Causes of death among women with human immunodeficiency virus infection in the era of combination antiretroviral therapy

PURPOSE: To examine changes in the causes of death and mortality in women with human immunodeficiency virus (HIV) infection in the era of combination antiretroviral therapy. METHODS: Among women with, or at risk of, HIV infection, who were enrolled in a national study from 1994 to 1995, we used an algorithm that classified cause of death as due to acquired immunodeficiency syndrome (AIDS) or non-AIDS causes based on data from death certificates and the CD4 count. Poisson regression models were used to estimate death rates and to determine the risk factors for AIDS and non-AIDS deaths. RESULTS: Of 2059 HIV-infected women and 569 who were at risk of HIV infection, 468 (18%) had died by April 2000 (451 HIV-infected and 17 not infected). Causes of death were available for 428 participants (414 HIV-infected and 14 not infected). Among HIV-infected women, deaths were classified as AIDS (n = 294), non-AIDS (n = 91), or indeterminate (n = 29). The non-AIDS causes included liver failure (n = 19), drug overdose (n = 16), non-AIDS malignancies (n = 12), cardiac disease (n = 10), and murder, suicide, or accident (n = 10). All-cause mortality declined an average of 26% per year (P = 0.03) and AIDS-related mortality declined by 39% per year (P = 0.01), whereas non-AIDS-related mortality remained stable (10% average annual decrease, P = 0.73). Factors that were independently associated with non-AIDS-related mortality included depression, history of injection drug use with hepatitis C infection, cigarette smoking, and age. CONCLUSION: A substantial minority (20%) of deaths among women with HIV was due to causes other than AIDS. Our data suggest that to decrease mortality further among HIV-infected women, attention must be paid to treatable conditions, such as hepatitis C, depression, and drug and tobacco use.     

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.     

Progression of HIV infection in the post-HAART era among a cohort of HIV+ Greek haemophilia patients

AIM: The study aims to describe the course of HIV-1 infection in the pre- and post-HAART period in a cohort of HIV+ haemophilia patients followed up for up to 21 years. METHODS: The cohort includes 158 haemophilic men with known seroconversion dates followed up prospectively for a median time of 12 and 5.7 years in the pre- (1980-96) and post-HAART period (1997-2003), respectively. RESULTS: The risk of developing AIDS was lowered by 56% in the post- as compared to the pre-HAART period. Of the 158 patients 69 developed AIDS in the pre-HAART period while of the 59 subjects still alive and AIDS free on 1/1/1997 six developed AIDS. The rate of PCP (12.0 cases per 1000 person-years) and NHL (5.4 cases per 1000 person-years), the most common causes of AIDS diagnosis in the pre-HAART era, were remarkably reduced in the post-HAART era (both rates: 2.8 cases per 1000 person-years). On the contrary, the corresponding risk for non-AIDS deaths was fourfold increased in the post-HAART period. Of the 38 non-AIDS related deaths in both periods, 13 occurred post-HAART. The predominant cause of non-AIDS mortality in both periods was end-stage liver disease (ESLD) (7 pre- and 4 post-HAART). The rate of non-AIDS related cancers was also increased during the post-HAART period. CONCLUSION: In this haemophilia cohort the risk of AIDS has substantially reduced in the post-HAART period, but the rate of non-AIDS mortality tended to increase. Among haemophilia subjects, due to the high rates of HCV/HIV coinfection, ESLD, the predominant cause of non-AIDS mortality, will become an increasingly important clinical problem.     

Causes of death in HIV-infected patients from the Cologne–Bonn cohort

Purpose

Causes of death in human immunodeficiency virus (HIV)-infected subjects have changed in countries with high resources over the last several years. Acquired immunodeficiency syndrome (AIDS)-related diseases have become less prevalent, whereas deaths due to non-AIDS causes are increasing. The aim of the present study was to analyse causes of death in the Cologne–Bonn cohort.

Methods

Causes of death from the Cologne–Bonn cohort between 2004 and 2010 were systematically recorded using the CoDe algorithm (The Coding Causes of Death in HIV Project).

