HIV Mortality Research Articles

Eighteen-year follow-up report of the surveillance and prevention of an HIV/AIDS outbreak amongst plasma donors in Hebei Province, China.

BackgroundThere has been a clear increase in HIV-1 infection cases in recent years in Hebei Province, China, and transmission via blood is one of the risk factors in the early. This article aimed to investigate the HIV infection rate and control efficiency among the paid blood donor population over a period of 18 years.MethodsFrom 1995–2013, HIV/AIDS cases among former blood donors in Hebei Province were registered and closely monitored to collect data of all-cause mortality, intervention measures to prevent family transmission, disease transmission between couples as well as between mothers and infants, and HAART therapy outcomes.ResultsA total of 326 cases were identified as directly infected with HIV/AIDS during plasma donation in Hebei Province. Of these, 146 cases (44.8 %) were identified in the same year as infection; 180 cases (55.2 %) were identified 1–18 years after infection because they did not participate in the 1995 screening. The final case was identified in February 2012. By 2013, the mortality rate and survival rate of plasma donor-related HIV/AIDS was 54.9 % and 45.1 %, respectively. The identified transmission rate between couples was 11.3 % (8/71); this rate during the same year as infection was 3.3 % (1/30), and the rate 4–17 years after HIV infection was 17.1 % (7/41). Approximately 91.2 % (145/159) of married women of childbearing age did not have children after being informed of HIV infection. Only 8.8 % (14/159) of these women had children after being informed of HIV infection. The mother-to-infant transmission rate was 38.5 % (5/13).The HAART coverage rate has increased from 10.1 % (16/159) in 2003 to 83.6 % (127/152) in 2013. Since 1999, the HIV mortality rate has trended up; by 2013, the cumulative mortality rate reached 54.9 % (179/326). After HAART was initiated in China, the death rate decreased to some extent. Second generation transmission (via couple or mother-to-infant transmission) among blood donor-related HIV cases accounted for approximately 4.0 % (13/326). All first- or second-generation cases were infected with HIV-1 subtype B.ConclusionsIn this accident of HIV-infection among plasma donors in Hebei Province, a total of 339 direct and second-generation cases have been identified over 18 years of monitoring. Favorable clinical results have been achieved using intervention measurements and antiviral therapy.

Cost-effectiveness of population-level expansion of highly active antiretroviral treatment for HIV in British Columbia, Canada: a modelling study

Widespread HIV screening and access to highly active antiretroviral treatment (ART) were cost effective in mathematical models, but population-level implementation has led to questions about cost, value, and feasibility. In 1996, British Columbia, Canada, introduced universal coverage of drug and other health-care costs for people with HIV/AIDS and and began extensive scale-up in access to ART. We aimed to assess the cost-effectiveness of ART scale-up in British Columbia compared with hypothetical scenarios of constrained treatment access. Using comprehensive linked population-level data, we populated a dynamic, compartmental transmission model to simulate the HIV/AIDS epidemic in British Columbia from 1997 to 2010. We estimated HIV incidence, prevalence, mortality, costs (in 2010 CAN$), and quality-adjusted life-years (QALYs) for the study period, which was 1997-2010. We calculated incremental cost-effectiveness ratios from societal and third-party-payer perspectives to compare actual practice (true numbers of individuals accessing ART) to scenarios of constrained expansion (75% and 50% probability of accessing ART). We also investigated structural and parameter uncertainty. Actual practice resulted in 263 averted incident cases compared with 75% of observed access and 676 averted cases compared with 50% of observed access to ART. From a third-party-payer perspective, actual practice resulted in incremental cost-effectiveness ratios of $23 679 per QALY versus 75% access and $24 250 per QALY versus 50% access. From a societal perspective, actual practice was cost saving within the study period. When the model was extended to 2035, current observed access resulted in cumulative savings of $25·1 million compared with the 75% access scenario and $65·5 million compared with the 50% access scenario. ART scale-up in British Columbia has decreased HIV-related morbidity, mortality, and transmission. Resulting incremental cost-effectiveness ratios for actual practice, derived within a limited timeframe, were within established cost-effectiveness thresholds and were cost saving from a societal perspective. BC Ministry of Health, National Institute of Drug Abuse at the US National Institutes of Health.

