Prospective Cohort Study

To investigate any emerging trends in causes of death amongst HIV-positive individuals in the current cART era, and to investigate the factors associated with each specific cause of death.

Factors associated with specific causes of death amongst HIV-positive individuals in the D:A:D Study.

Background: Few studies have monitored late presentation (LP) of HIV infection over the European continent, including Eastern Europe. Study objectives were to explore the impact of LP on AIDS and mortality. Methods and Findings: LP was defined in Collaboration of Observational HIV Epidemiological Research Europe (COHERE) as HIV diagnosis with a CD4 count ,350/mm 3 or an AIDS diagnosis within 6 months of HIV diagnosis among persons presenting for care between 1 January 2000 and 30 June 2011. Logistic regression was used to identify factors associated with LP and Poisson regression to explore the impact on AIDS/death. 84,524 individuals from 23 cohorts in 35 countries contributed data; 45,488 were LP (53.8%). LP was highest in heterosexual males (66.1%), Southern European countries (57.0%), and persons originating from Africa (65.1%). LP decreased from 57.3% in 2000 to 51.7% in 2010/2011 (adjusted odds ratio [aOR] 0.96; 95% CI 0.95–0.97). LP decreased over time in both Central and Northern Europe among homosexual men, and male and female heterosexuals, but increased over time for female heterosexuals and male intravenous drug users (IDUs) from Southern Europe and in male and female IDUs from Eastern Europe. 8,187 AIDS/deaths occurred during 327,003 person-years of follow-up. In the first year after HIV diagnosis, LP was associated with over a 13-fold increased incidence of AIDS/death in Southern Europe (adjusted incidence rate ratio [aIRR] 13.02; 95% CI 8.19–20.70) and over a 6-fold increased rate in Eastern Europe (aIRR 6.64; 95% CI 3.55–12.43). Conclusions: LP has decreased over time across Europe, but remains a significant issue in the region in all HIV exposure groups. LP increased in male IDUs and female heterosexuals from Southern Europe and IDUs in Eastern Europe. LP was associated with an increased rate of AIDS/deaths, particularly in the first year after HIV diagnosis, with significant variation across Europe. Earlier and more widespread testing, timely referrals after testing positive, and improved retention in care strategies are required to further reduce the incidence of LP. Please see later in the article for the Editors’ Summary.

/pdf/risk-factors-and-outcomes-for-late-presentation-for-hiv-12kdl4qt40.pdf

Risk Factors and Outcomes for Late Presentation for HIV-Positive Persons in Europe: Results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE).

OBJECTIVE: To evaluate deaths from AIDS-defining malignancies (ADM) and non-AIDS-defining malignancies (nADM) in the D:A:D Study and to investigate the relationship between these deaths and immunodeficiency. DESIGN: Observational cohort study. METHODS: Patients (23 437) were followed prospectively for 104 921 person-years. We used Poisson regression models to identify factors independently associated with deaths from ADM and nADM. Analyses of factors associated with mortality due to nADM were repeated after excluding nADM known to be associated with a specific risk factor. RESULTS: Three hundred five patients died due to a malignancy, 298 prior to the cutoff for this analysis (ADM: n = 110; nADM: n = 188). The mortality rate due to ADM decreased from 20.1/1000 person-years of follow-up [95% confidence interval (CI) 14.4, 25.9] when the most recent CD4 cell count was <50 cells/microl to 0.1 (0.03, 0.3)/1000 person-years of follow-up when the CD4 cell count was more than 500 cells/microl; the mortality rate from nADM decreased from 6.0 (95% CI 3.3, 10.1) to 0.6 (0.4, 0.8) per 1000 person-years of follow-up between these two CD4 cell count strata. In multivariable regression analyses, a two-fold higher latest CD4 cell count was associated with a halving of the risk of ADM mortality. Other predictors of an increased risk of ADM mortality were homosexual risk group, older age, a previous (non-malignancy) AIDS diagnosis and earlier calendar years. Predictors of an increased risk of nADM mortality included lower CD4 cell count, older age, current/ex-smoking status, longer cumulative exposure to combination antiretroviral therapy, active hepatitis B infection and earlier calendar year. CONCLUSION: The severity of immunosuppression is predictive of death from both ADM and nADM in HIV-infected populations.

https://www.zora.uzh.ch/id/eprint/11229/2/picrender_V.pdf

HIV-induced immunodeficiency and mortality from AIDS-defining and non-AIDS-defining malignancies.

