The European Journal of Public Health Advance Access originally published online on December 10, 2007
The European Journal of Public Health 2008 18(3):345-347; doi:10.1093/eurpub/ckm117
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Miscellaneous |
Characteristics trends, mortality and morbidity in persons newly diagnosed HIV positive during the last decade: the profile of new HIV diagnosed people
C. Delpierre1,2, V. Lauwers-Cances1, P. Pugliese3, I. Poizot-Martin4, E Billaud5, C. Duvivier6, Y. Yazdanpanah7, L. Cuzin1,8 and the nadis group*
1 Inserm U558, IFR126, Toulouse, F-31073, France
2 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, USA
3 Unit of Infectious and Tropical Diseases, Hôpital Archet-I, Nice, France
4 Unit CISIH-Sud, Hôpital Sainte-Marguerite, Marseille, France
5 Unit of Infectious and Tropical Diseases, Hôpital Hôtel-Dieu, Nantes, France
6 Unit of Infectious and Tropical Diseases, Inserm U720, University Pierre-et-Marie-Curie, Hôpital La Pitié-Salpêtrière, Paris, France
7 Unit of Infectious and Tropical Diseases, Hôpital de Tourcoing, Tourcoing, France
8 Unit of Infectious and Tropical Diseases, Hôpital Purpan, France
Correspondence: C. Delpierre, Harvard School of Public Health, Department of Society, Human Development and Health, Landmark centre, 401 park drive, Boston, MA, USA, tel: 617-998-1005, e-mail: cyrildelpierre{at}yahoo.fr; cdelpier{at}hsph.harvard.edu
Received September 19, 2007, accepted November 5, 2007
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Abstract |
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We analysed mortality, morbidity and trends in the characteristics, including risk factors of late testing, in 6805 the patients newly diagnosed for HIV infection between 1 January 1996 and 1 July 2006. The proportion of individuals in high risk groups of infection, as MSM, has decreased over time whereas the proportion of those in low risk of infection, as heterosexual persons in couple with children, has increased. This population is mainly diagnosed late with major consequences on morbidity and mortality.
Keywords: HAART era, HIV trends, Late testing, morbidity, mortality
Since the introduction of highly active antiretroviral therapy (HAART) and the use of preventive antimicrobials, the incidence of opportunistic infections and AIDS defining events (ADE) have been dramatically reduced.1 Therefore, AIDS surveillance data no longer provides a timely description of the HIV epidemic2 and several countries implemented new HIV surveillance systems, as in France in 2003.3
The use of cohort databases constitutes an alternative to collect data on patients newly diagnosed with HIV. The main purpose of this study was to analyse trends in the characteristics, including late testing, and to describe mortality and morbidity of the patients newly diagnosed HIV-positive between January 1996 and July 2006.
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Methods |
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The cohort database
Information was collected from six large universitary-affiliated infectious disease centres, well distributed on French territory, which maintain prospective cohorts of all HIV-1 infected patients who seek care in the centres, via an electronic medical record described in details elsewhere.4 This tool is used from 2000 and includes retrospective medical chart abstraction through 1996 with prospective real-time entry of medical data at each visit. There are an estimated 134 000 people living with HIV in France (http://www.invs.sante.fr/publications/2007/10ans_vih/rapport_vih_sida_10ans-3-Surveillance.pdf) thus, we estimate those diagnosed and followed by the participating centres during the study period (n = 6805) represent 5% of people living with HIV/AIDS in France.
Data collection
Collected variables at HIV diagnosis were: gender, age, route of transmission, calendar period of HIV diagnosis (5 periods of 2 years), the dates of any ADE or death with its cause, CD4 cell count, chronic hepatitis B or C coinfection status, employment status, living in couple or not, with or without children. Patients were classified as ‘late testers’ if they presented with an ADE or <200 CD4 cells/mm3 within the year of HIV diagnosis and as ‘unknown’ if CD4 count during the year following diagnosis was missing.
Statistical analysis
Trends over time were tested using the Cochran-Armitage test for trend. To analyse trends of risk factors of late testing, interactions between period and factors of interest were tested into a logistic regression model, adjusted on the medical centre. Statistical analyses were performed using SAS (version 9.1; SAS Institute; Cary, NC, USA).
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Results |
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Characteristics of the 6805 patients of the cohort are presented in table 1. The number of new diagnosis for HIV infection decreased over time. The proportion of patients <30 years decreased, from 33.6% in 1996–97 to 25.4% in 2004–06, as the proportion above 40 years increased. Women proportion increased over time, from 24.6% in 1996–97 to 33.4% in 2004–06. MSM proportion decreased until 2003 and stayed stable, since whereas the proportion of heterosexual women increased, as the proportion of unknown route of infection. Regarding employment status, the proportion of inactivity increased between until 2000–03 (11.3% in 1996–97 versus 20.1% in 2002–03, P < 0.0001) then decreased in 2004–06 (13.3%, P < 0.0001 compared to 2002–03). Regarding marital status, the proportion of persons living in couple with children has increased over time as the proportion of single persons without children decreased.
