AIDS In Italy Research Articles

Mortality of people with AIDS in Italy: comparison of AIDS surveillance and multiple cause-of-death registries.

To assess whether the use of multiple cause-of-death data could improve reporting of AIDS mortality in Italy. Population-based, record-linkage study, on 3,975,431 deaths recorded in the National Registry of Causes of Death (RCoD) and 4,530 deaths recorded in the National AIDS Registry (RAIDS), during 2006-2012. The record-linkage identified 3,646 AIDS-related deaths present in both registries, 884 deaths in the RAIDS without mention of HIV/AIDS in the RCoD, and 3,796 deaths in the RCoD with mention of HIV/AIDS that were not present in the RAIDS. In the latter, in-depth analysis of multiple cause-of-death allowed the identification of 1,484 deaths that were AIDS-related. On these results, we estimated 6,014 deceased people with AIDS. Of them, 14.7% (884) were not present in the RCoD and 24.7% (1,484) derived from the RCoD only. The integration of different nationwide registries allowed a more comprehensive estimate of the impact of AIDS-associated mortality in Italy.

Industry-based issues in the provision of hearing aids in Italy

Industry-based issues in the provision of hearing aids in Italy

Industry-based issues in the provision of hearing aids in Italy

Despite the availability of free hearing tests and aids provided by qualified community-based professionals specialising in audiology services, hearing aid adoption remains low in Italy. This article investigates the reasons why hearing aids have a low acceptance level in Italy. Interviews with different hearing health professionals were conducted along with an analysis of the regulations and documentation governing the provision of publicly funded hearing aids. A combined service management and hearing-health literature review was then carried out and analysis performed. Interviews were then conducted with other hearing health professionals to confirm our analysis and findings. We contend that industry operational issues related to the structure, culture and public financing of the Italian audiology industry adversely impact on consumer service experiences. Based on this finding we propose a conceptual framework and offer four theory building propositions that we have identified as related to this highly regulated service industry.

Multiple cause-of-death data among people with AIDS in Italy: a nationwide cross-sectional study

BackgroundMultiple cause-of-death (MCOD) data allow analyzing the contribution to mortality of conditions reported on the death certificate that are not selected as the underlying cause of death. Using MCOD data, this study aimed to fully describe the cause-specific mortality of people with AIDS (PWA) compared to people without AIDS.MethodsWe conducted a nationwide investigation based on death certificates of 2,515 Italian PWA and 123,224 people without AIDS who had died between 2006 and 2010. The conditions most frequently associated with PWA mortality, compared to people without AIDS, were identified using an age-standardized proportion ratio (ASPR) calculated as the ratio between the age-standardized proportion of a specific cause among PWA and the same proportion among people without AIDS.ResultsThe most frequently reported conditions at death among PWA were infectious/parasitic diseases (52%), digestive (36%), respiratory (33%), and circulatory (32%) system diseases, and neoplasms (29%). All AIDS-defining conditions resulted highly associated (ASPR significantly greater than unity) with PWA deaths. Significant associations also emerged for leishmaniasis (ASPR = 188.0), encephalitis/myelitis/encephalomyelitis (ASPR = 14.3), dementia (ASPR = 13.1), chronic viral hepatitis (ASPR = 13.1), liver fibrosis/cirrhosis (ASPR = 4.4), pneumonia (ASPR = 4.4), anal (ASPR = 12.1) and liver (ASPR = 1.9) cancers, and Hodgkin’s disease (ASPR = 3.1).ConclusionsStudy findings identified the contribution of several non-AIDS-defining conditions on PWA mortality, emphasizing the need of preventive public health interventions targeting this population.

The continued ageing of people with AIDS in Italy: recent trend from the national AIDS Registry.