Results

In 3,165 patients followed from 2004 to 2010, 182 deaths occurred (5.7 %, 153 males, 29 females). The median age at the time of death was 47 years (range 24–85 years). The most frequent causes of death were AIDS-defining events (n = 60, 33 %), with non-Hodgkin lymphoma (NHL) (n = 29, 16 %) and infections (n = 20, 11 %) being the leading entities in this category. Non-AIDS malignancies accounted for 16 % (n = 29), non-HIV-related infections for 10 % (n = 18), cardiovascular diseases for 7 % (n = 14), suicide or accident for 4 % (n = 7) and liver diseases for 3 % (n = 5) of deaths (unknown n = 47, 26 %). Although the majority of patients (92.5 %) was on antiretroviral therapy (ART), only 50 % were virologically suppressed (HIV-RNA <50 copies/mL) and 44 % had a decreased CD4+ count (<200/μL) at their last visit before death.

Conclusion

One-third of the causes of death in our cohort between 2004 and 2010 was AIDS-related. Since most of these deaths occur with severe immune suppression, they can possibly be prevented by the early diagnosis and treatment of HIV infection. Care providers must be aware of an increased risk for a broad range of diseases in HIV-infected patients and should apply appropriate preventive measures.     

Trends and determinants of severe morbidity in HIV-infected patients: the ANRS CO3 Aquitaine Cohort, 2000-2004

OBJECTIVE: The aim of the study was to characterize the causes, trends and determinants of severe morbidity in a large cohort of HIV-infected patients between 2000 and 2004. METHOD: Severe morbid events were defined as medical events associated with hospitalization or death. Epidemiological and biological data were recorded at the time of the morbid event. Trends were estimated using Poisson regression. RESULTS: Among 3863 individuals followed between 2000 and 2004, 1186 experienced one or more severe events, resulting in 1854 hospitalizations or deaths. The severe events recorded included bacterial infections (21%), AIDS events (20%), psychiatric events (10%), cardiovascular events (9%), digestive events including cirrhosis (7%), viral infections (6%) and non-AIDS cancers (5%). Between 2000 and 2004, the incidence rate of AIDS events decreased from 60 to 20 per 1000 person-years, that of bacterial infections decreased from 45 to 24 per 1000 person-years, and that of psychiatric events decreased from 26 to 14 per 1000 person-years (all P<0.01), whereas the incidences of cardiovascular events and of non-AIDS cancers remained stable at 14 and 10 per 1000 person-years, on average, respectively. CONCLUSION: Severe morbidity has shifted from AIDS-related to non-AIDS-related events during the course of HIV infection in developed countries. Limiting endpoints to AIDS events and death is insufficient to describe HIV disease progression in the era of combination antiretroviral therapy.     

Tuberculosis as primary cause of death among AIDS cases in Rio de Janeiro, Brazil

SETTING: Data from the mortality database, Rio de Janeiro City (RJC) Health Department, Rio de Janeiro, Brazil. OBJECTIVES: To determine the role played by tuberculosis (TB) in Brazil's human immunodeficiency virus (HIV) positive population, we investigated the frequency of TB as the primary cause of death among HIV-positive subjects in RJC. DESIGN: Information about acquired immune-deficiency syndrome (AIDS) deaths from 1996 to 2005 in individuals aged >12 years was obtained from the Mortality Information System (SIM), and the cause of death was classified according to the International Classification of Diseases (ICD-10), through primary causes coded in Chapter I--B20 to B24 (HIV disease). RESULTS: There were 8601 AIDS-related deaths in RJC between 1996 and 2005. TB was the primary cause of death in 9.0% of all AIDS-related deaths, while Pneumocystis carinii pneumonia (PCP) accounted for 4.7%. TB cases erroneously classified under other infectious diseases may have contributed to an underestimation of the number of TB deaths among HIV-positive patients. CONCLUSION: Our study showed that TB is the leading cause of AIDS-related deaths and is responsible for twice as many deaths as PCP, in a scenario of free access to antiretrovirals. The potential benefits of TB preventive treatment and of the availability of highly active antiretroviral treatment could not be established by this analysis.     

