Simultaneous HAART improves survival in children coinfected with HIV and TB

Objectives This study assesses the outcome of current treatment guidelines and the effect of highly active antiretroviral therapy (HAART) on survival of HIV/TB‐coinfected patients in a resource‐limited setting. Methods Observational cohort study at the pediatric HIV Clinic, RML Hospital, Delhi. All HIV‐infected patients who visited the clinic for the diagnosis of TB between 2002 and 2006 were observed until 31 March 2010. TB was diagnosed either at the time of enrolment or during follow‐up visits. Clinical and epidemiological data were registered. We compared children who were given HAART with TB treatment at time of diagnosis [simultaneous therapy (ST)] and children who received delayed HAART. Survival was assessed by Kaplan–Meier method and Cox regression model. Results Among the 298 children, 126 (42.2%) had TB, including 96 who received ST (76% of 126) and 30 who did not. There were no differences between the two groups except for a lower CD4 count in patients undergoing ST. ST was associated with improved survival [hazard ratio (HR), 0.35; 95% CI, 0.20–0.74; P = 0.002] and so were year of TB diagnosis and other AIDS‐defining conditions. Multivariate analysis revealed that ST was a powerful predictor of survival (HR, 0.30; 95% CI, 0.14–0.68; P = 0.003). After adjusting for other prognostic variables such as age, gender, CD4 count at time of TB diagnosis, by Cox multivariate analysis, ST remained robustly associated with improved survival (HR, 0.32; 95% CI, 0.17–0.71; P = 0.001). Conclusions Starting HAART during tuberculosis therapy significantly improves survival and provides further impetus for the integration of TB and HIV services.     

Resistance to first-line tuberculosis drugs in three cities of Nigeria

Objectives To determine the levels of resistance to first‐line tuberculosis drugs in three cities in three geopolitical zones in Nigeria. Methods A total of 527 smear‐positive sputum samples from Abuja, Ibadan and Nnewi were cultured on BACTEC‐ MGIT 960. Drug susceptibility tests (DST) for streptomycin, isoniazid, rifampicin and ethambutol were performed on 428 culture‐positive samples on BACTEC‐MGIT960. Results Eight per cent of the specimens cultured were multi‐drug‐resistant Mycobacterium tuberculosis (MDR‐TB) with varying levels of resistance to individual and multiple first–line drugs. MDR was strongly associated with previous treatment: 5% of new and 19% of previously treated patients had MDR‐TB (OR 4.1 (95% CI 1.9–8.8), P = 0.001) and with young adult age: 63% of patients with and 38% without MDR‐TB were 25–34 years old (P = 0.01). HIV status was documented in 71%. There was no association between MDR‐TB and HIV coinfection (P = 0.9) and gender (P > 0.2 for both). Conclusions  MDR‐TB is an emerging problem in Nigeria. Developing good quality drug susceptibility test facilities, routine monitoring of drug susceptibility and improved health systems for the delivery of and adherence to first‐ and second‐line treatment are imperative to solve this problem.     

Incidence,risk factors and causes of death in an HIV care programme with a large proportion of injecting drug users

Objectives To identify factors influencing mortality in an HIV programme providing care to large numbers of injecting drug users (IDUs) and patients co‐infected with hepatitis C (HCV). Methods A longitudinal analysis of monitoring data from HIV‐infected adults who started antiretroviral therapy (ART) between 2003 and 2009 was performed. Mortality and programme attrition rates within 2 years of ART initiation were estimated. Associations with individual‐level factors were assessed with multivariable Cox and piece‐wise Cox regression. Results A total of 1671 person‐years of follow‐up from 1014 individuals was analysed. Thirty‐four percent of patients were women and 33% were current or ex‐IDUs. 36.2% of patients (90.8% of IDUs) were co‐infected with HCV. Two‐year all‐cause mortality rate was 5.4 per 100 person‐years (95% CI, 4.4–6.7). Most HIV‐related deaths occurred within 6 months of ART start (36, 67.9%), but only 5 (25.0%) non‐HIV‐related deaths were recorded during this period. Mortality was higher in older patients (HR = 2.50; 95% CI, 1.42–4.40 for ≥40 compared to 15–29 years), and in those with initial BMI < 18.5 kg/m² (HR = 3.38; 95% CI, 1.82–5.32), poor adherence to treatment (HR = 5.13; 95% CI, 2.47–10.65 during the second year of therapy), or low initial CD4 cell count (HR = 4.55; 95% CI, 1.54–13.41 for <100 compared to ≥100 cells/μl). Risk of death was not associated with IDU status (P = 0.38). Conclusion Increased mortality was associated with late presentation of patients. In this programme, death rates were similar regardless of injection drug exposure, supporting the notion that satisfactory treatment outcomes can be achieved when comprehensive care is provided to these patients.     

