Acquired Immunodeficiency Syndrome Deaths Research Articles

PREVALENCE OF DEATHS IN ELDERLY PEOPLE WITH ACQUIRED HUMAN IMMUNODEFICIENCY SYNDROME IN THE NORTHEAST REGION

Acquired Immunodeficiency Syndrome (AIDS) is a disease of the immune system caused by the retrovirus HIV ― from English, Human Immunodeficiency Virus and the present study aims to analyze the prevalence and cases of AIDS deaths in the elderly population in the Northeastern state, from 2015 to 2019. This is a descriptive study obtained from the Health Information System provided by TABNET, referring to elderly people with HIV/AIDS, who were notified in the northeast region in the period from 2015 to 2017. Thus, in the years 2015 and 2017, there were 76 deaths from the Human Immunodeficiency Virus (HIV) reported in the Northeast region of Brazil. Of these, 22 cases of deaths were related to the elderly population of Bahia, and the State of Alagoas had the lowest number, just 2 deaths. Regarding AIDS cases identified in the Northeast state, from 2015 to 2019, 1,204 cases of AIDS were reported. Absolutely, the states that reported the most were Bahia (233 cases), Pernambuco (224 cases), Maranhão (190 cases) and Ceará (185 cases). Based on above considerations, prevention campaigns aimed only at the elderly population, health professionals and caregivers unprepared are necessary to provide information regarding sexuality and sexual practices for elderly people in the Federative Units and regions.

Application of random survival forest for competing risks in prediction of cumulative incidence function for progression to AIDS

Objective: There has remained a need to better understanding of prognostic factors that affect the survival or risk in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in developing countries. The aim of the present study aimed to identify the prognostic factors influencing AIDS progression in HIV positive patients in Hamadan province of Iran, using random survival forest in the presence of competing risks (death from causes not related to AIDS). This method considers all interactions between variables and their nonlinear effects.
 Method(s): A data set of 585 HIV-infected patients extracted from 1997 to 2011 was utilized. The effect of several prognostic factors on cumulative incidence function (probability) of AIDS progression and death were investigated.
 Result: The used model indicated that using antiretroviral therapy tuberculosis co-infection are two top most important variables in predicting cumulative incidence function for AIDS progression in the presence of competing risks, respectively. The patients with tuberculosis had much higher predicted cumulative incidence probability. Predicted cumulative incidence probability of AIDS progression was also higher for mother to child mode of HIV transmission. Moreover, transmission type and gender were two top most important variables for the competing event. Men and those patients with IDUS transmission mode had higher predicted risk compared to others.
 Conclusion: Considering nonlinear effects and interaction between variables, confection with tuberculosis was the most important variable in prediction of cumulative incidence probability of AIDS progression.

IMPACT OF EDUCATION ON KNOWLEDGE AND ATTITUDES TOWARDS HUMAN IMMUNODEFICIENCY VIRUS AMONG MEDICAL AND TECHNICAL STUDENTS IN AL-AFAQ COLLEGE OF SCIENCE, SANA'A CITY, YEMEN.

Acquired immunodeficiency syndrome (AIDS) is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV). . HIV is a sexually transmitted infection (STI), it suppress the immune system and interferes with the ability of body to fight against infection and disease. There's no cure for HIV/AIDS, but medications can dramatically slow the progression of the disease. These drugs have ability to reduce AIDS deaths in many developed nations. A number of knowledge, attitude, and practice studies conducted in different parts of world reveal widespread misconceptions about the disease among young people. Medical students are the budding doctors of tomorrow and have just entered the noble profession.
 Thus, there is a need to assess impact of education on knowledge and attitudes towards HIV/AIDS among students. The results of this study showed that the education had an effect on the students who participating; It also helped increase knowledge and change misconceptions about the disease.

Underreporting of AIDS deaths in Brazil: linkage of hospital records with death certificate data.