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Over the whole period, 2023 patients (29.7%) were classified as late testers, 3279 (48.2%) as non-late, and 1503 (22.1%) as ‘unknown’. The proportion of late testing decreased over time. In multivariate analysis it was associated with age over 30 years, route of infection other than MSM, chronic hepatitis B or C coinfection, living in couple with children and being diagnosed for HIV before 2003. Interactions between period of HIV diagnosis and risk factors were not statistically significant and thus no changes in risk factors for late testing were observed over time.
Regarding mortality, 181 deaths (2.7%) were recorded, 118 among late testers (5.8%) and 25 among non-late testers (0.8%). The overall mortality rate was 5.6/1000 persons-years, and was higher for late testers (12.8/1000 persons-years versus 1.7/1000 persons-years for non-late testers), particularly during the year of HIV diagnosis [24.4/1000 persons-years for late testers vs 0.3/1000 persons-years among non-late testers (P < 0.0001)]. Among the 139 patients (76.8%) with a specified cause of death, the main cause was AIDS/HIV-related (42.5%), followed by cardiovascular disease (12.2%), viral hepatitis (7.2%) and suicide (5%). Causes of death were not different according to late testing except for suicide, more frequent in non-late testers (25 vs 0%, P < 0.0001).
Regarding morbidity, 1377 patients (20.2%) presented with an ADE, among whom 998 patients (72.5%) within the year of HIV diagnosis, this proportion staying stable over time (table 1). Among the 1377 patients, 1097 had a description of their ADE, for a total of 1296 ADE, 160 patients (among whom 91.9% were late testers) having more than one described ADE. Pneumocystis jiroveci pneumonia (PCP) was the most frequent ADE (23.5%), followed by Tuberculosis (TB) (17.7%). The proportion of PCP stayed stable over time whereas the proportion of TB increased (12.2% in 1996–97 vs 22.8% in 2004–2006). These two ADE were more frequent among late testers (41.6 versus 27.5%, P = 0.008), whereas lymphoma and other ADE were more frequent among non-late testers (9.9 versus 3.5%, P = 0.006 and 26.4 versus 11.5%, P < 0.0001, respectively).
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Discussion |
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To our knowledge, this study provides the most up-to-date description of the population newly diagnosed for HIV infection in France since 1996. The proportion of heterosexual population has increased over time as the proportion of MSM decreased. The proportion of MSM stopped to decrease in 2003, which may be the first signs of a possible increase of new HIV infections in this population, as observed elsewhere in Europe.5,6
The increasing proportion of women, also reported in United Kingdom or Italia 2,7 could be partly attributed to the increasing proportion of women from sub-Saharan Africa over time in France.8 Due to legal restrictions, it was not possible to collect country of birth information in our cohort. But this population could declare more frequently unknown route of infection9 and may partly explain the increasing part of unknown modality of exposure in our study, which is for a large part heterosexual transmission.2
The proportion of persons living in couple, with children increased with time. This population was mainly diagnosed late. The proportion of late testing (38.2%) decreased over time, but related risk factors did not change over the whole period. Late testing had a major impact on mortality (65.2% of the deaths) particularly in the year following HIV diagnosis, and on morbidity (72.5% of the ADEs), due to lack of access to HAART and preventive chemotherapy. Thus, PCP remained the leading ADE, as observed elsewhere.10
Our study has some limits. Patients with missing data for late testing were younger, more frequently infected through intravenous drug use, with a chronic viral coinfection, unemployed and diagnosed in 1996–97. Some of these factors were associated with late testing in our study and thus the proportion of late testers could be underestimated. Moreover migrants could represent an important part of late testers.11 The rate of death could be underestimated in our population, as observed with other database.12 However, we focused only on patients diagnosed with HIV since 1996, with a limited risk of death limiting the potential bias. Moreover, the rate of death was comparable with other French studies conducted since 1996.13
This study showed that the profile of persons newly diagnosed with HIV has changed over time. The proportion of high risk groups of infection, as MSM or injecting drug users decreased as the proportion of groups at low risk of infection, as heterosexual persons increased. This population is more likely to be diagnosed late, with major consequences on morbidity and mortality. Actions focusing on this population should recognize the impact of late testing and promote more frequent HIV testing.
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Acknowledgements |
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We are indebted to all the participants in the cohort, and all the medical team in the different centres who collect the information, without whom this work would not have been possible. We are grateful to the National Agency of AIDS Research (ANRS) and to the Association of Aids Research (ARS) for their financial supports.
Conflicts of interest: None declared.
Key points
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Footnotes |
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* Isabelle Poizot-Martin, Patricia Enel, Marie-Pierrre Drogoul-Vey, Pierre Druart, Jean-Albert Gastaut, Lise Cuzin, Bruno Marchou, Martine Barone, Pascal Pugliese, Christian Pradier, Jacques Durant, Véronique Mondin, Pierre Dellamonica, Eric Billaud, Thomas Jovelin, Christine Guerbois, François Raffi, Yann Gérard, Yazdan Yazdanpanah, Philippe Choisy, Claudine Duvivier, Rachid Agher, Christine Katlama
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References |
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