Many US AIDS patients still die when 'opportunistic' infections strike
"The main cause of mortality arises from people stopping treatment entirely," said Dr. Robert Grant, a professor at the University of California, San Francisco, who reviewed the findings but was not involved in the research.
When HIV treatment lapses, so-called "opportunistic" infections and illnesses can arise, posing a real threat to patients' health, he explained.
The bottom line, according to Grant, is that there is still "a long way to go" in prolonging the lives of Americans with HIV/AIDS.
The new study was led by Dr. Sandra Schwarcz, associate professor of epidemiology and biostatistics at the University of California, San Francisco. She and her colleagues tracked 30 years of data kept by the city's Department of Public Health, which has kept medical records on San Franciscans with HIV/AIDS since the virus first became known in 1981.
The almost 21,000 medical records in the survey are even more detailed than those kept by the federal government, and include information gathered at diagnosis as well as follow-ups every 18 to 24 months.
Information included CD4 counts (AIDS is defined as the time when the CD4, or a type of white blood cell, falls below a count of 200) and each patient's viral load. The records also showed whether patients received immunizations against deadly, opportunistic infections common to AIDS patients, such as Pneumocystis pneumonia (PCP) and Mycobacterium avium complex (MAC) as well as other causes of death.
The records were divided into three treatment eras: 1981-1986; 1987-1996; and 1997-2012.
Medications to fight HIV evolved significantly through each of those eras and continues to become more effective. In the early era—before the advent of HIV-suppressing drugs—only 7 percent of people with AIDS-related opportunistic infections lived five years or more, the study found. But in the most recent era, 65 percent lived five years or longer, the research showed.
Why are people doing better now, relative to the 1980s and early 1990s? The researchers credit not only more effective medications, but also the widespread availability of HIV testing in San Francisco, better access to care, and more effective prevention messages.
Nevertheless, 35 percent of HIV-infected people in the study who acquired an opportunistic infection in 1997-2012 still died within five years, Schwarcz and colleagues reported.
There are ways to lower those numbers, Schwarcz said.
"Number one, get diagnosed early," she said. "Individuals as well as clinicians need to be promoting testing. Early treatment, adherence to treatment, as well as being on the lookout for a range of HIV-related [illnesses], including opportunistic infections, is important."
Schwarcz, who is also senior HIV epidemiologist at the San Francisco Department of Public Health, said doctors also need to discuss medication side effects—a prime reason for treatment lapses—with their patients. Often, doctors can work with patients to help minimize side effects so that medications continue to be taken as directed.
Other issues in a patient's life, such as whether they have stable housing or a drug and/or alcohol problem, also need to be monitored to ensure adherence, Schwarcz said.
She pointed out that the demographics of San Franciscans with HIV/AIDS has shifted over time—away from gay, white men to men of color and women.
Her team was also not able to account for the impact of chronic conditions such as heart disease and diabetes, because that information was not available. That's a shortcoming in the research, Schwarcz said, because as people with HIV live longer, they develop typical diseases of aging such as cancer and heart disease.
Still, opportunistic infections can arise if HIV medication is not taken as directed. These include a brain infection called progressive multifocal leukoencephalopathy (PML), brain lymphomas and other infection-related cancers—all of which remain highly fatal for people with AIDS even today, Schwarcz said.
Grant agreed that early diagnosis of HIV infection and strict adherence to treatment are key in raising survival rates. He added that, earlier this year, a major study confirmed "that starting therapy for HIV earlier brings clinical benefits."
But he also said that a population of aging, HIV-positive patients is increasingly encountering diseases that can affect everyone.
"The causes of mortality in HIV-positive persons has changed," Grant said. "While opportunistic infections and lymphomas were the main causes of mortality in the past, mortality is now often due to lung cancer, heart disease, suicide and overdose."
These too, can be prevented, however. "Attention to substance health—including tobacco use—and mental health are keys to decreasing mortality in this era," Grant said.
The study was published recently in the Journal of Infectious Diseases.
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