Secondary education and HIV infection in Botswana.

In The Lancet Global Health Jan-Walter De Neve and colleagues present exciting results from an important study of the effect of a policy change that increased access to education among junior high school students in Botswana in 1996. The policy change led to an average increase of 0.8 years of schooling among teenagers who were just young enough to benefit from this policy. Using age-specific exposure to the policy as an instrumental variable De Neve and colleagues identified increases in education that were unlikely to be correlated with other factors that also affect HIV status and then showed that individuals who gained an additional year of schooling due to the policy were 8.1 percentage points (p=0.008) less likely to test positive for HIV about a decade later when most of those exposed to the policy were then in their mid-20s. Hence De Neve and colleagues provide strong and convincing evidence that increased education in Botswana was protective against HIV infection among young adults and is even cost effective by most standards. Their results were strongest among women (11.6 percentage points per extra year p=0.046) which is especially important given the worldwide inequities in access to secondary schooling for girls especially in Africa. Although this study provides important new insights into this important global health issue it has a few limitations. First the results are generalisable only to individuals who were surveyed and provided a blood sample which could be undermined if there were important rates of mortality or migration or if education was associated with completing the survey or consenting to an HIV test. Second the study was also not able to identify effect of education on risk of HIV infection for the entire lifetime. Irrespective of these considerations increasing access to education in low-income countries should be an important priority because of the proven economic returns to such investments. The health returns from education such as its potential role in HIV and child mortality should also make it a top priority for the global health community. (Excerpts)

Unemployment, public-sector health care expenditure and HIV mortality: An analysis of 74 countries, 1981-2009.

BackgroundThe global economic downturn has been associated with increased unemployment and reduced public–sector expenditure on health care (PSEH). We determined the association between unemployment, PSEH and HIV mortality.MethodsData were obtained from the World Bank and the World Health Organisation (1981–2009). Multivariate regression analysis was implemented, controlling for country–specific demographics and infrastructure. Time–lag analyses and robustness–checks were performed.FindingsData were available for 74 countries (unemployment analysis) and 75 countries (PSEH analysis), equating to 2.19 billion and 2.22 billion people, respectively, as of 2009. A 1% increase in unemployment was associated with a significant increase in HIV mortality (men: 0.1861, 95% CI: 0.0977 to 0.2744, P = 0.0000, women: 0.0383, 95% CI: 0.0108 to 0.0657, P = 0.0064). A 1% increase in PSEH was associated with a significant decrease in HIV mortality (men: –0.5015, 95% CI: –0.7432 to –0.2598, P = 0.0001; women: –0.1562, 95% CI: –0.2404 to –0.0720, P = 0.0003). Time–lag analysis showed that significant changes in HIV mortality continued for up to 5 years following variations in both unemployment and PSEH.InterpretationUnemployment increases were associated with significant HIV mortality increases. PSEH increases were associated with reduced HIV mortality. The facilitation of access–to–care for the unemployed and policy interventions which aim to protect PSEH could contribute to improved HIV outcomes.

Effect of integrating HIV and addiction care for non-engaging HIV-infected opiate-dependent patients.