This study investigated the underreporting of deaths due to Acquired Immunodeficiency Syndrome (AIDS) in Brazil, using the product of the linkage between the Mortality Information System (SIM) and the Hospital Information System (SIH) for the years 2008 to 2012. The hypothesis was that there were deaths recorded in the SIM that should have AIDS as the underlying cause of death, but that had been poorly classified. Many of the decedents had previous hospitalizations due to the illness. Underreported AIDS deaths were defined taking into account the coding rules of the International Classification of Diseases 10th Revision, in order to discriminate AIDS deaths from those due to other causes in people living with HIV / AIDS. In this period, 60,362 deceased had AIDS as the underlying cause, and we found another 2,671 (4.2%) as underreported causes. Underreported deaths increased the average AIDS mortality rate from 6.3/100,000 to 6.6/100,000. In conclusion, this study demonstrated that, through linkage in between SIH and SIM, it is possible to find underreporting of AIDS deaths in Brazil. These results serve as a warning for the need for actions that would promote a better certification of the causes of death among AIDS patients.

LEVANTAMENTO EPIDEMIOLÓGICO DO HIV/AIDS NO MUNICÍPIO DE PARNAÍBA-PI, BRASIL, 1990-2018

Objetivo: Descrever o perfil epidemiológico de HIV/AIDS no município de Parnaíba-PI, no período de 1980-2018. Métodos: Estudo descritivo, tipo seccional, realizado a partir de dados notificados no Sistema de Informação de Agravos de Notificação (SINAN), declarados no Sistema de Informações de Mortalidade (SIM). Resultados: Foram registrados 354 casos da Síndrome da Imunodeficiência Adquirida (AIDS) no município. Acerca da variável raça/cor, pode-se observar uma maior prevalência de registros na população parda 61,5% (N=134) seguida da raça branca 12,4% (N=27). Em relação à escolaridade evidenciou-se o nível fundamental incompleto 36,2% (N=79). Outro fator relevante diz respeito ao número de gestantes cerca de 12% (N=15) das mulheres da amostra. Acerca dos óbitos por AIDS, entre os anos de 1996 a 2018 foram registrados o número total de 28% (N=96) no período. Conclusão: O estudo permitiu discussões sobre o perfil epidemiológico de HIV/AIDS no município de Parnaíba-PI, concluiu-se a necessidade de avanços nas políticas públicas voltadas para esse público, como a melhoria da qualificação desses indicadores, investimento na qualificação dos profissionais, para que haja redução da morbimortalidade por esse agravo.

Identifying risk factors for progression to AIDS and mortality post-HIV infection using illness-death multistate model

BackgroundThere has remained a need to better understanding of prognostic factors that affect the survival or risk in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in developing countries. The aim of the present study aimed to identify the prognostic factors influencing AIDS progression in HIV positive patients in Hamadan province of Iran, using random survival forest in the presence of competing risks (death from causes not related to AIDS). This method considers all interactions between variables and their nonlinear effects. MethodsA data set of 585 HIV-infected patients extracted from 1997 to 2011 was utilized. The effect of several prognostic factors on cumulative incidence function (probability) of AIDS progression and death were investigated. ResultsThe used model indicated that using antiretroviral therapy tuberculosis co-infection are two top most important variables in predicting cumulative incidence function for AIDS progression in the presence of competing risks, respectively. The patients with tuberculosis had much higher predicted cumulative incidence probability. Predicted cumulative incidence probability of AIDS progression was also higher for mother to child mode of HIV transmission. Moreover, transmission type and gender were two top most important variables for the competing event. Men and those patients with IDUS transmission mode had higher predicted risk compared to others. ConclusionsConsidering nonlinear effects and interaction between variables, confection with tuberculosis was the most important variable in prediction of cumulative incidence probability of AIDS progression.

Predictors of progression to AIDS and mortality post-HIV infection: a long-term retrospective cohort study