Table of Contents

1. Levels of evidence	
1.1 Reference	
2. Introduction	
3. Auditable targets	
4. Table summaries	
4.1 Initial diagnosis	
4.2 Assessment of ART-naive individuals	
4.3 ART initiation	
4.4 Initial assessment following commencement of ART	
4.5 Routine monitoring on ART	
4.6 References	
5. Newly diagnosed and transferring HIV-positive individuals	
5.1 Initial HIV-1 diagnosis	
5.2 Tests to determine whether acquisition of HIV infection is recent	
5.3 Individuals transferring care from a different HIV healthcare setting	
5.4 Communication with general practitioners and shared care	
5.5 Recommendations	
5.6 References	
6. Patient history	
6.1 Initial HIV-1 diagnosis	
6.2 Monitoring of ART-naive patients	
6.3 Pre-ART initiation assessment	
6.4 Monitoring individuals established on ART	
6.5 Assessment of adherence	
6.6 Recommendations	
6.7 References	
7. Examination	
7.1 Recommendations	
8. Identifying the need for psychological support	
8.1 References	
9. Assessment of immune status	
9.1 CD4 T cell counts	
9.2 CD4 T cell percentage	
9.3 References	
10. HIV viral load	
10.1 Initial diagnosis/ART naive	
10.2 Post ART initiation	
10.3 Individuals established on ART	
10.4 Recommendations	
10.5 References	
11. Technical aspects of viral load testing	
11.1 References	
12. Viral load kinetics during ART and viral load ‘blips’	
12.1 References	
13. Proviral DNA load	
13.1 References	
14. Resistance testing	
14.1 Initial HIV-1 diagnosis	
14.2 ART-naive	
14.3 Post treatment initiation	
14.4 ART-experienced	
14.5 References	
15. Subtype determination	
15.1 Disease progression	
15.2 Transmission	
15.3 Performance of molecular diagnostic assays	
15.4 Response to therapy	
15.5 Development of drug resistance	
15.6 References	
16. Other tests to guide use of specific antiretroviral agents	
16.1 Tropism testing	
16.2 HLA B*5701 testing	
16.3 References	
17. Therapeutic drug monitoring	
17.1 Recommendations	
17.2 References	
18. Biochemistry testing	
18.1 Introduction	
18.2 Liver function	
18.3 Renal function	
18.4 Dyslipidaemia in HIV-infected individuals	
18.5 Other biomarkers	
18.6 Bone disease in HIV-infected patients	
18.7 References	
19. Haematology	
19.1 Haematological assessment and monitoring	
19.2 Recommendations	
19.3 References	
20. Serology	
20.1 Overview	
20.2 Hepatitis viruses	
20.3 Herpes viruses	
20.4 Measles and rubella	
20.5 Cytomegalovirus (CMV)	
20.6 References	
21. Other microbiological screening	
21.1 Tuberculosis screening	
21.2 Toxoplasma serology	
21.3 Tropical screening	
21.4 References	
22. Sexual health screening including anal and cervical cytology	
22.1 Sexual history taking, counselling and sexually transmitted infection (STI) screening	
22.2 Cervical and anal cytology	
22.3 Recommendations	
22.4 References	
23. Routine monitoring recommended for specific patient groups	
23.1 Women	
23.2 Older age	
23.3 Injecting drug users	
23.4 Individuals coinfected with HBV and HCV	
23.5 Late presenters	
23.6 References	
Appendix

/pdf/british-hiv-association-guidelines-for-the-routine-25qp2zxz94.pdf

British HIV Association guidelines for the routine investigation and monitoring of adult HIV‐1‐infected individuals 2011

Objectives Across Europe, almost a third of individuals infected with HIV do not enter health care until late in the course of their infection. Surveillance to identify the extent to which late presentation occurs remains inadequate across Europe and is further complicated by the lack of a common clinical definition of late presentation. The objective of this article is to present a consensus definition of late presentation of HIV infection.

Methods Over the past year, two initiatives have moved towards a harmonized definition. In spring 2009, they joined efforts to identify a common definition of what is meant by a ‘late-presenting’ patient.

Results Two definitions were agreed upon, as follows. Late presentation: persons presenting for care with a CD4 count below 350 cells/μL or presenting with an AIDS-defining event, regardless of the CD4 cell count. Presentation with advanced HIV disease: persons presenting for care with a CD4 count below 200 cells/μL or presenting with an AIDS-defining event, regardless of the CD4 cell count.

Conclusion The European Late Presenter Consensus working group believe it would be beneficial if all national health agencies, institutions, and researchers were able to implement this definition (either on its own or alongside their own preferred definition) when reporting surveillance or research data relating to late presentation of HIV infection.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-1293.2010.00857.x

Late presentation of HIV infection: a consensus definition

Pilot of the CoDe (Coding of Death) Project: A Standardized approach to code causes of death in HIV Infected individuals

Months from HA measurement P=0.0052 Hyaluronic Acid as a Prognostic Marker of Hepatic Encephalopathy and Liver-related Death in HIV/Viral Hepatitis Coinfected Patients L Peters1, A Mocroft2, V Soriano3, J Rockstroh4, B Ledergerber5, A Karlsson6, B Knysz7, C Pradier8, K Zilmer9, JD Lundgren1, 10, for the EuroSIDA study group. 1Copenhagen HIV Programme, University of Copenhagen, Denmark, 2University College Medical School, Royal Free Campus, London, UK, 3Hospital Carlos III, Madrid, Spain, 4University of Bonn, Germany, 5University Hospital Zurich, Switzerland, 6Venhalsan, Sodersjukhuset, Stockholm, Sweden, 5Department of Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland 8CHU Nice Hopital de l Archet 1, Nice, France, 9West-Tallin Central Hospital, Tallinn, Estonia, 10Centre for Viral Disease/KMA, Rigshospitalet, Copenhagen, Denmark

M. Ellefson

Papers

Late presentation of HIV infection: a consensus definition

Pilot of the CoDe (Coding of Death) Project: A Standardized approach to code causes of death in HIV Infected individuals

Hyaluronic Acid as a Prognostic Marker of Hepatic Encephalopathy and Liver-related Death in HIV/Viral Hepatitis Coinfected Patients