Clinical Outcome In HIV-infected Patients Research Articles

Virologic response to antiretroviral therapy among human immunodeficiency virus-infected adults in a tertiary healthcare facility in Enugu State Nigeria

Background: Early and sustained viral suppression with antiretroviral therapy (ART) has been linked to good clinical outcome in HIV-infected patients. The global target is that at least 90% of the patients on ART should be virally suppressed. Objectives: We assessed the virologic response to first-line ART in the first year of treatment in our center and determined the factors influencing early viral load suppression among patients. Materials and Methods: We conducted a retrospective study involving review of the records of all eligible HIV-infected adults initiated on ART in our facility between 2009 and 2014, who did not miss any follow-up appointment during the first year on ART. Data were extracted with a proforma and analyzed with Epi Info 7. Frequencies and proportions were used to summarize patients who achieved undetectable viremia (viral load < 400 copies/mL]) at 12 and 24 weeks, whereas χ2 and logistic regression were done at 5% alpha to determine the factors influencing early viral load suppression. Results: The mean age of 478 participants was 38.6 (19.0) years and 310 (64.8%) were females. While 332 (69.5%) patients achieved undetectable viremia at 12 weeks of ART, 356 (74.5%) achieved it at 24weeks. After 24 weeks on ART, 121 (80.7%) of the150 patients on tenofovir/emtricitabine/efavirenz, 195 (71.2%) of the 274 patients on zidovudine/lamivudine/nevirapine, and 35 (71.4%) of the 49 patients on tenofovir/lamivudine+nevirapine achieved undetectable viremia (P = 0.13). Patients’ age, sex, marital status, baseline CD4 count, TB co-infection status, WHO clinical stage of disease, and plasma viral load at ART initiation were not significantly associated with early viral load suppression (p > 0.05). Conclusion: Three out of every four participants initiated on first-line ART achieved undetectable viremia after 24 weeks of treatment in our setting. The three ART regimens assessed have comparable effectiveness. The sociodemographic and clinical variables assessed did not influence viral suppression.

Clinical Outcomes Associated With Once-Daily Ritonavir-Boosted Darunavir Plus Tenofovir/Emtricitabine in HIV-Infected Patients Harboring at Minimum a M184V/I Resistance Mutation.

Limited data exist on the use of a boosted protease inhibitor plus <2 active nucleoside/nucleotide reverse transcriptase inhibitors without use of additional classes of antiretroviral (ARV) therapy in treatment-experienced patients with background resistance. To evaluate clinical outcomes in HIV-infected patients harboring single- or multiclass resistant virus and receiving once-daily tenofovir/emtricitabine (TDF/FTC) plus darunavir/ritonavir (DRV/r) administered for >24 weeks. This was a single-center chart review of HIV-infected patients receiving daily TDF/FTC plus DRV/r and identified with resistant virus (including, but not limited to, an M184V/I). The primary outcome was HIV viral load (VL) <200 copies/mL (cp/mL) at last measurement. Additional end points included virological rebound (VR), resuppression, or failure (VF); VL <40 cp/mL at last measurement; and development of additional mutations. Of 171 eligible patients, 32 were included in the study and received DRV 800 mg/r 100 mg daily with fixed-combination TDF/FTC. All patients had a baseline M184V/I mutation, with 10 (31%) having resistance to TDF; 27 (84%) achieved a VL <200 cp/mL, and 25(78%) had a VL <200 cp/mL at the last reading; 22 (69%) achieved a VL <40 cp/mL. VF occurred in 6/32 (19%) patients and VR in 1/32 (3%) patients. Conclusion and Relevance: Although providing a regimen containing ≤2 active drugs, the use of once-daily DRV/r plus TDF/FTC in treatment-experienced patients with single-/multiclass resistant virus resulted in virological suppression in more than three-fourths of patients. These retrospective data suggest that despite the presence of an M184V/I, this combination may be an option in patients seeking a once-daily ARV therapy to improve adherence.

Virologic response among HIV infected adults on antiretroviral therapy in a tertiary facility in Enugu, Nigeria, 2016

Introduction : early and sustained viral suppression with effective Antiretroviral Therapy (ART) has been linked to good clinical outcome in HIV-infected patients. Resource constraints limits pre-ART resistance testing to ensure potent customised ART in our environment. We assessed the virologic response to the first line ART regimen recommended by the national guideline.

