Although treatment advances have dramatically reduced deaths from opportunistic infections related to AIDS, a new study drawing on 30 years of data from more than 20,000 patients in San Francisco suggests there is still ample room to improve. About a third—35 percent—of AIDS patients diagnosed with their first opportunistic infection from 1997 to 2012 in that city died within five years, according to the study, published in the Journal of Infectious Diseases.
"While recent research suggests that many opportunistic infections in the U.S. are now less common and, oftentimes, less lethal, we cannot forget about them," said Kpandja Djawe, PhD, of the Centers for Disease Control and Prevention (CDC) and the lead author of the study, which included researchers from CDC and the San Francisco Department of Public Health. "We need to keep them in mind, even in the context of the changing epidemiology of HIV."
For the study, researchers analyzed HIV surveillance data collected continuously over the past 30-plus years by the San Francisco Department of Public Health on initial and subsequent AIDS-defining opportunistic infections, citywide, beginning in 1981.
Untreated HIV infection progresses to AIDS, opportunistic infections, and cancers. These were common during the early years of the U.S. epidemic, when death often quickly followed an AIDS diagnosis: From 1981 to 1986, only 7 percent of patients in San Francisco diagnosed with their first opportunistic infection lived more than five years, according to the study.
Since then, with advances in antiretroviral therapy (ART), wider availability of HIV testing, and improvements in the treatment of opportunistic illnesses, survival rates have markedly risen. During the most recent period analyzed in the study (1997 to 2012), 65 percent of patients diagnosed with an AIDS-related opportunistic infection lived five more years or longer, a trend consistent with other studies.
The remaining 35 percent of AIDS patients—those who died within five years of being diagnosed with an opportunistic infection—underscore the work still to be done to address AIDS-related illnesses today, the authors noted. "Better prevention and treatment strategies, including earlier HIV diagnosis, are needed to lessen the burden of AIDS opportunistic infections, even today, in the combination ART era," said Sandra Schwarcz, MD, senior HIV epidemiologist at the San Francisco Department of Public Health and one of the authors of the study.
Indeed, some of these infections, such as progressive multifocal leukoencephalopathy (PML), and infection-related cancers, including brain lymphoma, remain associated with substantial mortality risk today, the authors found, despite an overall improvement in survival rates. In addition, the health outcomes in San Francisco may be more favorable than in some other parts of the country, where HIV testing and treatment programs may be less robust.
"The results from San Francisco are encouraging, but highlight the need to remain focused on the potential for opportunistic infections to cause devastating disease,"Henry Masur, MD, and Sarah W. Read, MD, of the National Institutes of Health, noted in a related editorial commentary. "A 35 percent mortality rate within five years of the initial AIDS-defining opportunistic infection leaves considerable room for improvement."
- AIDS opportunistic infections and infection-related cancers can strike when the immune system is badly damaged and HIV infection is not treated and progresses to AIDS.
- From 1981 to 1986, only 7 percent of AIDS patients in San Francisco diagnosed with their first opportunistic infection lived more than five years. During the most recent study period (1997 to 2012), the five-year survival rate for these patients had improved to 65 percent.
- Despite advances in treatment, 35 percent of the remaining AIDS patients diagnosed with their first opportunistic infection from 1997 to 2012 in San Francisco died within five years.
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