIV阳性时年龄25~<50岁组的死亡风险低于年龄≥50岁组(HR=0.350,95%CI:0.196~0.625,P<0.001),相对于基线CD4^＋T淋巴细胞计数＜50个/mm³组,CD4^＋T淋巴细胞计数50~<200个/mm³组、≥200个/mm³组的病例死亡风险均降低(HR=0.447,95%CI:0.216~0.925,P=0.030;HR=0.286,95%CI:0.148~0.552,P<0.001)。 结论 首次确诊HIV阳性时的年龄和基线CD4^＋T淋巴细胞计数影响HIV/AIDS的生存时间,提示扩大HIV监测检测覆盖面,早诊早治是提高患者生存率的关键。     

Solidarity and AIDS: introduction

Perhaps more than any other disease in recent history, AIDS has taught a cruel and crucial lesson: the constraints on our response to this epidemic are as deep as our denial, as entrenched as the inequities that permeate our society, as circumscribed as our knowledge, and as unlimited as our compassion and our commitment to human rights. Elaborating on these themes, the final three articles in this Special Section on AIDS consider three widely divergent yet intimately connected topics: AIDS in Cuba, AIDS in Brazil, and global AIDS prevention in the 1990s. Together, they caution that if we persist in treating AIDS as a problem only of "others," no country will be spared the social and economic devastation that promises to be the cost of our contempt and our folly. Solidarity is not an option; it is a necessity. Without conscious recognition of the worldwide relationship between health, human rights, and social inequalities, our attempts to abate the spread of AIDS--and to ease the suffering that follows in its wake--most surely will fall short of our goals. Finally, as we mourn our dead, we must take to heart the words of Mother Jones, and "fight like hell for living." This is the politics of survival.     

A Public Policy Approach to Local Models of HIV/AIDS Control in Brazil

Objectives. We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability.Methods. We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará.Results. Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability.Conclusions. Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs.In low- and middle-income countries, the HIV/AIDS epidemic continues to spread among the most vulnerable groups, ¹ notably the poor and women (with vulnerability defined as “the extent to which individuals are capable of making and effecting free and informed decisions about their life”^2(p441)).^3,4 The global cumulative prevalence of HIV-infected people is 33.2 million persons. Countries of sub-Saharan Africa are particularly affected, with an HIV seroprevalence of 18% among young adults in some countries.¹ Where there are weak health care systems, control of the epidemic remains an unsolved issue.⁵In Brazil, the HIV seroprevalence among young adults is estimated at 0.65%, and AIDS mortality has decreased significantly since 1997, when highly active antiretroviral therapy became available for free.⁶ The Brazilian federal and local (state and municipal) AIDS programs are considered to be a model for low- and middle-income countries because they have developed a close cooperation between government, health services, and nongovernmental organization (NGO) actors (persons or groups involved in the formulation and implementation of policies and programs). The Ministry of Health defined ambitious prevention policies and provided free access to antiretroviral treatment.^7–13Implemented at 3 levels—federal, state, and municipal—the AIDS programs have been developed within the Brazilian universal health system (Systema Unico de Saude), impelled by the sanitarist movement.^14–16 This movement involved physicians, public health workers, and politicians who in the 1980s advocated and then implemented this new health system, which is based on prevention and free access to care. Programs have been established in 27 states and more than 400 municipalities. In these states and municipalities, several HIV/AIDS facilities have been implemented, including voluntary counseling and testing centers, specialized assistance services for ambulatory care, and hospital services.¹⁷ Many NGOs, whether AIDS-specific (AIDS NGOs) or generalist, are involved in service provision and policy-making.¹⁸During the past decade, the Brazilian epidemic has changed.¹³ Initially, the epidemic affected mainly urban men of middle and upper classes in the southeastern part of the country. Thereafter, it affected more and more the poor^19–21 and women^22,23 and diffused throughout the country. The national AIDS program has also been confronted with the rising cost of antiretroviral drugs, making the sustainability of the existing programs questionable.^24,25 These changes require strategic evolution of the current AIDS policies.To address these new trends, Brazil has, among recent initiatives, decentralized the handling of AIDS policies through incentivos (incentives), financial incentives allocated to states and municipalities that develop AIDS programs appropriate for the local epidemiological situation and integrated into the local health system. Within the incentives policy framework, states and municipalities define their action plan yearly. Such plans are adopted by state or municipal health councils, composed equally of health care professionals, end-users, and local government representatives. After approval by the national program, the states and municipalities receive federal resources earmarked for AIDS programs.The responses to these new trends in the HIV/AIDS epidemic have been studied by focusing on national AIDS policies, ignoring what happens at subnational levels.^7–13 Moreover, very few published articles have adopted a political science stance and public policy analysis to identify what happens at the front line, to assess how different actors cooperate, and to assess what consequences their cooperation induces for prevention of HIV infection, care of the patient, and sustainability of AIDS programs.We studied how decentralized approaches to the HIV/AIDS epidemic in Brazil addressed the new trends of the epidemic, highlighting positive effects and difficulties, and make recommendations for Brazilian policymakers and to other low- and middle-income countries.     