Clinical outcomes associated with once daily ritonavir-boosted darunavir in HIV infected patients harboring single or multi-class resistant virus

BackgroundLimited data exist on the use of a potent boosted protease inhibitor plus <2 active nucleotide reverse transcriptase inhibitors without use of additional classes of ART in treatment experienced patients with background resistance. We evaluated the clinical outcomes in HIV-infected patients harboring single or multi-class resistant virus (NRTI ± PI and/or NNRTI) treated with once daily darunavir/ritonavir (DRV/r) plus tenofovir/emtracitabine (TDF/FTC).MethodsThis was a single-center, retrospective chart review of HIV-1 infected patients harboring single or multi-class resistant virus and receiving an ART regimen of TDF/FTC plus DRV/r administered as a once daily regimen > 24 weeks. The primary outcome was HIV viral load (VL) < 200 copies/mL (cp/mL) at last measurement. Additional endpoints included virologic rebound, re-suppression, and/or failure; VL < 40 cp/mL at last measurement; development of additional mutations. Virologic failure (VF) was defined as failure to achieve a VL < 200 cp/mL or achievement of VL < 200 cp/mL but with rebound to > 200 cp/mL on all successive VLs.Results34 of 387 patients meet criteria for inclusion in the study and were receiving DRV 800 mg daily/r 100 mg daily with fixed combination TDF/FTC. All patients had baseline resistance to FTC (M184V/I), 12 (35.3%) had resistance to TDF, and none had high level DRV resistance. 27 (79%) achieved a VL < 200 cp/mL and 25 (74%) had a VL < 200 cp/mL at the last reading. 23 (68%) achieved a VL of < 40 cp/mL. VF occurred in 8/34 patients (24%) with the following baseline parameters: TDF resistance (2/8), low/ intermediate DRV resistance (2/8), and VL > 100,000 cp/mL (3/8). Both patients with baseline DRV resistance and VF demonstrated high level resistance to DRV on repeat genotype testing. Adherence was considered a major contributor to VF.ConclusionThe use of once daily DRV/r plus TDF/FTC in treatment experienced patients with single/multi-class resistant virus resulted in virologic suppression in over two-thirds of patients. VF was seen in nearly 25% of patients including development of high level DRV resistance. This combination is a potentially viable option in a patient population seeking a once-daily option to improve adherence.Disclosures All authors: No reported disclosures.

Depression in HIV infected patients: a review.

Depression is the most common neuropsychiatric complication in HIV-infected patients and may occur in all phases of the infection. Accurately, diagnosing major depressive disorder in the context of HIV is an ongoing challenge to clinicians and researchers, being complicated by the complex biological, psychological, and social factors associated with the HIV illness. Evidences exist to support the importance of improving the identification of depressive symptoms and their adequate treatment. Depression has long been recognized as a predictor of negative clinical outcomes in HIV-infected patients, such as reducing medication adherence, quality of life, and treatment outcome, and possibly worsening the progression of the illness and increasing mortality. By analyzing the most relevant studies (MEDLINE, EMBASE, PsycLit, Cochrane Library), the review discusses the epidemiology and the main clinical features of depression in HIV-infected patients, the causal pathways linking depression and HIV infection, the validity of screening tools, and the efficacy of different treatment approaches, including psychosocial interventions, psychopharmacology as well as HIV-specific health psychology health service models.

Mean Corpuscular Volume (MCV) Values Reflect Therapeutic Effectiveness in Zidovudine‐Receiving HIV Patients

An increase of the mean corpuscular volume (MCV) of erythrocytes and alterations in the lipid profiles have been described in HIV-infected patients under combination of anti-retroviral treatment (cART), particularly zidovudine (AZT). In 687 sera from 179 HIV-positive patients, MCV levels were correlated with the clinical outcome or therapeutic effectiveness. The sera were classified into three groups according to AZT treatment; cART with AZT (n = 317), cART without AZT (n = 262), and no anti-retroviral therapy (n = 108). The MCV and lipid profile values were increased after cART. The AZT-based cART group had higher MCV levels (111.6 ± 7.0 vs. 97.8 ± 7.0 fl, P < 0.001) and a higher incidence of macrocytosis (>99 fl; 95.3% vs. 38.2%, P < 0.001) than the non-AZT-based cART group. The receiver operating characteristic curve analysis showed that the area under the curve was 0.835 and the cut-off of MCV (>102 fl) had a sensitivity of 96.1% and specificity of 66.7% for detecting HIV-RNA (-) sera in AZT-based cART group. In the multivariate regression analysis, HIV-viral load and HDL-cholesterol were the only significant correlates to the MCV values in the AZT-base cART group (P < 0.05). The MCV values could be used as a surrogate marker to monitor the clinical outcome of HIV-infected patients receiving AZT-based cART.