This study was conducted to better understand the prognostic factors influencing the disease progression and mortality in patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in a high–middle-income country. This registry-based retrospective cohort study was conducted in Tehran from April 2004 to March 2014. We enrolled 2473 HIV-infected patients who had a medical record in Behavioral Diseases Counseling Centers. The outcomes of interest were the estimation of time: (1) from HIV diagnosis to AIDS progression and (2) from AIDS to AIDS-related death. The 1-year, 5-year, and 10-year probability of disease progression from HIV diagnosis to AIDS was 45.0%, 69.9%, and 90.4%, and that of AIDS-related death was 17.2%, 30.3%, and 39.2%, respectively. Multivariate Cox regression analysis indicated that AIDS progression was significantly associated with male sex (P = 0.022), an increase in age (P = 0.001), low educational levels (P = 0.001), and a decreased level of CD4 cell count (P = 0.001). Furthermore, the AIDS-related mortality was significantly associated with male sex (P = 0.010), tuberculosis coinfection (P = 0.001), and antiretroviral therapy (P = 0.001). The results of this study indicated that progression to AIDS and AIDS-related death is affected by several modifiable and non-modifiable predictors. We indicated that a substantial proportion of the HIV-positive people were unaware of their status and were diagnosed very late. This hidden source of HIV infection had the opportunity to transmit the infection to other people.

Trends in AIDS Deaths, New Infections and ART Coverage in the Top 30 Countries with the Highest AIDS Mortality Burden; 1990-2013.

BackgroundAntiretroviral therapy (ART) prevents human immunodeficiency virus (HIV) disease progression, mortality and transmission. We assess the impact of expanded HIV treatment for the prevention of Acquired Immunodeficiency Syndrome (AIDS)-related deaths and simulate four treatment scenarios for Nigeria and South Africa.MethodsFor 1990–2013, we used the Joint United Nations Programme on HIV/AIDS (UNAIDS) database to examine trends in AIDS deaths, HIV incidence and prevalence, ART coverage, annual AIDS death rate, AIDS death-to-treatment and HIV infections to treatment ratios for the top 30 countries with the highest AIDS mortality burden and compare them with data from high-income countries. We projected the 1990–2020 AIDS deaths for Nigeria and South Africa using four treatment scenarios: 1) no ART; 2) maintaining current ART coverage; 3) 90% ART coverage based on 2013 World Health Organization (WHO) ART guidelines by 2020; and 4) reaching the United Nations 90-90-90 Target by 2020.FindingsIn 2013, there were 1.3 million (1.1 million–1.6 million) AIDS deaths in the top 30 countries representing 87% of global AIDS deaths. Eight countries accounted for 58% of the global AIDS deaths; Nigeria and South Africa accounted for 27% of global AIDS deaths. The highest death rates per 1000 people living with HIV were in Central African Republic (91), South Sudan (82), Côte d’Ivoire (75), Cameroon (72) and Chad (71), nearly 8–10 times higher than the high-income countries. ART access in 2013 has averted as estimated 1,051,354 and 422,448 deaths in South Africa and Nigeria, respectively. Increasing ART coverage in these two countries to meet the proposed UN 90-90-90 Target by 2020 could avert 2.2 and 1.2 million deaths, respectively.InterpretationOver the past decade the expansion of access to ART averted millions of deaths. Reaching the proposed UN 90-90-90 Target by 2020 will prevent additional morbidity, mortality and HIV transmission. Despite progress, high-burden countries will need to accelerate access to ART treatment to avert millions of premature AIDS deaths and new HIV infections.

Migration patterns among Floridians with AIDS, 1993-2007: implications for HIV prevention and care.

To characterize migration patterns among people diagnosed as having and who died of acquired immunodeficiency syndrome (AIDS) from 1993 to 2007 because migrating to a new community can disrupt human immunodeficiency virus/AIDS care delivery and patients' adherence to care and affect migrants' social services and healthcare needs. Florida AIDS surveillance data were used to describe patterns of migration among people diagnosed as having and who died of AIDS from 1993 to 2007. Individual and community characteristics were compared between residence at the time of AIDS diagnosis and residence at the time of death by type of migration. Of 31,816 people in the cohort, 2510 (7.9%) migrated to another county in Florida and 1306 (4.1%) migrated to another state. Interstate migrants were more likely to be men, 20 to 39 years old, non-Hispanic white, and born in the United States, to have had a transmission mode of injection drug use (IDU) or men who have sex with men with IDU (MSM&IDU), and to have been diagnosed before 1999. Intercounty migrants were more likely to be non-Hispanic white, younger than 60 years, have had a transmission mode of MSM, IDU, or MSM&IDU, have higher CD4 counts/percentages, and to have lived in areas with low levels of poverty or low physician density. There was a small net movement from urban to rural areas within the state. A sizable percentage of people, particularly younger people and people with a transmission mode of IDU and IDU&MSM, migrated at least once between the time of their AIDS diagnosis and death. This has important implications for care and treatment, as well as efforts to prevent the disease. Further research is needed to explore barriers and facilitators to access to care upon migration and to assess the need for programs to help people transfer their human immunodeficiency virus/AIDS care, ensuring continuity of care and adherence.