Marker-dependent hazard estimation: An application to AIDS

The acquired immunodeficiency syndrome (AIDS) results from infection with the human immunodeficiency virus (HIV). The time of infection is generally unknown since transmission usually occurs during the course of repeated sexual contacts or needle sharing. Brookmeyer and Gail describe the biases that may arise in survival analyses using the recruitment time rather than the unknown infection time as the origin in prevalent cohorts of HIV-infected individuals. We apply a non-parametric hazard estimator, introduced by Nielsen, that assumes the hazard of an AIDS diagnosis depends upon the unknown time of infection solely through the value of possibly multidimensional markers of HIV-disease progression such as CD4⁺ T lymphocyte cell counts. Essentially, we estimate the hazard for a specific marker value y by dividing the number of occurrences among subjects with marker measurements in a neighbourhood of y by the total risk time in that neighbourhood. We present this estimator, which relies upon kernel estimator techniques to produce a smooth estimate, within a counting process framework. We apply this method to marker data from the San Francisco Men's Health Study.     

Alcohol consumption alters cytokine release during murine AIDS

Acquired immune deficiency syndrome (AIDS) is a clinical disorder caused by a human immunodeficiency virus (HIV), representing the end point in a progressive sequence of immunosuppressive changes. HIV, the key causative agent of AIDS, induces immunosuppression that render the body highly susceptible to opportunistic infections and neoplasm. However, the onset of clinical symptoms of AIDS (e.g., low CD4⁺ T cells count, opportunistic infections, and tumors) is quite variable among HIV⁺ individuals with a mean incubation time 3–10 years following seroconversion. Because of the deleterious effects of chronic alcohol (EtOH) consumption on cytokine release, immune response, host defense, nutritional status, and oxidative stress, it has been believed to be a possible cofactor that could enhance the host's susceptibility to HIV infection, and subsequently accelerate the development of AIDS. The purpose of this review is to present evidence of EtOH-induced cytokine dysregulation during murine AIDS. Our results done in murine AIDS indicate that EtOH consumption may accelerate the development of AIDS by disrupting cytokine production. These EtOH-induced abnormalities in cytokine release may promote a more rapid development of AIDS as a cofactor, which exacerbates the immune dysfunctions initiated by retrovirus infection.     

Prognostic factors of early fatal outcome and long-term survival in patients with Pneumocystis carinii pneumonia and acquired immunodeficiency syndrome

Fifty-five episodes of Pneumocystis carinii pneumonia (PCP) in AIDS patients were evaluated to assess clinical and laboratory risk factors predicting the probability of surviving the acute episode of PCP and the long-term survival after PCP. Age > 45 yrs, PaO₂ < 50 mmHg, AaPO₂ > 50 mmHg, and LDH > 800 IU/L correlated strongly with early mortality; patients who needed mechanical ventilation had a significantly lower PaO₂ and serum albumin, and higher AaPO₂ and LDH compared to the patients who did not. Neither age nor PaO₂, AaPO₂, LDH, albumin, days from onset, time for recovery, CD4+ cell count correlated with long-term survival of AIDS patients with PCP. Informations obtained at initial presentation of PCP may predict early outcome and influence therapeutic approach, improving chances for survival.     

成都市50岁及以上HIV/AIDS抗病毒治疗后生存分析

  目的  了解成都市50岁及以上艾滋病病毒感染者和艾滋病病人(HIV/AIDS)在接受抗病毒治疗后的生存情况,探讨50岁及以上HIV/AIDS抗病毒治疗后生存的影响因素,为制定50岁及以上HIV/AIDS治疗政策提供依据。  方法  选择成都市2010-2018年新报告的50岁及以上接受抗病毒治疗的HIV/AIDS,采用寿命表法描述生存情况,通过多因素Cox风险回归模型对可能的影响因素进行分层并进行生存分析。  结果  治疗后20个月内累计生存率从0.97下降到0.91,截至观察终点时间9年累计生存率为0.82。多因素分析显示:女性发生死亡危险是男性的0.689倍;70岁及以上发生死亡危险是50~岁的4.037倍;未婚和离异丧偶发生死亡危险是已婚的1.909倍和1.269倍;大专及以上发生死亡危险是文盲的0.403倍;首次CD4+T细胞检测值>500个/mm3发生死亡危险是 < 100个/mm3的0.318倍。  结论  成都市50岁及以上HIV/AIDS抗病毒治疗后的生存率较高,性别、年龄、文化程度、婚姻状况、首次CD4+T细胞检测值是影响50岁及以上HIV/AIDS病人生存的因素,应根据本地区实际情况,制定相应的治疗措施与宣传手段。