Availability of Volunteer-Led Home-Based Care System and Baseline Factors as Predictors of Clinical Outcomes in HIV-Infected Patients in Rural Zambia

BackgroundWe assessed the impact of home-based care (HBC) for HIV+ patients, comparing outcomes between two groups of Zambians receiving antiretroviral therapy (ART) who lived in villages with and without HBC teams.MethodsWe conducted a retrospective cohort study using medical charts from Macha Mission Hospital, a hospital providing HIV care in Zambia's rural Southern Province. Date of birth, date of ART initiation, place of residence, sex, body mass index (BMI), CD4+ cell count, and hemoglobin (Hgb) were abstracted. Logistic regression was used to test our hypothesis that HBC was associated with treatment outcomes.ResultsOf 655 patients, 523 (80%) were eligible and included in the study. There were 428 patients (82%) with favorable outcomes (alive and on ART) and 95 patients (18%) with unfavorable outcomes (died, lost to follow-up, or stopped treatment). A minority of the 523 eligible patients (n = 84, 16%) lived in villages with HBC available. Living in a village with HBC was not significantly associated with treatment outcomes; 80% of patients in a village with HBC had favorable outcomes, compared to 82% of patients in a village without HBC (P = 0.6 by χ2). In bivariable analysis, lower BMI (P<0.001), low CD4+ cell count (P = 0.02), low Hgb concentration (P = 0.02), and older age at ART initiation (P = 0.047) were associated with unfavorable outcomes. In multivariable analysis, low BMI remained associated with unfavorable outcomes (P<0.001).ConclusionsWe did not find that living in a village with HBC available was associated with improved treatment outcomes. We speculate that the ART clinic's rigorous treatment preparation before ART initiation and continuous adherence counseling during ART create a motivated group of patients whose outcomes did not improve with additional HBC support. An alternative explanation is that the quality of the HBC program is suboptimal.

What to Expect in HIV-Infected Patients with Severe Cerebral Toxoplasmosis

Little information is available on clinical outcomes of HIV-infected patients with severe cerebral toxoplasmosis in the era of effective combination

IL-2 immunotherapy in chronically SIV-infected Rhesus Macaques

BackgroundDespite inducing a sustained increase in CD4+ T cell counts, intermittent recombinant IL-2 (rIL-2) therapy did not confer a better clinical outcome in HIV-infected patients enrolled in large phase III clinical trials ESPRIT and SILCAAT. Several hypotheses were evoked to explain these discrepancies. Here, we investigated the impact of low and high doses of IL-2 in Rhesus macaques of Chinese origin infected with SIVmac251 in the absence of antiretroviral therapy (ART).ResultsWe demonstrated that rIL-2 induced a dose dependent expansion of CD4+ and CD8+ T cells without affecting viral load. rIL-2 increased CD4 and CD8 Treg cells as defined by the expression of CD25highFoxP3+CD127low. We also showed that rIL-2 modulated spontaneous and Fas-mediated CD4+ and CD8+ T cell apoptosis. The higher dose exhibited a dramatic pro-apoptotic effect on both CD4+ and CD8+ T cell populations. Finally, all the animals treated with rIL-2 developed a wasting syndrome in the month following treatment simultaneously to a dramatic decrease of circulating effector T cells.ConclusionThese data contribute to the understanding of the homeostatic and dosage effects of IL-2 in the context of SIV/HIV infection.

