Optimal antiretroviral therapy for aging

The introduction of highly active antiretroviral therapy (HAART) has irrevocably changed the nature of the HIV epidemic in developed countries. Although the use of HAART does not completely restore health in HIV-infected individuals, it has dramatically reduced morbidity and mortality. Increases in life expectancy resulting from effective long-term treatment mean that the proportion of older people living with HIV has increased substantially in the past 15 years. Increasing age is associated with many complications including cardiovascular disease, neurological complications, kidney and liver dysfunction, and metabolic complications such as dyslipidaemia and diabetes. HIV infection and antiretroviral drugs have also been associated with similar complications to those seen with increasing age. The increase in HIV prevalence in older age groups has not been accompanied by the development of treatment guidelines or recommendations for appropriate antiretroviral therapy or clinical management in these patients.     

HIV/AIDS and blindness

Nearly 34 million people are currently living with HIV/AIDS: ocular complications are common, affecting 50% to 75% of all such patients at some point during the course of their illness. Cytomegalovirus retinitis is by far the most frequent cause of vision loss in patients with AIDS. Although the prevalence of cytomegalovirus retinitis is decreasing in industrialized countries because of the widespread availability of highly active antiretroviral therapy, between 10% and 20% of HIV-infected patients worldwide can be expected to lose vision in one or both eyes as a result of ocular cytomegalovirus infection. Less frequent but important causes of bilateral vision loss in patients with HIV/AIDS include varicella zoster virus and herpes simplex virus retinitis, HIV-related ischaemic microvasculopathy, ocular syphilis, ocular tuberculosis, cryptococcal meningitis, and ocular toxic or allergic drug reactions. At present, most patients with HIV/AIDS in developing countries who lose their vision have a very limited life expectancy. As antiretroviral therapy makes its way to these countries, however, both life expectancy and the prevalence of blindness related to HIV/AIDS can be expected to increase dramatically.     

Antiretroviral therapy in critically ill patients: a French national study

SETTINGS: The HIV-positive population is still increasing because the incidence of the disease remains high while the effectiveness of highly active antiretroviral therapy (HAART) has dramatically reduced mortality. HIV infected patients have an increased life expectancy and are more readily admitted to intensive care units. METHOD: We conducted a nation-wide comparative study in France of how these patients are managed by ICU specialists, on one hand, and HIV specialists, on the other, to better understand the use of antiretroviral therapy in critically ill patients. RESULTS: The results show heterogeneous responses of ICU specialists with an important proportion of non decisive answers. The answers of HIV specialists are more homogeneous. There appears to be little or no cooperation between the two specialties. The CISIH (French centers for the information and care of human immunodeficiency) are rarely consulted. CONCLUSIONS: ICU specialists must be better informed on this rapidly evolving disease. Access to updated information or to an HIV specialists must be made easier. Studies should also be made on how HAART is employed in ICUs (pharmacology, pharmacodynamics...).     

整合酶抑制剂在HIV感染全程管理中的应用优势

随着HIV抗反转录病毒治疗（antiretroviral therapy, ART）的研究进展，ART时机的不断提前以及ART药物的迅速发展，HIV感染者可以获得期望寿命。现在对HIV感染者的关注不仅仅在于AIDS本身，更多应该关注HIV感染者的合并症，甚至心理疾病。中华医学会发布的《艾滋病诊疗指南（2018版）》提出全程管理的概念，而整合酶抑制剂在HIV感染全程管理的多个环节中优势显著，本文就其在全程管理中的地位以及应用展开讨论。     

Current trends in the treatment of HIV infection, 2003

The HIV/AIDS epidemic appears to have stabilized in the world's developed countries while it is still worsening in many areas of the resource-poor world. HIV/AIDS patients in countries such as the United States are living longer primarily due to the availability of potent antiretroviral drug combinations and tests to monitor the risk of progression of disease. Management of HIV is very complicated. General guidelines for treatment are available. Published guidelines, however, are often too simplistic and do not reflect new or controversial information. Most patients will develop resistant virus during their treatment. Several antiretroviral medications are on the horizon that will afford better options for treatment, and studies are underway to evaluate treatment strategies that would be potent, less toxic, and convenient for patients. Because the field of HIV care continues to evolve rapidly and there is increasing diversity among infected patients, treatment and prevention are optimized when provided by a dedicated care team supervised by an HIV specialist.     