HIV感染者/AIDS病人死亡原因的研究进展

近年来,随着越来越多的艾滋病病毒（HIV）感染者进入艾滋病（AIDS）发病期,越来越多的感染者死于AIDS相关疾病。另外,随着抗病毒治疗的覆盖率不断扩大,HIV感染者/AIDS病人死于AIDS相关疾病的比例不断降低,而死于其他非AIDS相关疾病的比例却不断升高。文章就当前国内外对HIV感染者/AIDS病人死亡原因的有关研究进展进行综述,为医疗机构加强和提高对重点疾病的诊疗技术水平提供理论支持,也为中国AIDS死因监测的建立提供理论依据。     

HIV-related malignancies: community-based study using linkage of cancer registry and HIV registry data

For people immunosuppressed by human immunodeficiency virus (HIV), we expect an increase in cancer incidence similar to that documented in transplant patients. We examined the cancer spectrum in an HIV-infected cohort, specifically malignancies not currently associated with acquired immunodeficiency syndrome (AIDS), in relation to the general population. Cancer incidence data for residents of Harris County, Texas, diagnosed between 1975 and 1994, were linked to HIV/AIDS registry data by Soundex code and date of birth to identify malignancies in an HIV-infected cohort of 14,986 persons. Incidence of cancer in this cohort was compared to the general population by standardized incidence ratio (SIR) analysis. From the HIV-infected cohort, 2289 persons (15%) were identified as having one or more malignancies, with 97% occurring in males. The linkage alone identified 29.5% of the malignancies, of which only 28.7% were diagnosed in males. Adjusting for age, HIV-infected men and women had incidences of cancer that were 16.7 [95% confidence interval (CI) 16.1-17.3] and 2.9 (95% CI 2.3-3.7) times that expected for the general population of Harris County, Texas. Besides Kaposi's sarcoma, non-Hodgkin's lymphoma, cervix cancer and brain lymphoma, non-AIDS related malignancies of Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females, exhibited significant SIRs of 5.6 (95% CI 3.6-8.4), 6.9 (95% CI 4.8-9.5) and 4.0 (95% CI 1.1-10.2). Increased incidences of lung, prostate and breast malignancies were not seen in this HIV cohort. Persons infected with HIV appear to be at increased risk for the non-AIDS related malignancies, Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females.     

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.     

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.     

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。     

Causes of death among HIV-infected patients in the era of highly active antiretroviral therapy,Bordeaux, France, 1998-1999

Objectives

To describe the causes of death in HIV‐infected patients in the era of highly active antiretroviral therapy (HAART).

Method

A retrospective survey conducted in Bordeaux, France. Medical records of all deaths that had occurred in 1998 and 1999 amongst patients followed within the Aquitaine cohort were reviewed by the same physician. Immediate and underlying causes of death were described, taking into account the morbidity at the time of death.

Results

Sixty‐six deaths occurred in 1998, and 41 in 1999. Sixty‐seven per cent of deceased patients were male. Median age at time of death was 43 years (range 25–71), median CD4 was 162 cells/µL (0–957); 28% of patients had a CD4 count > 200 cells/µL and 7% plasma viral load < 500 HIV‐RNA copies/mL. Amongst morbidity present at the time of death, there were 23 bacterial infections, 16 non‐Hodgkin's lymphomas, 16 cirrhoses, 15 non HIV‐related malignancies, 13 central nervous system diseases and 10 myocardiopathies. The main immediate causes of death were: multiple organ failure (21%), coma (18%), septic shock (15%) and acute respiratory failure (14%). Underlying causes of death were AIDS‐defining events (48%), non AIDS HIV‐related infection (3%), hepatitis B‐ or C‐associated cirrhosis (14%), non HIV‐related malignancies (11%), cardiovascular events (10%), suicide and overdose (6%), treatment‐related fatalities (4%), injury (2%) and unknown (2%). Patients dying from AIDS‐related events were more often female, had a lower CD4 count, a higher level of HIV‐RNA, a shorter history of HIV infection and were less often coinfected with hepatitis B and C viruses than those dying from other underlying causes.

Conclusions

AIDS‐related events are no longer the major causes of death of HIV‐infected patients in the era of HAART. This evolving mortality pattern justifies an adaptation of both the epidemiological surveillance and the clinical monitoring of HIV‐infected patients.