HIV-positive substance dependent patients contribute disproportionally to HIV morbidity and mortality as a result of poor compliance with their HIV treatment. For HIV-positive opiate-dependent patients integrating HIV and addiction care improves HIV morbidity but the effect on addiction morbidity is not known. This study aims to establish if integrating HIV and addiction care has a significant effect on addiction and HIV morbidity for non-engaging HIV-positive opiate-dependent patients. Patients attending the National Drug Treatment Centre who had disengaged from their HIV treatment in St James's Hospital were recruited to receive HIV care integrated into their methadone maintenance programme. Outcome was investigated in terms of urine toxicology (opiates, cocaine, cannabis and amphetamines); adherence to methadone; proportion receiving directly observed antiretroviral therapy; proportion HIV virally suppressed; and the CD4 cell count. No significant change in substance use or methadone adherence was demonstrated in the 19 recruited participants. There was a significant increase in the proportion receiving directly observed antiretroviral therapy, and in the CD4 cell count. Integration of HIV and addiction care optimises the physical health of non-engaging HIV-positive opiate-dependent patients with no substantial effect on their methadone maintenance programme.

Incidence and predictors of attrition from antiretroviral care among adults in a rural HIV clinic in Coastal Kenya: a retrospective cohort study

BackgroundScale up of antiretroviral therapy (ART) has led to substantial declines in HIV related morbidity and mortality. However, attrition from ART care remains a major public health concern and has been identified as one of the key reportable indicators in assessing the success of ART programs. This study describes the incidence and predictors of attrition among adults initiating ART in a rural HIV clinic in Coastal Kenya.MethodsA retrospective cohort study design was used. Adults (≥15 years) initiated ART between January 2008 and December 2010 were followed up for two years. Attrition was defined as individuals who were either reported dead or lost to follow up (LFU, ≥ 180 days late since the last clinic visit). Kaplan Meier survival probabilities and Weibull baseline hazard regression analyses were used to model the incidence and predictors of time to attrition.ResultsOf the 928 eligible participants, 308 (33.2% [95% CI, 30.2 – 36.3]) underwent attrition at an incident rate of 23.1 (95% CI, 20.6 – 25.8)/100 pyo. Attrition at 6 and 12 months was 18.4% (95% CI, 16.0 – 21.1) and 23.2% (95% CI, 19.9 – 25.3) respectively. Gender (male vs. female, adjusted hazard ratio [95% CI], p-value: 1.5 [1.1 – 2.0], p = 0.014), age (15 – 24 vs. ≥ 45 years, 2.2 [1.3 – 3.7], p = 0.034) and baseline CD4 T-cell count (100 – 350 cells/uL vs. <100 cells/uL, 0.5 [0.3 – 0.7], p = 0.002) were independent predictors of time to attrition.ConclusionsA third of individuals initiating ART were either reported dead or LFU during two years of care, with more than a half of these occurring within six months of treatment initiation. Practical and sustainable biomedical interventions and psychosocial support systems are warranted to improve ART retention in this setting.

Factors associated with methadone treatment duration: a Cox regression analysis.

This study examined retention rates and associated predictors of methadone maintenance treatment (MMT) duration among 128 newly admitted patients in Taiwan. A semi-structured questionnaire was used to obtain demographic and drug use history. Daily records of methadone taken and test results for HIV, HCV, and morphine toxicology were taken from a computerized medical registry. Cox regression analyses were performed to examine factors associated with MMT duration. MMT retention rates were 80.5%, 68.8%, 53.9%, and 41.4% for 3, 6, 12, and 18 months, respectively. Excluding 38 patients incarcerated during the study period, retention rates were 81.1%, 73.3%, 61.1%, and 48.9% for 3 months, 6 months, 12 months, and 18 months, respectively. No participant seroconverted to HIV and 1 died during the 18-months follow-up. Results showed that being female, imprisonment, a longer distance from house to clinic, having a lower methadone dose after 30 days, being HCV positive, and in the New Taipei city program predicted early patient dropout. The findings suggest favorable MMT outcomes of HIV seroincidence and mortality. Results indicate that the need to minimize travel distance and to provide programs that meet women’s requirements justify expansion of MMT clinics in Taiwan.

A comparison of liver disease mortality with HIV and overdose mortality among Georgia prisoners and releasees: a 2-decade cohort study of prisoners incarcerated in 1991.