Growth of infants born to HIV-infected women in South Africa according to maternal and infant characteristics

Objective To evaluate growth parameters assessed by weight and length in HIV‐infected and HIV‐uninfected infants born to HIV‐infected mothers in South Africa from birth to 6 months of age. Methods We calculated z‐scores for weight‐for‐age (WAZ), length‐for‐age (LAZ) and weight‐for‐length (WLZ) among a cohort of 840 mother–infant dyads. Multivariable Cox proportional hazards models with time‐varying covariates were used to estimate the risk of falling z‐scores for WAZ, LAZ, and WLZ as a function of infant and maternal characteristics. Results By 6 months after birth, a fifth of infants had WAZ P < 0.001). The risk of WAZ falling 相似文献   

Performance of the new WHO diagnostic algorithm for smear‐negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda

Objective To compare the performance of the new WHO (2007) diagnostic algorithm for pulmonary tuberculosis (PTB) in high HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03). Methods A prospective observational cohort design was used at Reach Out Mbuya Parish HIV/AIDS Initiative, an urban slum community‐based AIDS Service Organisation (ASO) and Kayunga Rural District Government Hospital. Newly diagnosed and enrolled HIV‐infected patients were assessed for PTB. Research staff interviewed patients and staff and observed operational constraints. Results WHO07 reduced the time to diagnosis of smear‐negative PTB with increased sensitivity compared with the UgWHO03 at both sites. Time to diagnosis of smear‐negative PTB was significantly shorter at the urban ASO than at the rural ASO (12.4 vs. 28.5 days, P = 0.003). Diagnostic specificity and sensitivity [95% confidence intervals (CIs)] for smear‐negative PTB were higher at the rural hospital compared with the urban ASO: [98% (93–100%) vs. 86% (77–92%), P = 0.001] and [95% (72–100%) vs. 90% (54–99%), P > 0.05], respectively. Common barriers to implementation of algorithms included failure by patients to attend follow‐up appointments and poor adherence by healthcare workers to algorithms. Conclusion At both sites, WHO07 expedited diagnosis of smear‐negative PTB with increased diagnostic accuracy compared with the UgWHO03. The WHO07 expedited diagnosis more at the urban ASO but with more diagnostic accuracy at the rural hospital. Barriers to implementation should be taken into account when operationalising these guidelines for TB diagnosis in resource‐limited settings.     

TB, HIV-associated TB and multidrug-resistant TB on Thailand's border with Myanmar, 2006-2007

Objective To measure the burden and improve management of tuberculosis (TB), HIV‐associated TB and MDR TB in Tak Province, Thailand, which borders Myanmar. Methods From September 2006 to August 2007, we collected uniform data about TB cases and enhanced human immunodeficiency virus (HIV) counselling and testing. We provided mycobacterial culture and drug‐susceptibility testing in public or non‐governmental organization facilities. Patients were classified by nationality and, for non‐Thais, by migration status. Results Of 1662 TB cases in the 12‐month period, 1087 (65%) occurred in non‐Thais. Of non‐Thais, 415 (38%) lived in Myanmar but crossed the border for healthcare. HIV infection was diagnosed in 18% of Thais compared with 12% of non‐Thais (P < 0.01); HIV status was unknown for 22% of Thais and 27% of non‐Thais (P = 0.02). Overall, multidrug‐resistant (MDR) TB was diagnosed in 27 patients, 19 (70%) in non‐Thais. Among TB cases never previously treated for TB, no MDR cases were diagnosed in Thais or in Myanmar refugees, but six cases were diagnosed in migrants from Myanmar. Conclusions In Thailand, TB, HIV‐associated TB and MDR TB in migrants from Myanmar are important public health problems; they need to be resolved in both the countries.     