Introduction. In industrialized countries, the availability of highly active antiretroviral therapy (HAART) caused a slow but substantial ageing of the AIDS epidemic mainly due to the longer survival of persons with HIV/AIDS which has turned HIV into a manageable, chronic disease. The number of older people with AIDS is growing in many European countries. We described the impact of AIDS among persons aged 50 years or more in Italy and compared the characteristics of these cases with those of persons diagnosed with AIDS at an age younger than 50. Methods. The source of data was the Italian AIDS Registry, from 1982 to 2011. We defined "older" persons those aged 50 years or more, and younger individuals those aged less than 50 years. We built two multivariate logistic regression models: the first one to identify factors associated with being older, and the second one to identify AIDS-defining diseases correlated with being older. Variables with a P value of <0.05 were entered in the model. Results. Of the total AIDS cases, 10.5% were among persons older than 49 years. This proportion progressively increased from 0.0% in 1983 to 26.4% in 2011. Among older cases, the incidence of AIDS was 2.0 per 100 000 residents in 1996, then decreased to 1.4 per 100 000 in 2000 and levelled off around 1 per 100 000 residents until 2011. Compared to younger cases, older cases were more frequently males, Italians, diagnosed with AIDS in recent years, residing in Northern or Central Italy, non-injecting drug users, and late testers. Discussion. These findings stress the need for physicians to consider carefully the possibility of HIV infection among older individuals not to miss the opportunity to deliver prevention messages, offer HIV testing, and make an early diagnosis.

Epidemic of Lung Cancer in Patients With HIV Infection

The survival of patients with HIV infection has improved dramatically over the past 20 years, largely owing to a significant reduction in opportunistic infections and AIDs-defining malignancies, such as lymphoma and Kaposi sarcoma. However, with improved survival, patients with HIV are experiencing morbidity and mortality from other (non-AIDs-defining) complications, such as solid organ malignancies. Of these, the leading cause of mortality in the HIV-infected population is lung cancer, accounting for nearly 30% of all cancer deaths and 10% of all non-HIV-related deaths. Importantly, the average age of onset of lung cancer in the HIV-infected population is 25 to 30 years earlier than that in the general population and at lower exposure to cigarette smoke. This article provides an overview of the epidemiology of lung cancer in the HIV-infected population and discusses some of the important risk factors and pathways that may enhance the risk of lung cancer in this population.

Non-AIDS-defining cancer mortality among people with AIDS in Italy

Materials and methods Between 1999 and 2006, 10,391 Italian citizens (15 years of age) had been diagnosed with AIDS in Italy. These PWAs constituted the population included in our study. Death certificates were retrieved through a record-linkage with the mortality databases at the National Institute of Statistics. This allowed the extraction of information about PWA dates of death, up to December 31, 2006. The underlying cause of death, for each deceased PWA, was identified following the International Classification of Diseases, 10 revision (ICD-10), applied also for the general population. The excess risks of death for each NADC were therefore estimated through standardized mortality ratios (SMRs) with 95% confidence intervals (CIs), in comparison with the Italian general population.

Cancer incidence in people with AIDS in Italy

People with HIV/AIDS (PWHA) have increased risk of some cancers. The introduction of highly active antiretroviral therapies (HAART) has improved their life expectancy, exposing them to the combined consequences of aging and of a prolonged exposure to cancer risk factors. The aim of this study was to estimate incidence rates (IR) in PWHA in Italy, before and after the introduction of HAART, after adjusting for sex and age through direct standardization. An anonymous record linkage between Italian AIDS Registry (21,951 cases) and Cancer Registries (17.3 million, 30% of Italian population) was performed. In PWHA, crude IR, sex- and age-standardized IR and age-specific IR were estimated. The standardized IR for Kaposi sarcoma and non-Hodgkin lymphoma greatly declined in the HAART period. Although the crude IR for all non-AIDS-defining cancers increased in the HAART period, standardized IR did not significantly differ in the 2 periods (352 and 379/100,000, respectively). Increases were seen only for cancer of the liver (IR ratio = 4.6, 95% CI: 1.3-17.0) and lung (IR ratio = 1.8, 95% CI: 1.0-3.2). Age-specific IRs for liver and lung cancers, however, largely overlapped in the 2 periods pointing to the strong influence of the shift in the age distribution of PWHA on the observed upward trends. In conclusion, standardized IRs for non-AIDS-defining cancers have not risen in the HAART period, even if crude IRs of these cancers increased. This scenario calls, however, for the intensification of cancer-prevention strategies, notably smoking cessation and screening programs, in middle-aged HIV-patients.