HIV treatment and worker absenteeism: Quasi-experimental evidence from a large-scale health program in South Africa

Over the past decade, large-scale HIV antiretroviral therapy (ART) programs have proven hugely successful in improving the life expectancy of people living with HIV. However, the extent to which treatment allows patients to maintain a productive work life remains an open question. We applied an instrumental variable method based on individual CD4 counts and exogenously changing treatment guidelines to identify the causal effect of ART on health-related absenteeism rates among workers living with HIV. We used monthly data from the occupational health program of one of the world's largest mining companies in South Africa (128,052 observations among 1,924 workers, from 2009 to 2017). Eighteen months after ART initiation, the treatment significantly reduced absenteeism by 1.033 days per worker and month. Using publicly available wage and treatment cost data, we find that the cost savings due to the absenteeism effect of ART alone outweigh treatment costs in the mining sector in several sub-Saharan African countries.     

HIV感染及抗病毒治疗与糖尿病关系研究进展

随着抗病毒治疗的广泛使用,HIV感染者的预期寿命、生活质量得到较大改善。与此同时,HIV相关的代谢性疾病,尤其是糖尿病的患病风险也有所增加。HIV感染者中糖尿病的风险增加与很多因素共同作用有关。近年来研究表明HIV感染及抗病毒治疗与糖尿病密切相关。本文综述了近年来HIV感染及抗病毒治疗在糖尿病发生发展中的作用机制。     

AIDS treatment and mental health: Evidence from Uganda

Increased access to antiretroviral therapy (ART) in developing countries over the last decade is believed to have contributed to reductions in HIV transmission and improvements in life expectancy. While numerous studies document the effects of ART on physical health and functioning, comparatively less attention has been paid to the effects of ART on mental health outcomes. In this paper we study the impact of ART on depression in a cohort of patients in Uganda entering HIV care. We find that 12 months after beginning ART, the prevalence of major and minor depression in the treatment group had fallen by approximately 15 and 27 percentage points respectively relative to a comparison group of patients in HIV care but not receiving ART. We also find some evidence that ART helps to close the well-known gender gap in depression between men and women.     

Pharmacogenetics of non-nucleoside reverse transcriptase inhibitors (NNRTIs) in resource-limited settings: Influence on antiretroviral therapy response and concomitant anti-tubercular,antimalarial and contraceptive treatments

The burden of human immunodeficiency virus (HIV) is mainly concentrated to resources-limited countries where the response to available antiretroviral therapy is often limited by the occurrence of toxicity or by the emergence of HIV drug resistance. Efavirenz and nevirapine are the antiretroviral drugs most prescribed in resources-limited countries as part of antiretroviral combination therapy. Their metabolism and conjugation are largely influenced by enzymatic genetic polymorphisms. The genetic variability of their metabolism could be associated to different metabolic phenotypes causing reduced patients' adherence because of toxicity or drug–drug interactions with concomitant therapies. The purpose of this review is to summarize published evidence on pharmacogenetic and pharmacokinetic aspects related to efavirenz and nevirapine, the influence of concomitant anti-tubercular, anti-malarial or contraceptive treatments, and the impact of human genetic variation and drug–drug interaction on the virologic and immunologic response to antiretroviral therapy in resources-limited countries.     

HIV-associated kidney disease in the context of an aging population

Acute renal failure and chronic kidney disease are more common in HIV-infected patients compared with the general population. Several studies have shown age to be a risk factor for HIV-associated kidney disease. The improved life expectancy of HIV-infected patients as a result of widespread use of antiretroviral therapy has resulted in progressive aging of HIV cohorts in the developed world, and an increased burden of cardiovascular and kidney disease. Consequently, HIV care increasingly needs to incorporate strategies to detect and manage these non-infectious co-morbidities.     

Life expectancy of HIV-positive adults: a review

We review studies estimating life expectancy (LE), the average number of additional years a person can expect to live, for HIV-positive adults and show variation by sociodemographic factors and level of immunosuppression. The LE of patients starting antiretroviral therapy early in the course of HIV infection and attaining restoration of a normal CD4 count may approach that of the general population. Improvements in treatment and the associated increase in LE imply that increasing numbers of HIV-positive patients will live to older age. Late diagnosis and presentation to care and treatment not concordant with guidelines contribute to reducing LE.     