We investigated whether eventual causes of death among a cohort of inmates imprisoned in the southeastern United States differed from those in previous prisoner studies. We matched 23 510 prisoners in Georgia, a state with historically low levels of heroin consumption but moderate amounts of injection drug use, who were incarcerated on June 30, 1991, to death registries through 2010. Main exposure was 4-year time intervals over 2 decades of observation; main outcome was mortality from liver disease, HIV, and overdose. Although the HIV-related mortality rate exceeded that from liver-related conditions before 2003, liver disease subsequently surpassed HIV as a cause of death. Among 3863 deaths, 22 (0.6%) occurred within 2 weeks after release from prison. Of these, only 2 were caused by accidental poisoning (likely drug overdose). Cardiovascular disease and cancer were the most frequent causes of death in this aging cohort. Our study design deemphasized immediate deaths but highlighted long-term sequelae of exposure to viral hepatitis and alcohol. Treating hepatitis C and implementing interventions to manage alcohol use disorders may improve survival among prisoners in the Southeast.

Latent and Active Tuberculosis Infection Increase Immune Activation in Individuals Co-Infected with HIV

In recent years, chronic immune activation and systemic inflammation have emerged as hallmarks of HIV disease progression and mortality. Several studies indicate that soluble inflammatory biomarkers (sCD14, IL-6, IL-8, CRP and hyaluronic acid), as well as surface markers of T-cell activation (CD38, HLA-DR) independently predict progression to AIDS and mortality in HIV-infected individuals. While co-infections have been shown to contribute to immune activation, the impact of latent tuberculosis infection (LTBI), which is widely endemic in the areas most affected by the global AIDS epidemic, has not been evaluated. We hypothesized that both active and latent states of Mycobacterium tuberculosis co-infection contribute to elevated immune activation as measured by these markers. In HIV-infected individuals with active, but not latent TB, we found elevated levels of soluble markers associated with monocyte activation. Interestingly, T-cell activation was elevated individuals with both latent and active TB. These results suggest that in the highly TB- and HIV-endemic settings of southern Africa, latent TB-associated T-cell activation may contribute to HIV disease progression and exacerbate the HIV epidemic. In addition, our findings indicate that aggressive campaigns to treat LTBI in HIV-infected individuals in high-burden countries will not only impact TB rates, but may also slow HIV progression. SignificanceLatent tuberculosis, which affects an estimated 1/3 of the world's population, has long been thought to be a relatively benign, quiescent state of M. tuberculosis infection. While HIV co-infection is known to exacerbate M. tuberculosis infection and increase the risk of developing active TB, little is known about the potential effect of latent TB infection on HIV disease. This study shows that HIV-infected individuals with both active and latent TB have elevated levels of inflammation and immune activation, biomarkers of HIV disease progression and elevated risk of mortality. These results suggest that, in the context of HIV, latent TB infection may be associated with increased risk of progression to AIDS and mortality.

Delayed initiation of anti-retroviral therapy in TB/HIV co-infected patients, Sanyati District, Zimbabwe, 2011-2012.

IntroductionTuberculosis (TB) remains a public health problem and is driven by HIV. Recent studies indicate that anti-retroviral therapy (ART) initiated during the first two months of anti-TB treatment (ATT) reduces risk of HIV morbidity and mortality. In Sanyati district, 14% of TB/HIV co-infected patients were initiated on ART during TB treatment, in 2010. The study was conducted to determine the magnitude and determinants of delay in ART initiation, in TB/HIV co-infected patients.MethodsAn analytic cross sectional study was conducted at three study sites in Sanyati district. The outcome was delayed ART initiation, being failure to be initiated on ART during the first two months of ATT. Respondents were interviewed using pre-tested questionnaires. Epi-Info™ was used to generate frequencies, means, odds ratios and 95% confidence intervals. Stratified and logistic regression analysis was done.ResultsOf the 186 respondents, 63% had delayed ART initiation. Median delay from initiation of ATT to ART was 48 days (Q1=20; Q3=82). Risk factors for delayed ART initiation were: being treated for TB first time, AOR=2.23 (p=0.03); initially registered for HIV care outside Sanyati, AOR=3.08 (p<0.01); staying more than 5km from a clinic, AOR=3.29 (p<0.01). Enabling factors for early ART initiation was having a family member on ART, AOR=0.23 (p<0.01).ConclusionSignificant delay and barriers to ART initiation were identified. Decentralization of ART initiation should be expedited. ART initiation should be expedited in patients with identified risk factors for delaying ART initiation. Peer support should be strengthened in families and community. Periodic evaluation of magnitude of delay and impact of early ART initiation in TB/HIV patients is recommended.