Risk of death among Italian AIDS cases with AIDS-defining cancers in the post-HAART era

This study intended to quantify the impact of AIDS-defining cancers on the risk of death in the post-HAART era. With this aim in mind, data regarding all Italian AIDS cases reported to the National AIDS Registry were analyzed. Between 1999 and 2005, a total of 12,433 individuals were diagnosed with AIDS in Italy. Specifically excluded from this analysis were people with AIDS who were: 1) not-Italian citizen (n = 1918); 2) resident in Italian areas where individual information on death was not available (n = 108); 3) resident in unknown areas (n = 119); 4) pediatric or vertical transmission cases (n = 50); 5) diagnosed solely at autopsy (n = 576). The presence of AIDS-defining cancers (i.e., Kaposi's sarcoma-KS, non-Hodgkin lymphoma-NHL, and invasive cervical cancer-ICC) at AIDS diagnosis is routinely ascertained at the National AIDS Registry, together with some other information, including age, sex, date of AIDS diagnosis, HIV transmission category, CD4+ cells count. Information on vital status of AIDS cases, as of December 2006, was assessed through a semi-automated linkage procedure, ensuring confidentiality of individual data, with the national death certificates database. Survival function was estimated by the Kaplan-Meier method; Cox regression model was used to estimate death hazard ratios (HR), and corresponding 95% confidence intervals (CI), associated to the presence of AIDS-defining cancers at diagnosis, adjusted for age at AIDS diagnosis, sex, HIV transmission category, and CD4+ cells count at diagnosis. Of the 9,662 AIDS cases included in the present study, 478 had KS, 429 immunoblastic NHL, 158 Burkitt's lymphoma, 69 ICC, and 58 NHL of the central nervous system (CNS). As of December 2006, 3,096 deaths were registered: of these deaths, 505 occurred among cases with AIDS-defining cancers. The proportion of AIDS cases still alive 5 years after AIDS diagnosis was 66.6 percent. The shortest survival period was seen among individuals diagnosed with CNS NHL (median survival = 4 months), followed by those with immunoblastic NHL or Burkitt's lymphoma (median survival = 16 and 38 months, respectively), whereas the longest ones were recorded among cases with ICC or KS (median not reached). In comparison with AIDS cases without AIDS-defining cancers, those with a CNS NHL had a 4.7-fold higher risk of death (95% CI: 3.5–6.4), those with immunoblastic NHL or Burkitt's lymphoma had more than twice the risk (HR = 2.6, 95% CI: 2.2–2.9; and HR = 2.3, 95% CI: 1.8–2.8, respectively), and, among women, those with ICC had a 1.8-fold elevated risk (95% CI: 1.2–2.7). Conversely, among individuals with KS (HR = 0.7, 95% CI: 0.6–0.9) the risk of death was lower than that of cases without AIDS-defining cancers. In conclusion, this exhaustive survival analysis of Italian AIDS cases in the post-HAART era highlighted the persisting lethality of NHL and the long survival of cases with KS and ICC.

Pattern of cancer risk in persons with AIDS in Italy in the HAART era

A record-linkage study was carried out between the Italian AIDS Registry and 24 Italian cancer registries to compare cancer excess among persons with HIV/AIDS (PWHA) before and after the introduction of highly active antiretroviral therapy (HAART) in 1996. Standardised incidence ratios (SIR) were computed in 21951 AIDS cases aged 16–69 years reported between 1986 and 2005. Of 101 669 person-years available, 45 026 were after 1996. SIR for Kaposi sarcoma (KS) and non-Hodgkin lymphoma greatly decreased in 1997–2004 compared with 1986–1996, but high SIRs for KS persisted in the increasingly large fraction of PWHA who had an interval of <1 year between first HIV-positive test and AIDS diagnosis. A significant excess of liver cancer (SIR=6.4) emerged in 1997–2004, whereas the SIRs for cancer of the cervix (41.5), anus (44.0), lung (4.1), brain (3.2), skin (non-melanoma, 1.8), Hodgkin lymphoma (20.7), myeloma (3.9), and non-AIDS-defining cancers (2.2) were similarly elevated in the two periods. The excess of some potentially preventable cancers in PWHA suggests that HAART use must be accompanied by cancer-prevention strategies, notably antismoking and cervical cancer screening programmes. Improvements in the timely identification of HIV-positive individuals are also a priority in Italy to avoid the adverse consequences of delayed HAART use.