     

AIDS and non-AIDS-related malignancies: a new vexing challenge in HIV-positive patients. Part II. Cervical and anal squamous epithelial lesions, lung cancer, testicular germ cell cancers, and skin cancers

As the AIDS epidemic progresses, more and more HIV-infected patients will develop malignancies. The natural history of a malignancy may change dramatically in the presence of HIV infection. Among the AIDS and non-AIDS malignancies, the most frequently reported solid tumors are cervical and anal cancer, testicular germ cell tumors, lung cancer, and skin cancer. Regardless of epidemiology and outcome, the natural history of the majority of non-AIDS-defining tumors changes in the setting of HIV infection. Physicians who treat patients with AIDS and non-AIDS-related cancers need to become familiar with antiretroviral agents, drug-drug interactions, and the prophylaxis and management of opportunistic infections.     

Main causes of death in cirrhosis

The main causes of 436 deaths among 532 patients with cirrhosis followed up for up to 16 years constituted liver failure (24%), liver failure with gastrointestinal bleeding (13%), gastrointestinal bleeding (14%), primary liver cell carcinoma (4%), other liver-related causes (2%), infections (7%), cardiovascular diseases (22%), extrahepatic malignancies (9%), and other non-liver-related causes (5%). Totally, 57% died of liver-related causes. A high frequency of liver-related death was found among patients with a short observation time, high biochemical activity, pronounced change in liver architecture, ascites, and other signs of a poor prognosis at the time of diagnosis. The findings favoured the hypothesis that cirrhosis of the liver is a disease with an initial active and a subsequent inactive phase. Half of the patients were treated with prednisone, but this had no detectable influence on the distribution of causes of or on the frequency of single causes of death as infections or gastrointestinal bleeding. The group of patients responding favourably to prednisone treatment with regard to survival (non-alcoholic women without ascites) showed causes of death not different from those of the total material.     

Riesgo de cáncer en personas con VIH en España, 2004-2015. Estudio de la cohorte CoRIS

IntroductionCancer is a leading cause of death in individuals with HIV.MethodsThe incidence of cancer in HIV patients of the CoRIS cohort in the 2004-2009 and 2010-2015 periods has been analysed and compared to the incidence in the Spanish general population, estimated from data of the Spanish Cancer Registry Network.ResultsBetween January 2004 and November 2015, 12,239 patients were included in CoRIS and 338 incident cancer cases were diagnosed. The overall incidence of cancer per 100,000 persons-year (95% CI) was 702.39 (629.51-781.42) with no significant differences between the 2 periods. A 38% of the incident cancer cases were AIDS defining cancers (ADC) and 62% non-AIDS defining cancers (NADC). In the period 2010-2015, there was a significant decrease in the incidence of ADC (standardised incidence ratio [SIR]); 95% CI: 0.38; 0.21-0.66) and NADC predominated. Compared to the general population, the incidence of cancer was double in men with HIV. Higher relative risks were documented (SIR; 95% CI) for Hodgkin's lymphoma in both sexes (males: 8.37, 5.13-14.17; females: 21.83, 2.66-47.79), non-Hodgkin's lymphoma in males (5.30, 2.86-8.45) and cervical cancer (7.43, 3.15-13.87) and head and neck cancer (3.28, 1.21-5.82) in women.ConclusionsThe overall incidence of cancer in individuals with HIV is higher than in the Spanish general population, and it has remained stable since 2004 with a current predominance of NADC. These data suggest that additional efforts should be made in the prevention and the early detection of cancer in these patients.     

河南省部分艾滋病高流行村庄居民死亡状况调查

目的了解艾滋病(AIDS)相关死亡的变化趋势,以及艾滋病相关死亡对当地死亡状况造成的影响。方法采用回顾性调查的方法,对河南省驻马店市上蔡县7个行政村,1995年1月1日-2007年10月31日,所有死亡者进行名单摸底、入户调查和死因推断,分析死亡构成及变化。结果共计死亡2546人,其中艾滋病病毒感染者(HIV)/AIDS死亡521例(20.5%),疑似AIDS死亡525例(20.6%),非AIDS死亡1500例(58.9%)。30～49岁青壮年死亡人数的比例,从1995-1997年的15%上升到1998年的21.5%,在2002年达到42.3%,之后逐年下降,到2007年为25.5%。30～49岁年龄组HIV/AIDS死亡者和疑似AIDS死亡者,分别占该组死亡人数的59.7%和59.8%。全人群死亡率在1995-1999年为7‰左右,在2002年出现高峰,为14.9‰。结论艾滋病和疑似艾滋病的死亡,成为当地死亡的主要原因,尤其是青壮年的死亡。     

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.     