Risk of polysubstance use and co-occurring internalizing and externalizing symptoms among adolescent sexual minority girls

Risk of polysubstance use and co-occurring internalizing and externalizing symptoms among adolescent sexual minority girls

Inpatient mortality of HIV-infected adults in sub-Saharan Africa and possible interventions: a mixed methods review.

BackgroundDespite the increased availability of anti-retroviral therapy, in-hospital HIV mortality remains high in sub-Saharan Africa. Reports from Senegal, Malawi, and Tanzania show rates of in-hospital, HIV-related mortality ranging from 24.2% to 44%. This mixed methods review explored the potential causes of preventable in-hospital mortality associated with HIV infections in sub-Saharan Africa in the anti-retroviral era.ResultsBased on our experience as healthcare providers in Africa and a review of the literature we identified 5 health systems failures which may cause preventable in-hospital mortality, including: 1) late presentation of HIV cases, 2) low rates of in-hospital HIV testing, 3) poor laboratory capacity which limits CD4 T-cell testing and the diagnosis of opportunistic infections, 4) delay in initiation of anti-retroviral therapy in-hospital, and 5) problems associated with loss to follow-up upon discharge from hospital.ConclusionOur findings, together with the current available literature, should be used to develop practical interventions that can be implemented to reduce in-hospital mortality.

The relationship of physical performance with HIV disease and mortality.

To evaluate whether HIV infection was associated with reduced physical performance, and to examine if reduced physical performance predicted mortality in our aging cohort of HIV-infected and HIV-uninfected persons. Prospective, observational cohort of current and former injection drug users in the AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland, USA. The Short Physical Performance Battery (SPPB) was used as an objective measure of physical performance and measured semiannually along with behavioral and demographic data. Correlates of reduced physical performance (SPPB score ≤10) were identified and the relationship between reduced physical performance, HIV infection and mortality was analyzed by Cox regression. Among 12 270 person-visits contributed by 1627 participants, the median age was 51, 30.3% were HIV-infected and 32.6% had an SPPB score 10 or less. In multivariable models, HIV infection was independently associated with 30% increased odds of reduced physical performance [odds ratio 1.30; 95% confidence interval (CI):1.12-1.52]. Reduced physical performance predicted mortality in a dose-response manner and within all HIV disease strata. Whereas reduced physical performance alone (hazard ratio 2.52, 95% CI: 1.59-4.00) and HIV infection alone (hazard ratio 2.78, 95% CI: 1.70-4.54) increased mortality, HIV-infected participants with reduced physical performance had a six-fold increased mortality risk (hazard ratio 6.03, 95% CI: 3.80-10.0) compared with HIV-uninfected participants with higher physical performance. HIV infection was independently associated with reduced physical performance. HIV and reduced physical performance have independent and joint effects on mortality. Physical performance measurement may be an important research and clinical tool to predict adverse outcomes among aging HIV-infected persons.

Annual rates of decline in child, maternal, HIV, and tuberculosis mortality across 109 countries of low and middle income from 1990 to 2013: an assessment of the feasibility of post-2015 goals.