Effect of Left Ventricular Dysfunction and Viral Load on Risk of Sudden Cardiac Death in Patients With Human Immunodeficiency Virus

Human immunodeficiency virus (HIV)-infected patients are disproportionately affected by cardiovascular disease and sudden cardiac death (SCD). Whether left ventricular (LV) dysfunction predicts SCD in those with HIV is unknown. We sought to determine the impact of LV dysfunction on SCD in patients with HIV. We previously characterized all SCDs and acquired immunodeficiency syndrome (AIDS) deaths in 2,860 consecutive patients in a public HIV clinic from 2000 to 2009. Transthoracic echocardiograms (TTEs) performed during the study period were identified. The effect of ejection fraction (EF), diastolic dysfunction, pulmonary artery pressure, and LV mass on SCD and AIDS death were evaluated: 423 patients had at least 1 TTE; 13 SCDs and 55 AIDS deaths had at least 1 TTE. In the propensity-adjusted analysis, EF 30% to 39% and EF<30% predicted SCD (hazard ratio [HR] 9.5, 95% confidence interval [CI] 1.7 to 53.3, p=0.01 and HR 38.5, 95% CI 7.6 to 195.0, p<0.001, respectively) but not AIDS death. Diastolic dysfunction also predicted SCD (HR 14.8, 95% CI 4.0 to 55.4, p<0.001) but not AIDS death, even after adjusting for EF. The association between EF<40% and SCD was greater in subjects with detectable versus undetectable HIV RNA (adjusted HR 11.7, 95% CI 2.9 to 47.2, p=0.001 vs HR 2.7, 95% CI 0.3 to 27.6, p=0.41; p=0.07 for interaction). In conclusion, LV systolic dysfunction and diastolic dysfunction predict SCD but not AIDS death in a large HIV cohort, with greater effect in those with detectable HIV RNA. Further investigation is needed to thoroughly evaluate the effect of low EF and HIV factors on SCD incidence and the potential benefit of implantable cardioverter-defibrillator therapy in this high-risk population.

Biological, behavioral, and socioeconomic factors associated with death from AIDS in Brasília, Brazil, in 2007

In the jurisdiction of Brasília, Brazil, significant reductions in mortality rates and lethality resulting from acquired immunodeficiency syndrome (AIDS) were observed shortly after the introduction of highly active antiretroviral therapy. In recent years, however, the decline of these rates has not been as significant. Non-adherence to treatment and delayed diagnosis appear to be the main factors that increase the risk of death from AIDS. Behavioral, socioeconomic, and biological factors could also be associated with increased risk of death due to AIDS. This study aimed to identify which of these factors were associated with deaths from AIDS in Brasília. A case-control study was undertaken using the data recorded in the Information System of Notifiable Diseases. Cases consisted of AIDS deaths occurring in 2007, residing in Brasília, and over 12 years of age. Controls consisted of AIDS patients who did not die until December 31 2007, also residing in Brasília, and over 12 years of age. For each group, frequency and proportion tables for the variables were prepared. The statistical association of each factor in isolation with the occurrence of the deaths was verified through a model of multivariate analysis using logistic regression. The factors that were associated with an increased risk of death were intravenous drug use, age 50 years or more, and residing in a region whose residents have low per capita income. We identified factors associated with death due to AIDS that can guide health planning.