Clinical Significance of Hyperbilirubinemia Among HIV-1–Infected Patients Treated with Atazanavir/Ritonavir Through 96 Weeks in the CASTLE Study

CASTLE was a randomized 96-week study that demonstrated that atazanavir/ritonavir (ATV/r) was noninferior to lopinavir/ritonavir (LPV/r) in treatment-naïve HIV-infected patients. Analyses were carried out among patients who received ATV/r in the CASTLE study to better understand the clinical significance of unconjugated hyperbilirubinemia associated with administration of boosted ATV. Hyperbilirubinemia was defined as total bilirubin (conjugated and unconjugated) elevation greater than 2.5 times the upper limit of normal (grade 3-4). Patients in the ATV/r arm were assessed based on the presence or absence of hyperbilirubinemia through week 96. Analyses included number of confirmed virologic responders (CVR; HIV RNA<50 copies per milliliter), impact of hyperbilirubinemia on symptoms, elevations in liver enzymes, patient quality of life, and medication adherence. Through 96 weeks in the CASTLE study, 44% of patients who received ATV/r had hyperbilirubinemia at any time point, and between 12.5% and 21.6% had hyperbilirubinemia at any single study visit. At 96 weeks, 74% of patients overall and 84% and 69% of patients with and without hyperbilirubinemia, respectively, achieved CVR. Symptoms of jaundice or scleral icterus occurred in 5% of patients overall and in 11% with hyperbilirubinemia and 0% without hyperbilirubinemia. Four percent of patients with and 3% of patients without hyperbilirubinemia had grade 3-4 elevations in liver transaminases. Less than 1% of patients discontinued treatment due to hyperbilirubinemia. There were no differences in quality of life or adherence between patients with or without hyperbilirubinemia. In the CASTLE study, hyperbilirubinemia observed in the ATV/r group did not negatively impact clinical outcomes in HIV-infected patients.

CD4+ cell counts and HIV-RNA levels do not predict outcomes of community-acquired pneumonia in hospitalized HIV-infected patients

Outcomes of community-acquired pneumonia (CAP) in relation to CD4+ cell counts have not been established. We examined the correlation of CD4+ cell count and HIV-RNA level with the clinical outcomes of CAP in hospitalized HIV-infected patients. This was a retrospective study of 127 adult hospitalized patients with HIV infection enrolled with the CAP Organization (CAPO), examining the time to clinical stability (TCS), length of hospital stay (LOS), and all-cause mortality. Mortality data were available for 117 HIV-infected patients with CAP. Death within 28 days was reported in 28 patients. The risk of mortality at 28 days was not significant when adjusted for CD4+ cell count (p=0.123), HIV-RNA <400-1000 copies/ml (p=0.093), HIV-RNA ≥ 1000-10,000 copies/ml (p=0.543), and HIV-RNA ≥ 10,000-100,000 copies/ml (p=0.383). The propensity-adjusted Cox proportional hazards regression models did not show any statistically significant differences in LOS or TCS for CD4+ cell counts (p=0.590 and p=0.420, respectively) or HIV-RNA levels (p=0.470 and p=0.080, respectively). Multivariable Cox proportional hazards models did not reveal any statistically significant relationships between CD4+ cell counts or HIV-RNA levels with LOS or TCS. Our study shows that clinical outcomes of HIV-infected patients with CAP are not predicted by CD4+ cell counts or HIV-RNA levels after adjusting for confounders. The management of CAP in patients with HIV infection should not be based on CD4+ cell counts or HIV-RNA levels of the HIV infection.

Clinical Outcome of HIV-Infected Patients with Discordant Virological and Immunological Response to Antiretroviral Therapy

A subgroup of human immunodeficiency virus type 1 (HIV-1)-infected patients with severe immunodeficiency show persistently low CD4+ cell counts despite sustained viral suppression. It is unclear whether this immuno-virological discordance translates into an increased risk for clinical events. Data analysis from a large multicenter cohort incorporating 14,433 HIV-1-infected patients in Germany. Treatment-naive patients beginning antiretroviral therapy (ART) with CD4+ cell counts <200 cells/μL who achieved complete and sustained viral suppression <50 copies/mL (n = 1318) were stratified according to the duration of immuno-virological discordance (failure to achieve a CD4+ cell count ≥200 cells/μL). Groups were compared by descriptive and Poisson statistics. The time-varying discordance status was analyzed in a multivariable Cox model. During a total of 5038 person years of follow-up, 42 new AIDS events occurred. The incidence rate of new AIDS events was highest in the initial 6 months of complete viral suppression (immuno-virological discordance group, 55.06; 95% confidence interval [CI], 30.82-90.82; and immune responder group, 24.54; 95% CI, 10.59-48.35) and decreased significantly by 65% per year in patients with immuno-virological discordance (incidence risk ratio, 0.35; 95% CI, 0.14-0.92; P = .03). Immuno-virological discordance and prior AIDS diagnosis were independently associated with new AIDS events (hazard ratio, 3.10; 95% CI, 1.09-8.82; P = .03). Compared with immune responders, patients with immuno-virological discordance seem to remain at increased risk for AIDS. Absolute risk is greatly reduced after the first 6 months of complete viral suppression.