Unrecognised tuberculosis at antiretroviral therapy initiation is associated with lower CD4+ T cell recovery

Objectives To investigate whether an unrecognised diagnosis of tuberculosis (TB) at the start of antiretroviral therapy (ART) influences subsequent CD4+ T cell (CD4) count recovery in an urban HIV clinic in Uganda. Methods In a retrospective cohort study, a multivariable polynomial mixed effects model was used to estimate CD4 recovery in the first 96 weeks of ART in two groups of patients: prevalent TB (started ART while on TB treatment), unrecognised TB (developed TB within 6 months after start ART). Results Included were 511 patients with a median baseline CD4 count of 57 cells/mm³ (interquartile range: 22–130), of whom 368 (72%) had prevalent TB and 143 (28%) had unrecognised TB. Compared with prevalent TB, unrecognised TB was associated with lower CD4 count recovery at 96 weeks: ?22.3 cells/mm³ (95% confidence interval ?43.2 to ?1.5, P = 0.036). These estimates were adjusted for gender, age, baseline CD4 count and the use of zidovudine‐based regimen. Conclusions Unrecognised TB at the time of ART initiation resulted in impaired CD4 recovery compared with TB treated before ART initiation. More vigilant screening with more sensitive and rapid TB diagnostics prior to ART initiation is needed to decrease the risk of ART‐associated TB and sub‐optimal immune reconstitution.     

Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub‐Saharan Africa: systematic review and meta‐analysis

Objectives To assess the proportion of patients lost to programme (died, lost to follow‐up, transferred out) between HIV diagnosis and start of antiretroviral therapy (ART) in sub‐Saharan Africa, and determine factors associated with loss to programme. Methods Systematic review and meta‐analysis. We searched PubMed and EMBASE databases for studies in adults. Outcomes were the percentage of patients dying before starting ART, the percentage lost to follow‐up, the percentage with a CD4 cell count, the distribution of first CD4 counts and the percentage of eligible patients starting ART. Data were combined using random‐effects meta‐analysis. Results Twenty‐nine studies from sub‐Saharan Africa including 148 912 patients were analysed. Six studies covered the whole period from HIV diagnosis to ART start. Meta‐analysis of these studies showed that of the 100 patients with a positive HIV test, 72 (95% CI 60–84) had a CD4 cell count measured, 40 (95% CI 26–55) were eligible for ART and 25 (95% CI 13–37) started ART. There was substantial heterogeneity between studies (P < 0.0001). Median CD4 cell count at presentation ranged from 154 to 274 cells/μl. Patients eligible for ART were less likely to become lost to programme (25%vs. 54%, P < 0.0001), but eligible patients were more likely to die (11%vs. 5%, P < 0.0001) than ineligible patients. Loss to programme was higher in men, in patients with low CD4 cell counts and low socio‐economic status and in recent time periods. Conclusions Monitoring and care in the pre‐ART time period need improvement, with greater emphasis on patients not yet eligible for ART.     

Clinical characteristics and treatment outcome of patients with visceral leishmaniasis and HIV co‐infection in northwest Ethiopia