Causes of death in patients with rheumatoid arthritis autopsied during a 40-year period

We studied causes of death (CoDs) between 1952 and 1991 assessed by a clinician before autopsy and then determined at autopsy by a pathologist in 369 subjects with rheumatoid arthritis (RA) and 370 subjects without RA (non-RA). We analysed clinical data for RA subjects between 1973 and 1991. In RA subjects, leading autopsy-based CoDs were RA, cardiovascular diseases and infections. Between diagnoses of CoDs by the clinician and those determined by the pathologist, RA subjects had lower agreement than did the non-RA regarding coronary deaths (Kappa reliability measure: 0.33 vs. 0.46). In non-RA subjects, autopsy-based coronary deaths showed a decline since the 1970s with no such decline in RA. Between subjects treated at any time during RA with disease-modifying anti-rheumatic drugs and those without, autopsy-based CoDs were similar. Coronary death being less accurately diagnosed in RA subjects may indicate that coronary heart disease in RA patients often remains unrecognized.     

1997--2011年昆明市HIV感染者和AIDS病人死亡情况分析

目的分析昆明市艾滋病病毒（HIV）感染者和艾滋病（AIDS）病人（简称HIV/AIDS病人）死亡情况。方法从＂国家艾滋病综合防治数据信息系统＂中下载历史卡片,按录入日期选择2011年12月31日前现住址为昆明市的死亡病例进行分析。结果至2011年底,累计报告现住址为昆明市的HIV/AIDS死亡病例851例,其中男性占78.5%,汉族占91.1%,已婚有配偶的占42.5%,初中文化程度占43.1%,农民和家政/家务和待业的分别占37.0%和34.7%。平均死亡年龄（40.2±12.2）岁,71.0%的死亡年龄在25～44岁间。因AIDS、非AIDS其他疾病、吸毒过量、其他原因而死亡的分别占47.7%、23.1%、9.2%、6.2%,还有13.7%的死亡原因不详。HIV确认阳性后存活时间的中位数只有1.1年,确认阳性后1年内死亡的比例达47.9%。结论近几年昆明市HIV/AIDS死亡病例数逐年增加,AIDS已经成为主要的死亡原因;死亡原因的报告质量急需提高;病例发现晚,急需扩大HIV检测覆盖面。     

Cutaneous manifestations of human immunodeficiency virus infection in Taiwan

Cutaneous manifestations are common and often the presenting feature of human immunodeficiency virus (HIV) infection, but a comprehensive study of HIV-associated skin lesions is not available in Taiwan. We reviewed all skin lesions in all HIV patients diagnosed in our department between 1990 and 1998 to document the spectrum of skin manifestations, the frequency of each disorder, and their relationship with CD4 counts. A total of 64 HIV patients were studied, including 38 with acquired immunodeficiency syndrome (AIDS) (CD4 < 200 x 10(6) cells/L) and 26 who had not developed AIDS (non-AIDS). There were 142 episodes of skin conditions representing 25 different skin diseases, including oral candidiasis (15% in non-AIDS vs 71% in AIDS patients), drug eruptions, herpes simplex, seborrheic dermatitis, dermatophytosis, herpes zoster, secondary syphilis, condyloma acuminatum, Kaposi's sarcoma (16% among AIDS patients), hairy leukoplakia, and molluscum contagiosum (13% among AIDS patients), in decreasing order. Several unusual cases are briefly described, including verrucous herpes infection, condyloma-like molluscum contagiosum, and AIDS-associated pigmented erythroderma. In our study, 70% of all HIV patients had skin diseases, with an average of 2.2 conditions per patient (3.2 in AIDS patients vs 0.7 in non-AIDS patients; p < 0.001). A broad spectrum of HIV-associated skin diseases was observed in our series. The frequency of HIV-associated skin disease was 92% in AIDS patients and 39% in non-AIDS patients; 78% of skin lesions in AIDS patients were diagnosed when CD4 counts were below 100 x 10(6) cells/L.