Measuring a country's health performance has focused mostly on estimating levels of mortality. An alternative is to measure rates of decline in mortality, which are more sensitive to changes in health policy than are mortality levels. Historical rates of decline in mortality can also help test the feasibility of future health goals (eg, post-2015). We aimed to assess the annual rates of decline in under-5, maternal, tuberculosis, and HIV mortality over the past two decades for 109 low-income and middle-income countries. For the period 1990-2013, we estimated annual rates of decline in under-5 mortality (deaths per 1000 livebirths), the maternal mortality ratio (deaths per 100 000 livebirths), and tuberculosis and HIV mortality (deaths per 100 000 population per year) using published data from UNICEF and WHO. For every 5-year interval (eg, 1990-95), we defined performance as the size of the annual rate of decline for every mortality indicator. Subsequently, we tested the feasibility of post-2015 goals by estimating the year by which countries would achieve 2030 targets proposed by The Lancet's Commission on Investing in Health (ie, 20 deaths per 1000 for under-5 mortality, 94 deaths per 100 000 for maternal mortality, four deaths per 100 000 for tuberculosis mortality, and eight deaths per 100 000 for HIV mortality) at observed country and aspirational best-performer (90th percentile) rates. From 2005 to 2013, the mean annual rate of decline in under-5 mortality was 4·3% (95% uncertainty interval [UI] 3·9-4·6), for maternal mortality it was 3·3% (2·5-4·1), for tuberculosis mortality 4·1% (2·8-5·4), and for HIV mortality 2·2% (0·1-4·3); aspirational best-performer rates per year were 7·1% (6·8-7·5), 6·3% (5·5-7·1), 12·8% (11·5-14·1), and 15·3% (13·2-17·4), respectively. The top two country performers were Macedonia and South Africa for under-5 mortality, Belarus and Bulgaria for maternal mortality, Uzbekistan and Macedonia for tuberculosis mortality, and Namibia and Rwanda for HIV mortality. At aspirational rates of decline, The Lancet's Commission on Investing in Health target for under-5 mortality would be achieved by 50-64% of countries, 35-41% of countries would achieve the 2030 target for maternal mortality, 74-90% of countries would meet the goal for tuberculosis mortality, and 66-82% of countries would achieve the target for HIV mortality.

Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study

BackgroundAntiretroviral treatment (ART) has significantly reduced HIV mortality in South Africa. The benefits have not been experienced by all groups. Here we investigate the factors associated with these inequities.DesignThis study was located in a rural South African setting and used data collected from 2007 to 2010, the period when decentralised ART became available. Approximately one-third of the population were of Mozambican origin. There was a pattern of repeated circular migration between urban areas and this community. Survival analysis models were developed to identify demographic, socioeconomic, and spatial risk factors for HIV mortality.ResultsAmong the study population of 105,149 individuals, there were 2,890 deaths. The HIV/TB mortality rate decreased by 27% between 2007–2008 and 2009–2010. For other causes of death, the reduction was 10%. Bivariate analysis found that the HIV/TB mortality risk was lower for: those living within 5 km of the Bhubezi Community Health Centre; women; young adults; in-migrants with a longer period of residence; permanent residents; and members of households owning motorised transport, holding higher socioeconomic positions, and with higher levels of education. Multivariate modelling showed, in addition, that those with South Africa as their country of origin had an increased risk of HIV/TB mortality compared to those with Mozambican origins. For males, those of South African origin, and recent in-migrants, the risk of death associated with HIV/TB was significantly greater than that due to other causes.ConclusionsIn this community, a combination of factors was associated with an increased risk of dying of HIV/TB over the period of the roll-out of ART. There is evidence for the presence of barriers to successful treatment for particular sub-groups in the population, which must be addressed if the recent improvements in population-level mortality are to be maintained.

Quality of life and wellbeing among HIV outpatients in East Africa: a multicentre observational study.