Medication persistence in the treatment of HIV infection: a review of the literature and implications for future clinical care and research

Persistence, continuous treatment with a prescribed medication or intervention, is an important, but underrecognized aspect of medication treatment, especially for HIV. In contrast to adherence, which measures the percentage of patient behavior to a prescribed therapy, persistence measures the duration during which a patient remains on a prescribed therapy. Decreased persistence for HIV treatment, or shorter duration on therapy, is associated with increased rates of virological failure, development of antiretroviral resistance, and increased morbidity and mortality. Additionally, frequency and duration of nonpersistent episodes rather than adherence may be a better predictor of clinical outcomes in HIV-infected patients on certain regimens. In this review, we codify the constructs of persistence and adherence, and further define persistence as either patient or regimen persistence. Furthermore, current literature on the clinical consequences of and factors associated with suboptimal persistence is summarized. Finally, methods to measure persistence as well as interventions that may improve persistence and clinical outcomes are suggested.

How Effective Is ART for AIDS-Related Kaposi Sarcoma?

Kaposi sarcoma (KS) is the most common HIV-related malignancy. To characterize clinical outcomes of HIV-infected patients with KS, researchers analyzed

Clinical outcomes of HIV-infected patients hospitalized with bacterial community-acquired pneumonia

There are limited and conflicting data on clinical outcomes of community-acquired pneumonia (CAP) among HIV-infected patients. Secondary analyses of clinical outcomes of CAP were performed for 118 patients with HIV infection and 2790 patients without HIV infection enrolled in the Community-Acquired Pneumonia Organization (CAPO) international study. After adjustment for significant confounders, the effect of HIV infection on length of stay (LOS) and time to clinical stability (TCS) were examined by survival analyses and overall mortality and CAP-related mortality by logistic regression methods. After adjusting for significant confounders, hospitalized HIV-infected patients with CAP did not have longer times to reach clinical stability (HR 1.126; 95% CI 0.917-1.391; p=0.251) or longer stays in the hospital (HR 1.191, 95% CI 0.979-1.449; p=0.080). In addition, HIV infection did not significantly influence overall mortality rates (OR 1.205, 95% CI 0.686-2.116; p=0.517) or CAP-related mortality rates (OR 1.338; 95% CI 0.623-3.725; p=0.355). The presence of HIV infection did not influence the clinical outcomes of CAP among patients assessed at CAPO centers. It is not intended that our results be extrapolated to populations receiving limited healthcare for advanced HIV disease, malnourishment and parasitic diseases.

Patients’ Perception and Effectiveness of a Treatment Containing Enfuvirtide When Used in HIV-Infected Patients Without Very Advanced Disease

Purpose: To evaluate the satisfaction with self-injected enfuvirtide (ENF) and the clinical outcome of HIV-infected patients without very advanced disease. Method: ESPPE is a multicenter observational study that included 103 evaluated patients showing baseline characteristics predictive of positive outcome: CD4 >100 cells/mm3, viral load (VL) <100,000 copies/mL, previous treatment with a maximum of 10 antiretroviral drugs, and concomitant use of ≥2 active drugs. By using validated surveys, patients were questioned 6 months after the prescription of ENF about their quality of life (QoL) and acceptance of self-injections and adherence to the treatment. Results: At 6 months, the mean CD4 increase was 121 cells/mm3 (p < .05) and 65% (intent-to-treat, ENF stopped=failure) had VL <50 copies/mL (p < .001). Fourteen patients discontinued the treatment, mostly due to intolerance (6). The majority (>89%) assessed all items relating QoL as “excellent,” “very good,” or “good.” The treatment satisfaction index on a visual analog scale scored a median of 8.1 out of 10; when participants were asked about the interference of injections on their daily activities, 87% answered “never” or “only sometimes.” Conclusion: Effectiveness and patients’ perception about ENF remain good when ENF was used in patients without very advanced disease. QoL was not impaired after ENF use.