Marginal Structural Models for Case-Cohort Study Designs to Estimate the Association of Antiretroviral Therapy Initiation With Incident AIDS or Death

To estimate the association of antiretroviral therapy initiation with incident acquired immunodeficiency syndrome (AIDS) or death while accounting for time-varying confounding in a cost-efficient manner, the authors combined a case-cohort study design with inverse probability-weighted estimation of a marginal structural Cox proportional hazards model. A total of 950 adults who were positive for human immunodeficiency virus type 1 were followed in 2 US cohort studies between 1995 and 2007. In the full cohort, 211 AIDS cases or deaths occurred during 4,456 person-years. In an illustrative 20% random subcohort of 190 participants, 41 AIDS cases or deaths occurred during 861 person-years. Accounting for measured confounders and determinants of dropout by inverse probability weighting, the full cohort hazard ratio was 0.41 (95% confidence interval: 0.26, 0.65) and the case-cohort hazard ratio was 0.47 (95% confidence interval: 0.26, 0.83). Standard multivariable-adjusted hazard ratios were closer to the null, regardless of study design. The precision lost with the case-cohort design was modest given the cost savings. Results from Monte Carlo simulations demonstrated that the proposed approach yields approximately unbiased estimates of the hazard ratio with appropriate confidence interval coverage. Marginal structural model analysis of case-cohort study designs provides a cost-efficient design coupled with an accurate analytic method for research settings in which there is time-varying confounding.

AIDS Morbidity and Mortality in Brazilian Children Before and After Highly Active Antiretroviral Treatment Implementation

The objective of this study was to analyze regional trends over time of acquired immunodeficiency syndrome (AIDS) cases and deaths in Brazilian children, before and after implementation of free access to highly active antiretroviral treatment (HAART). We performed a nation-wide study with an ecologic design and a time-series analysis of AIDS incidence and mortality rates in children (0-12 years of age), using polynomial regression models. Data were obtained from official national databases on age group, residence region, and year of AIDS diagnosis and death (1984-2008). Between 1984 and 2008, 14,314 (2.7%) AIDS cases and 5041 deaths (2.3% of all AIDS-related deaths) were reported in Brazilian children. Incidence after 1996 was reduced by 23%, as compared with the pre-HAART era. The mortality rate observed in the HAART era was reduced by 63.6%. There was a significant reduction in the incidence in the Southeast and Central-West regions (P < 0.001), but the less industrialized North region showed an increase in the pre-HAART era (P < 0.001), and the Northeast region showed a stabilization trend (P < 0.001). In the South region, the incidence of AIDS increased in the 0 to 4 years subgroup. A reduction of AIDS mortality in the Southeast (P < 0.001), South, and Central-West regions (P < 0.001) was seen, but the Northeast and North regions maintained an increasing mortality trend (P < 0.001). Despite the overall reduction in AIDS-related cases and deaths among children in Brazil since HAART, marked regional differences continue to exist. These reflect structural factors, different transmission dynamics, and operational issues. There is a need for improving the health service network with special emphasis on the less developed regions.

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

PurposeTo examine changes in the causes of death and mortality in women with human immunodeficiency virus (HIV) infection in the era of combination antiretroviral therapy. MethodsAmong 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. ResultsOf 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. ConclusionA 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.

Survival after AIDS diagnosis in adolescents and adults during the treatment era, United States, 1984-1997.

Declines in the number of acquired immunodeficiency syndrome (AIDS) deaths were first observed in 1996, attributed to improvements in antiretroviral therapy and an increase in the proportion of persons receiving therapy. To examine national trends in survival time among persons diagnosed as having AIDS in 1984-1997. Retrospective cohort study using data from a population-based registry of AIDS cases and deaths reported in the United States. Months of survival after AIDS diagnosis through December 31, 1998, compared by year of diagnosis. Among 394 705 persons with an AIDS-defining opportunistic illness (OI) diagnosed in 1984-1997, median survival time improved from 11 months for 1984 diagnoses to 46 months for 1995 diagnoses. Among persons with an OI diagnosed in 1996 and 1997, 67% were alive at least 36 months after diagnosis and 77% were alive at least 24 months after diagnosis, respectively. Among 296 621 AIDS cases diagnosed during 1993-1997, 65% were based on immunologic criteria and 35% on OI criteria; 80% were among men; and 42% were among non-Hispanic blacks, 40% among non-Hispanic whites, 17% among Hispanics, 1% among Asians/Pacific islanders, and less than 1% among American Indians/Alaska natives. The probability of surviving at least 24 months increased from 67% for those with immunologic diagnoses in 1993 to 90% in 1997 and from 49% for those with OI diagnoses in 1993 to 80% in 1997. Survival time increased with each year of diagnosis from 1984 to 1997 for blacks, whites, and Hispanics. The greatest annual survival gains occurred among persons receiving an AIDS diagnosis in 1995 and 1996. Survival time after AIDS diagnosis improved from 1984 to 1997. While AIDS incidence is declining, improved survival times present a growing public health challenge as the number of persons living with chronic human immunodeficiency virus disease/AIDS increases.