BackgroundGlobal health investment has reduced HIV mortality and transmission. However, little is known of patient-reported outcomes alongside ART rollout. This study aimed to measure wellbeing using patient-reported outcome measures (PROMS) among outpatients at PEPFAR-funded facilities.MethodsIn a multicentre 2 country cross-sectional study, adults attending 12 facilities in Kenya and Uganda gave self-reported data on quality of life (physical and mental wellbeing dimensions), functional and a measure of multidimensional problems (physical, psychological, social and spiritual).ResultsAmong the 1,337 participants, multidimensional problems were more common in psychological, spiritual and social domains than in physical. In multivariable analysis using GEE to adjust for facility effect, the mental health subscale of quality of life was lower for people with limited functional status (B = -5.27, 95% CI -5.99, 1. -4.56 p < 0.001) and higher for wealthier people (B = 0.91, 95% CI 0.48, 1.33, p < 0.001). The physical health subscale of quality of life was lower for those with limited functional status (B = -8.58, 95% CI -9.46 to -7.70, p < 0.001) and those who had a caregiver present (B = -1.97, 95% CI -3.72 to -0.23, p = 0.027), higher for wealthier people (B = 1.14, 95% CI 0.65, 1.64, p < 0.001), and positively associated with CD4 count (B = 1.61, 95% CI 1.08-2.14, p < 0.001). Multidimensional problems were more burdensome for people with limited functional status (B = -2.06, 95% CI -2.46 to -1.66, p < 0.001), and less burdensome with more education (B = 0.63, 95% CI 0.25-1.00, p = 0.001) or ART use (B = 0.94, 95% CI 0.34-1.53, p = 0.002).ConclusionsMultidimensional problems are highly prevalent, and worse with declining function. Importantly, ART use does not appear to be protective for self-reported physical and mental dimensions of quality of life. Assessment and management of self-reported wellbeing must form part of HIV care and treatment services to ensure maximum benefit from ART investment.

The association between development assistance for health and malaria, HIV and tuberculosis mortality: A cross-national analysis

Development assistance for health (DAH) and foreign aid have been criticized for being poorly associated with health and economic outcomes on a national level. This study is an attempt to examine whether DAH targeted specifically to malaria, HIV and tuberculosis (TB) is associated with changes in malaria, HIV and TB mortality, respectively. A dataset of DAH targeted to malaria, HIV and TB and corresponding malaria-, HIV- and TB-specific mortality was compiled for 120 low- and middle-income countries. Regression analysis was performed using country and time-period fixed effects and control variables. While malaria and HIV DAH were associated with reductions in malaria and HIV mortality, respectively, TB DAH was not significantly associated with reductions in TB mortality. Estimates were consistent in various sensitivity analyses, including generalized method of moments estimation, addition of extra controls and analysis of a multiply imputed dataset. In conclusion, targeted DAH is associated with reduction of HIV and malaria mortality on a national level.

Saquinavir/r containing initial antiretroviral therapy (ART)-long term evaluation in Polish Observational Cohort of HIV/AIDS Patients (POLCA) Study Group

BackgroundSince the introduction of highly active antiretroviral treatment significant decrease of HIV related morbidity and mortality has been noted. Ritonavir boosted saquinavir is an alternatively recommended protease inhibitor. Therefore we evaluated log term efficacy and safety of saquinavir/r (SQV/r) containing initial antiretroviral regimen on the basis of Polish Observational Cohort of HIV/AIDS Patients (POLCA).Materials and Methods The analysed data were prospectively collected in routine clinical practice and included ART naive patients starting SQV/r regiment as their first ART. ResultsFrom among 259 naive patients, who started SQV/r containing regimen 56.1% continued it for 24 months. Majority of the patients were male (74.9%). Similar proportion of patients was infected by IVDU (40.1%) and by sexual contact (47.1%). Median time from initial diagnosis was 2.16 years. Median baseline lymphocytes count was 210cells/mm3.Viral failure defined as HIV RNA>200copies/ml in at least two consecutive tests or>500copies/ml in one test was observed in 30 patients (11.5%). Analysing treatment related toxicities we found gradual decrease in proportion of patients with proteinuria (44.4–26%). Proportion of patients with normal total cholesterol, LDL and triglycerides decreased after 6 months of treatment and remained stable, whereas proportion of patients with normal HDL increased gradually to the end of observation. 23% of patients discontinued SQV/r containing regimen due to side effects, mainly gastrointestinal. ConclusionsSaquinavir/r containing regimen remains a valuable and safe option for patients with indications to protease inhibitor based antiretroviral treatment.