Incidence of AIDS-defining cancers after AIDS diagnosis among people with AIDS in Italy, 1986-1998.

A record linkage was carried out between the Italian National Registry of AIDS and 19 cancer registries. The aim was to evaluate the 1986 through 1998 trends in incidence rate (IR) of AIDS-defining cancers (ADCs) among persons with AIDS (PWA) in Italy overall and according to various characteristics. A steady decrease in IRs was found for Kaposi sarcoma (KS) in men between 1986-1992 (2.5 per 100 person-years [py]) and 1997-1998 (1.0 per 100 py). Conversely, the first decrease in IRs of KS in women (from 0.9 to 0.6 per 100 py) and of non-Hodgkin lymphoma in both genders (from 1.7 to 0.7 per 100 py) was seen between 1993-1996 and 1997-1998, thus pointing to a favorable impact of highly active antiretroviral therapies. The decline was consistent across different age and HIV transmission groups, but it was more marked in PWA with a CD4 count >50 cells/microL than in PWA with more severe immune suppression. As a proportion of AIDS cases, invasive cervical cancer increased from 1.5% in 1993-1996 to 2.4% in 1997-1998, but IRs after AIDS could not be evaluated. On account of the marked decline of KS in men in 1997-1998, the overall burden of ADCs in Italy became similar in both genders.

Lung cancer in persons with AIDS in Italy, 1985–1998

The Italian Cancer and AIDS Registries Linkage Study was used to compare the incidence of lung cancer in persons with HIV/AIDS (PWA) before and after the introduction of highly active antiretroviral therapy (HAART). Twenty-one lung cancers were identified in 12 104 PWA. Incidence rates of lung cancer in PWA exceeded those in the general population, but no increase emerged after HAART. Population-based studies with long follow-up are needed to monitor trends in non-AIDS defining cancer in PWA.

Risk of cancer in persons with AIDS in Italy, 1985-1998.

A record linkage was carried out between the Italian Registry of AIDS and 19 Cancer Registries (CRs), which covered 23% of the Italian population, to estimate the overall cancer burden among persons with HIV or AIDS (PWHA) in Italy, according to various characteristics. Observed and expected numbers of cancer and standardised incidence ratios (SIRs) were assessed until 1998 in 12 104 PWHA aged 15–69 years, for a total of 60 421 person-years. Significantly increased SIRs were observed for Kaposi's sarcoma (KS, 1749-fold higher than the general population), non-Hodgkin's lymphomas (NHL, 352), and invasive cervical cancer (22). SIR was significantly elevated also for cancer of the anus (34), lung cancer (2.4), brain tumours (4.4), Hodgkin's disease (16), and leukaemias (5.3). The majority of lung and brain cancers were not histologically confirmed, and the possibility of misclassification with KS or NHL cannot be ruled out. The SIR for all non-AIDS-defining cancers was 2.2 in men and 2.5 in women. Intravenous drug users showed significantly more elevated SIRs for lung cancer (9.4), and brain tumours (6.7) than other transmission categories (SIR=1.4 and 2.3, respectively). This study confirmed increased SIRs for haemolymphopoietic neoplasms other than NHL in PWHA, although many-fold smaller than for NHL. An association with human papillomavirus-related cancers was also confirmed.

Increasing Proportion of Late Diagnosis of HIV Infection Among Patients With AIDS in Italy Following Introduction of Combination Antiretroviral Therapy