Team care: a necessity for a child with HIV infection]

In four children, a boy aged 2.5 years, a girl of 4, her brother of 7 years and a girl aged 10 months, HIV infection was diagnosed. Since 1996 HIV-infected children in the Netherlands are treated with a combination of two nucleoside analogs and a protease-inhibitor. This therapy improves the quality of life, increases the life expectancy of HIV-infected children and is generally well tolerated. However, the current combination therapy is complex and puts a burden on the child and the family. Therefore, long term compliance will be difficult. Moreover, the majority of the families have extremely difficult social circumstances which interfere with an optimal medical treatment for the child. The parents of three of the children were refugees from African countries. Intensive support of the family by a team of health care and social workers is usually necessary to make antiretroviral combination therapy possible. Care directed at the individual needs of the child and family is crucial to help this vulnerable group of children and families in our society.     

Epidemiologische Entwicklung bei ausgewählten sexuell übertragbaren Infektionen (STI) in Deutschland

The number of people living with HIV infection has been increasing since the mid 1990s and is expected to rise further in the coming years. The HIV epidemic in Germany is still most affected by developments in the group of men who have sex with men (MSM). In this group, the number of newly diagnosed HIV infections has increased in recent years especially in large cities. Despite increased efforts to motivate HIV-infected people, who were not previously diagnosed, to be tested as early as possible and to seek medical treatment, the number of undiagnosed HIV-infected persons has increased. There are more people infected with HIV than those who have been tested positive for HIV and subsequently receive antiretroviral treatment. However, early testing and treatment alone are not sufficient to effectively contain the infection. Increased efforts are required to more effectively prevent new HIV infections by combining all the available options. In Germany as in all other developed countries, a stronger increase in the number of syphilis infections among MSM is reported, which is primarily due to a higher willingness to risk unprotected contacts, whereby the risk of HIV infection is also increased. The public prevention messages available for HIV are only partially effective against syphilis. More frequent examinations and optimized therapy management are necessary in addition to the use of condoms to prevent the spread of syphilis, gonorrhea, and Chlamydia trachomatis. Sustainable containment of new HIV infections must, therefore, be accompanied by both containment of sexually transmitted infections (STI) and use of public prevention messages for HIV/STI.     

不同死亡评价指标在艾滋病防治中的应用

自艾滋病抗病毒治疗药物出现以来,艾滋病已从致命性疾病转变为可控的慢性传染病。我国自2003年开始实行针对HIV感染者和AIDS患者的免费抗病毒治疗,为进一步评价抗病毒治疗的公共卫生效果,需要采用死亡评价指标。常用的死亡评价指标包括死亡率、病死率、超额死亡率、标化死亡比、潜在减寿年数、伤残调整寿命年和期望寿命。本文总结了国内外在艾滋病防治效果评价时所使用的各种死亡指标,并分别阐述这些指标的应用范围和意义,提出我国今后应在艾滋病防治效果评价中增加期望寿命和疾病负担等方面的研究。     

Relative Importance of Demographic,Socioeconomic and Health Factors on Life Expectancy in Low- and Lower-Middle-Income Countries

Background

We attempted to identify the pathways by which demographic changes, socioeconomic inequalities, and availability of health factors influence life expectancy in low- and lower-middle-income countries.

Methods

Data for 91 countries were obtained from United Nations agencies. The response variable was life expectancy, and the determinant factors were demographic events (total fertility rate and adolescent fertility rate), socioeconomic status (mean years of schooling and gross national income per capita), and health factors (physician density and human immunodeficiency virus [HIV] prevalence rate). Path analysis was used to determine the direct, indirect, and total effects of these factors on life expectancy.

Results

All determinant factors were significantly correlated with life expectancy. Mean years of schooling, total fertility rate, and HIV prevalence rate had significant direct and indirect effects on life expectancy. The total effect of higher physician density was to increase life expectancy.