Objectives To describe the clinical presentation of patients with visceral leishmaniasis (VL) with and without human immunodeficiency virus (HIV) co‐infection and factors associated with poor outcome in northwest Ethiopia. Method Retrospective review of 241 patients with VL (92 with and 149 without HIV co‐infection). Results HIV co‐infection was present in 92 (38%) of the patients. Clinical presentation of VL was indistinguishable between patients with and without HIV co‐infection. Co‐infected patients had a poorer outcome i.e. either death or treatment failure (31.5%vs. 5.6%, P < 0.001). The presence of tuberculosis or sepsis syndrome among patients with VL and HIV co‐infected independently predicted death or treatment failure [odds ratio 4.5 (95% CI 1.47–13.92, P = 0.009) and 9.1 (95% CI 2.16–37.97, P = 0.003), respectively]. Despite having similar clinical presentation at the time of diagnosis, VL and HIV co‐infected patients had a higher mortality and treatment failure than immunocompetent patients. Conclusion The frequency of HIV co‐infection among patients with VL is high in the study area, and this co‐infection was associated with death or treatment failure. The clinical management of VL in HIV co‐infected patients is a major challenge that requires new treatment approaches to improve its outcome.     

Cryptococcal meningitis in HIV‐infected patients: a longitudinal study in Cambodia

Objective To describe the frequency of diagnosis of cryptococcosis among HIV‐infected patients in Phnom Penh, Cambodia, at programme entry, to investigate associated risk factors, and to determine the incidence of cryptococcal meningitis. Methods We analysed individual monitoring data from 11 970 HIV‐infected adults enrolled between 1999 and 2008. We used Kaplan–Meier naïve methods to estimate survival and retention in care and multiple logistic regression to investigate associations with individual‐level factors. Results Cryptococcal meningitis was diagnosed in 12.0% of the patients: 1066 at inclusion and 374 during follow‐up. Incidence was 20.3 per 1000 person‐years and decreased over time. At diagnosis, median age was 33 years, median CD4 cell count was 8 cells/μl, and 2.4% of patients were receiving combined antiretroviral therapy; 38.7% died and 34.6% were lost to follow‐up. Of 750 patients alive and in care after 3 months of diagnosis, 85.9% received secondary cryptococcal meningitis prophylaxis and 13.7% relapsed in median 5.7 months [interquartile range 4.1–8.8] after cryptococcal meningitis diagnosis (relapse incidence = 5.7 per 100 person‐years; 95%CI 4.7–6.9). Cryptococcal meningitis was more common in men at programme entry (adjusted OR = 2.24, 95% CI 1.67–3.00) and fell with higher levels of CD4 cell counts (P < 0.0001). Conclusions Cryptococcal meningitis remains an important cause of morbidity and mortality in Cambodian HIV‐infected patients. Our findings highlight the importance of increasing early access to HIV care and cryptococcal meningitis prophylaxis and of improving its diagnosis in resource‐limited settings.     

Increasing incidence of HIV‐ associated tuberculosis in Romanian injecting drug users

Background

A high prevalence of tuberculosis (TB) among HIV‐positive injecting drug users (IDUs) may fuel the TB epidemic in the general population of Romania. We determined the frequency and characteristics of TB in HIV‐infected IDUs referred to a national centre.

Methods

Prospective observational cohort study of all newly‐diagnosed HIV‐positive IDUs admitted to Victor Babes Hospital, Bucharest, between January 2009 and December 2014. Socio‐demographics, clinical characteristics and outcomes of HIV/TB co‐infected IDUs were compared to HIV‐positive IDUs without TB.

Results

170/598 (28.5%) HIV‐infected IDUs were diagnosed with TB. The prevalence increased from 12.5% in 2009 to 32.1% in 2014 (P < 0.001). HIV/TB co‐infected individuals had lower median CD4 cell counts 75 (vs. 450/mm³, P < 0.0001) and higher median HIV viral loads 5.6 log₁₀ (vs. 4.9 log₁₀, P < 0.0001) when presenting to healthcare services. 103/170 (60.6%) HIV/TB co‐infected IDUs were diagnosed with pulmonary TB. Resistant Mycobacterium tuberculosis strains were common, with 18/105 (17.1%) of patients having Multi‐Drug Resistant (MDR) disease. Higher mortality rate was associated with TB co‐infection (P < 0.0001), extra‐pulmonary TB (P = 0.0026) and extensively drug resistant TB (P = 0.024).