Effects of Depression and Selective Serotonin Reuptake Inhibitor Use on Adherence to Highly Active Antiretroviral Therapy and on Clinical Outcomes in HIV-Infected Patients

To determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures. Retrospective cohort study. In 2 large health maintenance organizations, we measured the effects of depression (with and without SSRI use) on adherence and changes in viral and immunologic control among HIV-infected patients starting a new HAART regimen. HAART adherence, HIV RNA levels, and changes in CD4 T-cell counts through 12 months were measured. A total of 3359 patients were evaluated; 42% had a depression diagnosis, and 15% used SSRIs during HAART. Depression without SSRI use was associated with significantly decreased odds of achieving > or =90% adherence to HAART (odds ratio [OR] = 0.81, 95% confidence interval [CI]: 0.70 to 0.98; P = 0.03). Depression was associated with significantly lower odds of an HIV RNA level <500 copies/mL (OR = 0.77, 95% CI: 0.62 to 0.95; P = 0.02). Depressed patients compliant with SSRI medication (>80% adherence to SSRI) had HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART. Comparing depressed with nondepressed HIV-infected patients, CD4 T-cell responses were statistically similar; among depressed patients, those compliant with SSRI had statistically greater increases in CD4 cell responses. Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.

Clinical Outcome of HIV-Infected Patients with Sustained Virologic Response to Antiretroviral Therapy: Long-Term Follow-Up of a Multicenter Cohort

BackgroundLimited information exists on long-term prognosis of patients with sustained virologic response to antiretroviral therapy. We aimed to assess predictors of unfavorable clinical outcome in patients who maintain viral suppression with HAART.MethodsUsing data collected from ten clinic-based cohorts in Spain, we selected all antiretroviral-naive adults who initiated HAART and maintained plasma HIV-1 RNA levels <500 copies/mL throughout follow-up. Factors associated with disease progression were determined by Cox proportional-hazards models.ResultsOf 2,613 patients who started HAART, 757 fulfilled the inclusion criteria. 61% of them initiated a protease inhibitor-based HAART regimen, 29.7% a nonnucleoside reverse-transcriptase inhibitor-based regimen, and 7.8% a triple-nucleoside regimen. During 2,556 person-years of follow-up, 22 (2.9%) patients died (mortality rate 0.86 per 100 person-years), and 40 (5.3%) died or developed a new AIDS-defining event. The most common causes of death were neoplasias and liver failure. Mortality was independently associated with a CD4-T cell response <50 cells/L after 12 months of HAART (adjusted hazard ratio [AHR], 4.26 [95% confidence interval {CI}, 1.68–10.83]; P = .002), and age at initiation of HAART (AHR, 1.06 per year; 95% CI, 1.02–1.09; P = .001). Initial antiretroviral regimen chosen was not associated with different risk of clinical progression.ConclusionsPatients with sustained virologic response on HAART have a low mortality rate over time. Long-term outcome of these patients is driven by immunologic response at the end of the first year of therapy and age at the time of HAART initiation, but not by the initial antiretroviral regimen selected.

Editorial

Editorial

Osteonecrosis in Patients Infected With HIV

There is a paucity of data on clinical epidemiology of osteonecrosis in HIV-infected patients. We aimed to describe patients' characteristics and natural history of this poorly known condition. All cases of symptomatic HIV-related osteonecrosis diagnosed from 1990 through 2003 in 19 Spanish clinics were reviewed. Functional status at the last visit was assessed with the validated Western Ontario and McMaster Universities Index questionnaire. Of 54 patients analyzed, 29 (53.7%) had a single bone necrosis, and 25 (46.3%) had 2 or more sites involved. Progression of symptoms happened more often in patients with hip involvement (17/39 vs 0/8 patients; P = 0.019). Twenty patients (37%) required surgical intervention. Male sex and higher CD4 cell count were associated with surgery on multivariable analysis. Overall, at the end of the follow-up period, half of the patients had moderate to severe disability (Western Ontario and McMaster Universities Index score > or =60). During a follow-up period of 137 person-years, only 2 new episodes of osteonecrosis were observed (rate of recurrences, 1.5/100 person-years; 95% confidence interval, 0.4-5.1). HIV-related osteonecrosis is associated with significant disability over time. Location of bone necrosis, sex, and CD4 cell count may influence the outcome. The risk for recurrences for patients who have experienced 1 episode is low.