Conclusions

We identified several direct and indirect pathways that predict life expectancy. The findings suggest that policies should concentrate on improving reproductive decisions, increasing education, and reducing HIV transmission. In addition, special attention should be paid to the emerging need to increase life expectancy by increasing physician density.Key words: life expectancy, socioeconomic and health factors, low- and lower-middle-income countries, path analysis     

艾滋病相关骨科疾病的临床研究进展

随着高效抗反转录病毒治疗的应用，艾滋病患者生存时间明显延长，预期寿命甚至已接近一般人群，艾滋病已成为一种慢性疾病。近年来，艾滋病相关骨科疾病的发生率逐渐升高，因此需要骨科手术治疗的艾滋病患者越来越多，艾滋病相关骨科疾病的诊治已经逐渐引起临床专家的高度重视。本文回顾性复习了艾滋病合并各类骨科疾病的临床研究进展，以期为医生提供更多该领域的临床进展信息。     

Length of life inequality around the globe

Inequality in the distribution of adult length of life – defined as age at death in the population aged 15 and over – is studied for virtually all countries of the world using a new database with over 9000 life tables covering a period of up to two centuries. The data reveal huge variation among countries and time periods in the degree to which the available years of life are distributed equally among the population. Most length of life inequality (about 90%) is within-country inequality. Our findings make clear that measures of length of life inequality should be adjusted for life expectancy to get a more relevant indicator of length of life differentials across populations. At similar levels of life expectancy, substantial differences in inequality are observed, even among highly developed countries. Expressed as premature mortality, inequality may be 35–70% higher in the most unequal countries compared to the most equal ones. Countries that reached a certain level of life expectancy earlier in time than other countries, and countries that improved their life expectancy more quickly than others, experienced higher levels of inequality.     

Estimating the welfare gains from anti-retroviral therapy in Sub-Saharan Africa

Since the start of the century, many countries in Sub-Saharan Africa have experienced large gains in life expectancy and average consumption levels. Around the same time, an unprecedented international effort has taken place to combat HIV/AIDS mortality with the expansion of anti-retroviral therapy (ART) across many of the hardest hit countries. In this paper, I estimate the impact of ART on average welfare over time in 42 countries using the equivalent consumption approach. I decompose the change in welfare to isolate the relative contribution of ART-driven improvements in life expectancy and consumption. The results indicate that ART has accounted for around 12% of total welfare growth in SSA between 2000 and 2017. In those countries most affected by HIV/AIDS, this figure rises to around 40%. Moreover, the estimates suggest that welfare in some of the worst-hit countries would have declined over time without the ART expansion.     

Socioeconomic Factors in Adherence to HIV Therapy in Low- and Middle-income Countries

It is not clear what effect socioeconomic factors have on adherence to antiretroviral therapy (ART) among patients in low- and middle-income countries.  We performed a systematic review of the association of socioeconomic status (SES) with adherence to treatment of patients with HIV/AIDS in low- and middle-income countries. We searched electronic databases to identify studies concerning SES and HIV/AIDS and collected data on the association between various determinants of SES (income, education, occupation) and adherence to ART in low- and middle-income countries. From 252 potentially-relevant articles initially identified, 62 original studies were reviewed in detail, which contained data evaluating the association between SES and adherence to treatment of patients with HIV/AIDS. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 15 studies (41.7%), 10 studies (20.4%), and 3 studies (11.1%) respectively out of 36, 49, and 27 studies reviewed. One study for income, four studies for education, and two studies for employment found a negative and significant association with adherence to ART. However, the aforementioned SES determinants were not found to be significantly associated with adherence in relation to 20 income-related (55.6%), 35 education-related (71.4%), 23 employment/occupational status-related (81.5%), and 2 SES-related (100%) studies. The systematic review of the available evidence does not provide conclusive support for the existence of a clear association between SES and adherence to ART among adult patients infected with HIV/AIDS in low- and middle-income countries. There seems to be a positive trend among components of SES (income, education, employment status) and adherence to antiretroviral therapy in many of the reviewed studies.Key words: Antiretroviral therapy, highly active; Education; Employment; Income; Occupations; Social class     

A pestilent monster on prowl

World AIDS Day 1997 was commemorated in Delhi, India, with a "walk for life" led by the Union Minister of State for Health and the premier of a telefilm on AIDS. In India, by August 1997, 66,460 out of 3,156,800 HIV tests had positive results and nearly 1% of the adult population is estimated to be infected. An estimated 1 million children are HIV-positive. As a result of the strong associations between AIDS and poverty, inequality, culture, and high-risk sexual behaviors, Asia will soon hold half the world's AIDS cases. The epidemic has reversed many recent gains in health and life expectancy and is overwhelming the health care system. Only 2.5% of the HIV-infected Indian population has access to newly developed antiretroviral drugs that slow the progression to AIDS. As this editorial states, "AIDS is a war where the target is clear, but the strategies are still amorphous, thereby making the attacks blurred."