Using the TIME model in Spectrum to estimate tuberculosis-HIV incidence and mortality.

Objectives:Reliable estimates of the joint burden of HIV and tuberculosis epidemics are crucial to planning strategic global and national tuberculosis responses. Prior to the Global Tuberculosis Report 2013, the Global Tuberculosis Programme (GTB) released estimates for tuberculosis–HIV incidence at the global level only. Neither GTB nor United Nations Programme on HIV/AIDS (UNAIDS) published country specific estimates for tuberculosis–HIV mortality. We used a regression approach that combined all available data from GTB and UNAIDS in order to estimate tuberculosis–HIV incidence and mortality at country level.Methods:A regression method was devised to relate CD4 dynamics (based on national Spectrum files) to an increased relative risk (RR) of tuberculosis disease. The objective function is based on least squares and incorporates all available country-level estimates of tuberculosis–HIV incidence. Global regression parameters, obtained from averaging results over countries with population survey estimates for tuberculosis–HIV burden, were applied to countries with no survey tuberculosis–HIV incidence estimates.Results:The method produced results that are in reasonably close agreement with existing GTB estimates for global tuberculosis–HIV burden. It estimated that tuberculosis–HIV accounts for 12.6% of global tuberculosis incidence, 21.3% of all tuberculosis deaths, and 20% of all HIV deaths as estimated by the Spectrum AIDS Impact Module (AIM). Regional estimates show the highest absolute incidence burden in East and Southeast Asia, and the highest per capita burden in sub-Saharan Africa, where between 12.5% (Central sub-Saharan Africa) and 60.6% (Southern sub-Saharan Africa) of all tuberculosis disease occurs in people living with HIV (PLWH). Tuberculosis mortality follows a similar pattern, except that a disproportionate percentage of global tuberculosis deaths (12.1%) relative to global incidence (8.7%) occurred in Southern sub-Saharan Africa.Conclusion:The disaggregation of tuberculosis incidence using a regression method on RR of tuberculosis disease and all available data on HIV burden (from UNAIDS) and tuberculosis–HIV testing (survey, sentinel and routine surveillance data) produces results that closely match GTB estimates for 2011. The tuberculosis–HIV incidence and mortality results were published in the Global Tuberculosis Report 2013. Several limitations of and potential improvements to the process are suggested.

Correcting and estimating HIV mortality in Thailand based on 2005 verbal autopsy data focusing on demographic factors, 1996-2009

Background: It is known that death registry (DR) underestimates HIV deaths. The objectives of this study were to examine under-reporting/misclassification and to estimate HIV mortality in Thailand during 1996-2009 from a model based on 2005 verbal autopsy (VA) data. Methods: Logistic regression was used to predict HIV deaths from the VA dataset with and without demographic covariates. This full model was then used to predict individual HIV deaths from the DR dataset of provinces in which VA was conducted. The proportions in the remaining provinces were predicted from spatial interpolation based on coefficients of the VA provinces. Results: Area under Receiver Operating Characteristic curve of the full model was 0.969 compared to 0.879 of the simple cross-referencing model when demographic covariates were not included. DR-reported HIV deaths accounted for only one-third of all VA-estimated HIV deaths. The most misclassified HIV deaths were those registered as tuberculosis and mental and nervous system. Under-reporting was most common among females and people aged 20-39 years, and effect of province was highest in the upper north and upper south regions. Conclusions: For approximately two-thirds of all HIV deaths estimated by the full model, the causes were reported under other categories, not HIV. Demographic variables are essential for accurately correcting causes of death from death registries.