Excess mortality due to pneumonia or influenza during influenza seasons among persons with acquired immunodeficiency syndrome.

Anecdotal reports suggest that influenza-related morbidity may be high among persons with acquired immunodeficiency syndrome (AIDS), but little information is available concerning the population-level impact of influenza on mortality in persons with AIDS. Using the Multiple Cause-of-Death data files, which contain information on all deaths occurring in the United States each year, we calculated the numbers of excess deaths and rates of excess death due to pneumonia or influenza among persons with AIDS aged 13 years and older during the influenza seasons 1991-1992 through 1993-1994. For comparison, numbers of excess deaths and excess death rates were also calculated for several other groups including the general US population aged 13 years and older and the general US population aged 65 years and older. During the 1991-1992, 1992-1993, and 1993-1994 influenza seasons, there were 261, 254, and 191 excess deaths due to pneumonia or influenza in persons with AIDS and excess death rates of 19.74, 15.38, and 10.17 deaths per 10 000 persons, respectively, compared with a summer baseline period. For the same seasons, we observed excess death rates of 1.40, 1.62, and 1.48 for the general US population aged 13 years and older and 8.10, 9.28, and 8.54 for the general US population aged 65 years and older. Thus, persons with AIDS had excess death rates substantially higher than the general US population and similar to, if not somewhat higher than, the general US population aged 65 years and older, a group that is already targeted for annual vaccination. The findings were similar when we compared the preinfluenza season with the influenza season. Persons with AIDS have significant excess mortality due to pneumonia or influenza during influenza seasons and should be considered a high-risk group that is targeted for the prevention of influenza.

HIV/AIDS Among Racial/Ethnic Minority Men Who Have Sex With Men—United States, 1989-1998

In the United States, racial/ethnic minority populations account for an increasing proportion of acquired immunodeficiency syndrome (AIDS) cases, including cases among men who have sex with men (MSM) (1). This report presents recent trends in AIDS incidence and deaths among MSM who belong to racial/ethnic minority populations, and compares data on human immunodeficiency virus (HIV) diagnoses with AIDS diagnoses during 1996-1998 among racial/ethnic minority MSM in the 25 states that have conducted confidential HIV surveillance and AIDS case surveillance since 1994. The findings indicate that among MSM, non-Hispanic black and Hispanic men accounted for an increasing proportion of AIDS cases and had smaller proportionate declines in AIDS incidence and deaths from 1996 to 1998. Of HIV and AIDS diagnoses among racial/ethnic minority MSM, the proportion who are young (aged 13-24 years) is higher than among white MSM.

Diagnosis and Reporting of HIV and AIDS in States With Integrated HIV and AIDS Surveillance— United States, January 1994-June 1997

Recent reports based on acquired immunodeficiency syndrome (AIDS) surveillance data have highlighted substantial declines in AIDS incidence and deaths. As a result of improvements in treatment and care of persons infected with human immunodeficiency virus (HIV), surveillance of AIDS alone no longer accurately reflects the magnitude or direction of the epidemic. Current public health and clinical recommendations promote early diagnosis and treatment of HIV disease. Data on persons in whom HIV infection is diagnosed before AIDS is diagnosed are needed to determine populations in need of prevention and treatment services. This report examines data for persons aged > or =13 years in whom HIV infection was diagnosed in 25 states that conducted name-based HIV surveillance in addition to AIDS surveillance during January 1994-June 1997. Provisional data indicate that declines in AIDS incidence in these states were not accompanied by comparable declines in the number of newly diagnosed HIV cases.