Conclusions

Tuberculosis (TB) is an increasing problem in HIV‐infected IDUs in Romania. Presentation is often with advanced HIV, significant TB drug resistance and consequent outcomes are poor.

     

Impact of a national HIV voluntary counselling and testing (VCT) campaign on VCT in a rural hospital in Tanzania

Objective  To evaluate the impact of a national HIV voluntary counselling and testing (VCT) campaign on presentation to HIV care in a rural population in Tanzania. Methods  Retrospective analysis of data of the VCT and of the National AIDS Control Programme registers of the St. Francis Designated District Hospital at Ifakara for the two 6‐month periods before (2007) and after (2008) the National VCT Campaign. Results  There were 4354 individuals presenting at St. Francis Hospital tested for HIV; 2065 (47.4%) before the VCT Campaign and 2289 (52.6%) afterwards. The overall HIV test positivity was 24.6% and higher in 2007 than in 2008 (26%vs. 23%, P = 0.034). This rate was much higher than the Tanzanian National HIV prevalence of 5.7%. Of 1069 individuals who tested HIV‐positive, the proportion of married, divorced or widowed individuals and those who lived further than 10 km from the hospital increased from 2007 to 2008. In 356 HIV‐infected persons with available data, the median CD4 cell count increased from 137 to 163 cells/mm³ (P = 0.058), while the WHO clinical stage was similar in both periods. Enroling into the National AIDS Control Programme was significantly more common in 2008 (42%vs. 30%, P < 0.001). In a multivariate analysis, the only positive predictor of testing HIV positive when presenting for care after the National VCT Campaign was being married (OR 1.61, 95%CI 1.21–2.15, P = 0.001) or divorced/widowed compared to single (OR 4.58, 95% CI 3.00–8.12, P < 0.001). Conclusions  Our results suggest that the National VCT Campaign raised awareness and readiness to test for HIV in a remote rural setting and that the HIV‐positive test rate is much higher in conjunction with a specific HIV care programme.     

Standard-dose efavirenz vs. standard-dose nevirapine in antiretroviral regimens among HIV-1 and tuberculosis co-infected patients who received rifampicin

Background

There is limited comparative data between efavirenz (EFV) 600 mg/day and nevirapine (NVP) 400 mg/day‐based antiretroviral therapy (ART) among HIV‐1 patients with tuberculosis (TB) and receiving rifampicin.

Methods

A retrospective cohort study was conducted in all ART‐naïve patients who were receiving rifampicin between January 2002 and December 2005.

Results

Of 188 patients, 77 and 111 patients were initiated on EFV‐based ART (EFV group) and NVP‐based ART (NVP group), respectively. Overall, median [interquartile range (IQR)] CD4 count was 36 (15–77) cells/μL and median (IQR) viral load was 5.6 (5.2–5.9) HIV‐1 RNA log copies/mL. At 48 weeks, 77.9% (60/77) in the EFV group and 67.6% (75/111) in the NVP group achieved HIV‐1 RNA <50 copies/mL (P=0.140, odds ratio =0.590, 95% confidence interval=0.302–1.153). At 24 and 48 weeks, respective median CD4 counts were 174 and 254 cells/μL in the EFV group and 156 and 218 cells/μL in the NVP group (P>0.05). By binary logistic regression, treatment group was not associated with HIV‐1 RNA <50 copies/mL (P>0.05). No patient in the EFV group and eight (7.2%) patients in the NVP group discontinued ART because of adverse reactions (P=0.084).

Conclusions

For HIV–TB co‐infected patients who receive rifampicin, efficacy of 600 mg EFV‐based and 400 mg NVP‐based ART may be similar, although adverse events tend to be higher in NVP‐based ART.     