We analyzed trends over time and determinants of late diagnosis of HIV infection among people diagnosed with AIDS in 1986 to 1998 in a tertiary care center in Rome, Italy. Information on the date of a first HIV test was collected prospectively, in addition to data routinely collected for AIDS reporting. Patients with AIDS were defined as “late testers” if the time interval between first positive HIV test result and AIDS diagnosis was ≤3 months. Overall, 503 people with AIDS of 1977 included in the analysis (25.4%) were late testers. the proportion of late testers decreased from 62.5% in 1986 to 16% in 1995. Thereafter, this proportion increased to 20.5% in 1996, 33.7% in 1997, and 36.6% in 1998. In multivariate analysis, the following variables were significantly associated with late testing: AIDS diagnosis in years 1986 to 1993 or 1997 to 1998 compared with 1995, male gender, age ≥45 years, men who have sex with men, heterosexual contacts, or having unknown transmission mode compared with intravenous drug users, and being born outside Italy. Since 1996, the overall number of AIDS cases diagnosed at our center began to decrease whereas the number of late-testing AIDS patients did not decrease, resulting in an increasing proportion of late testers during the last 3 years of the study. This findings may reflect the effect of combination antiretroviral therapy in slowing progression to AIDS of HIV-infected persons aware of their status. A relevant number of people still discover their HIV infection late and may therefore miss treatment opportunities. New testing strategies are needed to reach more people who engage in high-risk behaviors, especially those at risk for sexual transmission, and those born outside Italy.

Increasing survival time after AIDS in Italy: the role of new combination antiretroviral therapies. Tuscany AIDS Study Group.

In Italy, antiretroviral combination therapy was adopted in mid-1995 and protease inhibitors in mid-1996. To conduct a prospective, population-based, observational study to evaluate the effect of these therapies on the survival of persons with AIDS (PWA). PWA living in the Tuscany region diagnosed between 1985 and 31 March 1997 (National AIDS Registry) were studied. Information on antiretroviral drugs, prophylactic treatment, CD4 cell count, and AIDS-defining illnesses was collected for PWA still alive at 1 January 1996 and those diagnosed thereafter (analysis cut-off date, 30 November 1997). Kaplan-Meier curves were calculated by year of diagnosis. A Cox model was then used to estimate the adjusted (by sex, age, HIV exposure category, CD4 cell count, type and number of AIDS-defining illnesses) relative hazard (RH) of death by year of diagnosis and calendar date (considered as a time-dependent variable). Similar analyses were repeated for PWA diagnosed after 1989, having been stratified by disease-specific AIDS condition. A final analysis was performed for PWA still alive at 1 January 1996 or diagnosed thereafter for estimating the effect of single, double and triple combination therapy (time-dependent variables), having adjusted for the above variables and for prophylactic treatment. A total of 1683 (79.5%) out of 2118 PWA died before 1 December 1997. Use of more potent combination therapies, including protease inhibitors, greatly increased during 1997. Median survival was 2.9, 12.3, 13.4, 11.4 and 17.6 months for diagnoses before 1987, in 1987-1990, 1991-1993, 1994 and 1995, respectively; an estimated 62% of those diagnosed in 1996-1997 had survived 15 months after diagnosis. The Cox model showed a trend of decrease of RH for calendar time starting in the first half of 1996, compared with 1994. When stratifying by specific AIDS-defining disease there was no statistically significant evidence that the improved overall survival was due to increased survival only for certain diseases. The final multivariate analysis for the 771 PWA still alive at 1 January 1996 or diagnosed thereafter estimated significant RH < 1.0 for double and triple therapy (RH, 0.61 and 0.36, respectively) compared with no therapy. A significant reduction in risk of death after AIDS was observed from the second half of 1996, apparently due to the widespread use of antiretroviral combination therapies.

Risk of cancer other than Kaposi's sarcoma and non-Hodgkin's lymphoma in persons with AIDS in Italy. Cancer and AIDS Registry Linkage Study.

Record linkage was carried out between the national Registry of AIDS and 13 Cancer Registries (CRs) covering, in 1991, about 15% of the Italian population. Observed and expected numbers of cancers and standardized incidence ratios (SIRs) were assessed in 6067 persons with AIDS, for a total of 25,759 person-years. Significantly increased SIRs were found for Hodgkin's disease [8.9, 95% confidence interval (CI) 4.4-16.0], in which seven of 11 cases were of mixed cellularity type; invasive carcinoma of the cervix uteri (15.5; 95% CI 4.0-40.1); and non-melanomatous skin cancer (3.0, 95% CI 1.3-5.9), in which five of eight cases were basal cell carcinoma. An excess was also seen for brain tumours, but this may be partly due to misdiagnosis of brain non-Hodgkin's lymphoma or other brain diseases occurring near the time of the AIDS diagnosis. The risk for all cancer types, after exclusion of Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL), was approximately twice the general population risk. An increased SIR for Hodgkin's disease in persons with AIDS is thus confirmed, though it is many times smaller than that for NHL. An association with invasive carcinoma of the cervix is also shown at a population level. The excess of non-melanomatous skin cancer seems to be lower than in transplant recipients.