HUMAN IMMUNODEFICIENCY VIRUS AND OBSTETRIC ANESTHESIA

Acquired immunodeficiency syndrome (AIDS) is a worldwide epidemic with an estimated 23 million persons infected with the human immunodeficiency virus (HIV).24 The Global AIDS Policy Coalition predicts that, if current trends continue, between 60 to 70 million adults will be infected with HIV by the end of the year 2000. Of the current HIV-infected persons, approximately 42% are women and an estimated 1 million are children less than 15 years old, with 90% of the infected children in the developing world.9 One in every three children orphaned by HIV disease is under age five. Since the beginning of the global epidemic, over 9 million children under age 15 have lost their mother to HIV. In the United States, it is estimated that 1.5 million Americans are infected with HIV and that through June 1997, 612,078 persons were diagnosed as having AIDS with a case-fatality rate of approximately 62%.11 Thus, at least 380,000 persons have died from AIDS with the death toll total still rising, despite some recent encouraging drug intervention (Fig. 1). Sadly, approximately 21% of the new cases in the United States are women who are mostly in the reproductive age group (25–44 years old). Thus, while the geographic differences are dramatic (Fig. 2), the labor and delivery suites of most hospitals in the United States will see HIV-infected women and, in some large urban centers, it will be a common occurrence.37 The anesthesiologist is now faced with a disease that “didn't exist” until 1981. At that time, an obscure report noted four homosexual men with Pneumocystis carinii. It seemed to be only a medical curiosity at the time.30 By the early part of 1995, AIDS death rates had surpassed all causes of death among persons aged 25 to 44 years in the United States (Fig. 3).63 The death rate from AIDS has recently declined yet on occasion we are involved in caring for HIV-positive patients in the operating suite. To care properly for this group of patients, the clinician needs to understand the disease itself, unique concerns in pregnancy, therapeutic intervention, opportunistic and associated infections, and infection control techniques. With this information at hand, anesthetic intervention and pain control can be planned appropriately. The management of the HIV-positive patient is now, essentially, a medical specialty. Consultation with the patient's primary care physician is particularly important. Pharmacologic intervention is an ever-changing aspect of the care of these patients with implications for the anesthesiologist. Opportunistic infections can put the patient at significant risk. The clear overlap with tuberculosis and hepatitis C epidemics must be taken into consideration. This chapter will focus on these and related concerns since the operating room and obstetric suite are now a common interface with the HIV-positive patient. While this discussion will focus on the parturient and her child, much of this information is equally pertinent to the general operating theater as well as labor and delivery.

Clinical and immunological features of human immunodeficiency virus infection in patients from Bangkok, Thailand.

To assess the association between the CD4 count and clinical diseases in a cohort of Thai patients. In all, 1902 patients who presented with human immunodeficiency virus (HIV) infection at the Chulalongkorn University Hospital in Bangkok were investigated. At the time of presentation 295 (15.5%) patients had acquired immunodeficiency syndrome (AIDS) and there was a highly significant tendency for lower CD4 counts in this group (median 67/mm3) than in patients free of AIDS (median 369/mm3). A total of 757 patients had data available on follow-up and were free of AIDS at the first visit. During a median follow-up of 0.9 years, 110 developed AIDS or AIDS-related death (12.2/100 person years). Subjects with CD4 count < 200/mm3 at initial visit showed over a ninefold increase in risk of developing AIDS compared to subjects with levels > or = 500/mm3 (relative risk [RR] = 9.1; 95% CI: 5.4-16.0). The rate/100 person years was 47.1 compared with 6.0 in subjects with levels > or = 500/mm3. After adjusting for initial CD4 count, homosexual men showed over a twofold increase in risk of developing AIDS compared to heterosexuals (RR = 2.4; 95% CI: 1.6-4.4) and intravenous drug users (IVDU) showed nearly a twofold increase (RR = 1.8; 95% CI: 0.9-3.9). The increased risk in homosexual men persisted even after further adjustment for clinical stage (RR = 2.2; 95% CI: 1.3-3.7) but the increased risk in IVDU was attenuated (RR = 1.5; 95% CI: 0.7-3.2) although it remained increased albeit non-significantly. Men tended to progress faster to AIDS than women but the difference was not significant. However, the faster progression in homosexual men was seen even when compared to heterosexual men only. The rate of progression of AIDS according to CD4 count group at baseline in this Thai cohort is broadly comparable with Western cohorts. It appears that heterosexuals in Thailand show slower progression to AIDS than homosexual men.