Septicaemia in a population‐based HIV clinical cohort in rural Uganda, 1996–2007: incidence,aetiology, antimicrobial drug resistance and impact of antiretroviral therapy

Objectives To describe the incidence and aetiology of septicaemia, and antimicrobial drug resistance in HIV‐infected and uninfected individuals, and the impact of antiretroviral therapy (ART) on septicaemia. Methods Between 1996 and 2007, we followed up a rural population–based cohort of HIV‐infected and uninfected participants. The aetiology and incidence of septicaemia, and antimicrobial drug resistances were determined. ART became available in 2004, and its impact on the incidence of septicaemia was examined. Results The overall septicaemia incidence (per 1000 pyrs) was 32.4 (95% CI 26.2–40.6) but was only 2.6 (95% CI 1.3–6.2) in HIV‐negative patients and 67.1 (95% CI 53.4–85.4) in HIV‐positive patients not on ART. Among those on ART, the overall incidence was 71.5 (95% CI 47.1–114.3), although it was 121.4 (95%CI 77.9–200.4) in the first year on ART and 37.4 (95%CI 18.9–85.2) in the subsequent period. Septicaemia incidence was significantly associated with lower CD4 counts. The commonest isolates were Streptococcus pneumoniae (SPN, n = 68) and Non‐typhi salmonellae (NTS, n = 42). Most SPN isolates were susceptible to ceftriaxone and erythromycin, while resistance to cotrimoxazole and penicillin was common. All NTS isolates were susceptible to ciprofloxacin, but resistance to cotrimoxazole and chloramphenicol was common. Conclusions Septicaemia incidence was higher in HIV‐infected than in HIV‐uninfected participants, and it remained high for some time among those who started ART. Starting ART earlier at higher CD4 counts is likely to lead to lower septicaemia incidence. Both SPN and NTS, the commonest isolates, were resistant to most commonly available antimicrobials. Blood culture laboratory surveillance systems to monitor antibiotic susceptibility and inform treatment guidelines are needed in Africa.     

The changing pattern of tuberculosis and HIV co-infection in immigrants and Spaniards in the last 20 years

OBJECTIVES: To evaluate the impact of immigration on tuberculosis (TB)-HIV co-infection in Spain in a prospective cohort of HIV patients. METHODS: Among 7761 HIV patients, we evaluated 1284 with at least one episode of TB between 1987 and 2006. Variables were compared between immigrants and Spaniards. RESULTS: Incidence of TB decreased from 20 to five cases per 100 patient-years in 2006 (P<0.01) and was always higher in immigrants than in Spaniards. The proportion of immigrants increased, reaching almost 50% of both new cases of HIV and TB-HIV co-infection in 2006. In 34.4% of patients, TB and HIV infection were diagnosed within the same year; simultaneous diagnosis was more frequent in immigrants (83.3%vs. 16.7%, P<0.001). Mortality was associated independently with age [hazard ratio (HR) 1.03, 95% confidence interval (CI) 1.01-1.05], TB diagnosis before 1996 (HR 2.6, 95% CI 1.8-3.6), use of highly active antiretroviral treatment (HR 0.494, 95% CI 0.37-0.66) and CD4 cell count at TB diagnosis (HR 0.996, 95% CI 0.995-0.997). CONCLUSIONS: Immigrants have a major impact on the incidence of TB in HIV patients, slowing down the decreasing trend in Spain. Simultaneous diagnosis of the co-infection in immigrants reveals a need to intensify HIV case finding in immigrants in Spain.     

The role of diabetes co-morbidity for tuberculosis treatment outcomes: a prospective cohort study from mwanza, Tanzania

ABSTRACT: BACKGROUND: Due to the association between diabetes and pulmonary tuberculosis (TB), diabetes may threaten the control of TB. In a prospective cohort study nested in a nutrition trial, we investigated the role of diabetes on changes in anthropometry, grip strength, and clinical parameters over a five months follow-up period. METHODS: Among pulmonary TB patients with known diabetes status, we assessed anthropometry and clinical parameters (e.g. haemoglobin) at baseline and after two and five months of TB treatment. A linear mixed-effects model (repeated measurements) was used to investigate the role of diabetes during recovery. RESULTS: Of 1205 TB patients, the mean (standard deviation) age was 36.6 (13.0) years, 40.9 % were females, 48.9 % were HIV co-infected, and 16.3 % had diabetes. TB patients with diabetes co-morbidity experienced a lower weight gain at two (1.3 kg, CI95% 0.5; 2.0, p = 0.001) and five months (1.0 kg, CI 95 % 0.3; 1.7, p = 0.007). Similarly, the increase in the level of haemoglobin was lower among TB patients with diabetes co-morbidity after two (Delta 0.6 g/dL, CI95% 0.3; 0.9 p < 0.001) and five months (Delta 0.5 g/dL, CI95% 0.2; 0.9 p = 0.004) of TB treatment, respectively. CONCLUSION: TB patients initiating TB treatment with diabetes co-morbidity experience delayed recovery of body mass and haemoglobin, which are important for the functional recovery from disease.     