AIDS as a leading cause of death among young adults in Italy.

The objective of this study is to describe the impact of AIDS on the mortality of young adult (aged 25 to 44 years) in Italy, at both the national and regional level. We analyzed the official mortality data for Italy: the most recent data available being from 1990. General mortality trends show that while mortality among young women is still decreasing (i.e. from a standardized rate of 83.8 per 100,000 in 1980 to 68.4 in 1990), mortality among young men began to rise in the mid-1980s, after a steady decrease over many years. Among the 25-34 year olds, however, this reversal in trend is more marked, notwithstanding a decrease or stabilization in most major causes of death. In fact it coincides with the appearance and spread of AIDS in Italy, which has affected young men in particular. (The peak age group for AIDS deaths is the 25-34 year olds). Mortality data from 1990 reveal that AIDS is the fourth leading cause of death in Italy among men between the ages of 25 and 44 years. Among 25-34 year-old men, however, AIDS is the second leading cause of death, after road accidents. AIDS also contributes greatly to the general mortality in individual regions, both among 25-44 year-old men (Lombardy, Liguria, Lazio, Emilia-Romagna, Tuscany), and especially among 25-34 year-old men (Lombardy, Liguria, Lazio, Sardinia, where it is the number one cause of death, Emilia-Romagna, Tuscany, and Veneto, where it is the number two cause of death).

Non-Hodgkinʼs lymphoma among homosexual men and intravenous drug users with AIDS in Italy

Non-Hodgkinʼs lymphoma among homosexual men and intravenous drug users with AIDS in Italy

Does breast-feeding delay progression to AIDS in HIV-infected children?

Researchers gathered data from the National Registry of AIDS in Italy to examine the effect breast feeding has on the incubation time for AIDS in 117 vertically infected children. 36 children received breast milk and 64 were bottle fed. No perinatal feeding data existed in the registry for the remaining 17 children. There was a significant difference between the median incubation periods for the 36 breast fed (19 months) and 64 bottle fed (9.7 months) children (p=.003). An overlap in the incubation curves took place shortly before 60 months however. Further the breast fed children had a longer survival rate than the bottle fed children (Breslow p=.01; Mantel-Cox p=.003). From 198 when the 1st case occurred to 1986 breast feeding and bottle feeding patterns remained stable but beginning in 1987 the frequency of breast feeding declined significantly (p<.05). Limitations of the registry data included no information was recorded on potential confounding factors duration of breast feeding and mothers clinical conditions. For example perhaps asymptomatic HIV positive mothers tended to breast feed their children more so than mothers who had full blown AIDS or AIDS related complex. In addition since there were no data on duration of breast feeding the researchers could not determine a dose response effect. Nevertheless the results of this study suggest that breast feeding does postpone the development of AIDS in children. Researchers need to conduct prospective studies to confirm or deny these tentative results. The value of breast feeding and time of weaning will increase if indeed future studies prove that breast feeding does delay development of AIDS.

High prevalence of antibodies to human immunodeficiency virus in heterosexual persons attending a sexually transmitted disease clinic in Italy

The prevalence of antibodies to human immunodeficiency virus (anti-HIV-1) was determined in 924 outpatients attending a sexually transmitted disease clinic. The overall prevalence of anti-HIV-1 was 9%. Six of 14 intravenous drug addicts and 4 of 34 patients of African origin were anti-HIV-1 positive. In the other 876 patients, the anti-HIV prevalence was 6.6% in 467 heterosexual men, 5% in 261 heterosexual women and 22.3% in 148 homosexual or bisexual men. The prevalence of anti-HIV-1 in the heterosexual subjects was much higher than that expected in the general population and than that observed in patients attending sexually transmitted disease clinics in other developed countries. Intravenous drug abusers, who represent the most important group at risk for AIDS in Italy, could contribute to the spread of HIV infection through heterosexual contacts with persons without other known risk factors.