The impact of gender and income on survival and retention in a South African antiretroviral therapy programme

Objectives Despite the rapid expansion of antiretroviral therapy (ART) services in Africa, there are few data on whether outcomes differ for women and men and what factors may drive such variation. We investigated the association of gender and income with survival and retention in a South African ART programme. Methods A total of 2196 treatment‐naïve adults were followed for 1 year on ART. Proportional hazards regression was used to explore associations between baseline characteristics and survival and loss‐to‐follow‐up (LTFU). Results Patients were predominantly female (67%). Men presented at an older age and with more advanced HIV disease, and during early ART the crude death rate was higher among men than women (22.8 vs 12.5/100 person‐years; P = 0.002). However in multivariate analysis, gender was not significantly associated with survival after adjusting for baseline clinical and immunovirological status (HR = 1.46, 95% CI = 0.96–2.22; P = 0.076). In late ART (4–12 months), there was no gender difference in mortality rates (3.5 vs 3.8/100 person‐years; P = 0.817). In multivariate analysis, survival was strongly associated with age (HR = 1.05, 95% CI = 1.02–1.09; P < 0.001), CD4 count >150 vs <50 cells/μl (HR = 0.35, 95% CI = 0.14–0.87; P = 0.023) and any monthly income vs none (HR = 0.47, 95% CI = 0.25–0.88; P = 0.018). Having some monthly income was protective against LTFU at 1 year on ART (adjusted HR = 0.56, 95% CI = 0.39–0.82; P = 0.002). Conclusion Men’s high early mortality on ART appears due largely to their presentation with more advanced HIV disease. Efforts are needed to enrol men into care earlier in HIV disease and to reduce socio‐economic inequalities in ART programme outcomes.     

Major surgery seems not to influence HIV disease progression in haemophilia patients

The influence of major surgery on HIV disease progression and decline in CD4⁺ cell count was evaluated in 23 seropositive haemophilia patients. 24 HIV-infected patients served as non-operated controls. In addition, 32 age-matched seronegative subjects were included. The follow-up time was up to 5 years. During the course of the study, eight of the operated (35%) and 11 of the non-operated (48%) subjects developed HIV-related symptoms (P = 0.267). The relative risk for developing HIV-related symptoms after surgery was 0.60 (95% CI 0.25; 1.48). A significant decline in CD4⁺ cell counts was observed in both the surgery (4.0 × 10⁶/l/month, 95% CI 2.0; 6.0 × 10⁶, P = 0.001) and the non-surgery (4.0 × 10⁶/l/month, 95% CI 2.0; 6.0 × 10⁶, P = 0.004) seropositive subgroup, but no difference between the two subgroups was seen (P = 0.793). HIV (6.0 × 10⁶/l/month, 95% CI 2.1; 9.9 × 10⁶, P = 0.0005) but not surgery (?1.0 × 10⁶/l/month, 95% CI ?3.0; 0.96 × 10⁶, P = 0.647) was an independent predictor for the decline in CD34⁺ cell count. No interaction effect was observed between HIV infection and surgery (P = 0.361). The annual amount of factor concentrate used for regular replacement therapy did not influence the decline in CD4⁺ cell count (P = 0.492). We conclude that major surgery may be considered in symptom-free HIV-seropositive haemophilia patients, with CD4⁺ cell counts 0.20 × 10⁹/l under similar premises as for seronegative subjects.