Global Issues | HIV/AIDS |
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27 February 2002 Text: Half of U.S. HIV/AIDS Sufferers are Tested or Treated, CDC SaysHIV-infected people in United States number just under 1 million The U.S. Centers for Disease Control (CDC) is reporting a variety of new findings about the occurrence of HIV/AIDS in the United States, notably that an estimated 850,000 to 950,000 people carry the virus. Of that number, half have gone untreated or untested, according to research CDC presented at the 9th Conference on Retroviruses and Opportunistic Infections held February 24-28 in Seattle, Washington. CDC issued a document summarizing the results of several studies presented by its scientists. Estimates on the number of HIV-infected people show an increase of about 50,000 from 1998 and 2000 in the United States. The researchers attribute the increase to the wider use of highly active antiretroviral therapies (HAART), a treatment regimen that has significantly improved the long-term survival rate of those who are diagnosed with AIDS. The researchers found in another study that therapy comes with a price, however. One class of drugs frequently used in HAART, protease inhibitors, is associated with a small but heightened risk of heart attack among HIV patients. The drugs help to prevent the virus's assault on the body at the cellular level. Following is the CDC summary of findings presented this week: (begin text) CDC HIV/AIDS update Key Findings from CDC9th Conference on Retroviruses and Opportunistic Infections Seattle, February 24-28, 2002 -- An estimated 850,000 to 950,000 individuals are living with HIV in the United States, with roughly one-half untested, untreated, or both. Estimated HIV prevalence in the U.S. has increased by approximately 50,000 since 1998, with an estimated 42 to 59 percent of infected individuals not diagnosed or linked to ongoing care. -- Protease inhibitors associated with small, but increasing risk of heart attack among HIV patients. New study suggests that patients taking protease inhibitors are more likely to experience heart attacks than other HIV patients. -- Forty percent of HIV patients began treatment late; differences identified by race, risk and gender. An overall 40 percent of HIV patients in CDC study began treatment late (below CD4 level of 200). People of color, injection drug users and heterosexuals were more likely to initiate treatment late. -- Study examines shift in conditions present at death among HIV-infected. Comparison of conditions present at death in HIV-infected individuals before and after the availability of HAART shows they are less likely to die with tuberculosis, pneumocystis pneumonia, and other opportunistic illnesses and more likely to die with liver and kidney disease. AN ESTIMATED 850,000 to 950,000 INDIVIDUALS ARE LIVING WITH HIV IN THE UNITED STATES, WITH ROUGHLY ONE-HALF UNTESTED, UNTREATED, OR BOTH HIV prevalence in the United States, 2000 Between 1998 and 2000, the number of individuals living with HIV in the United States is estimated to have increased by approximately 50,000, and roughly half of all infected individuals remain untested, untreated, or both, according to a new analysis by CDC epidemiologist Patricia Fleming, Ph.D. and colleagues. According to Fleming, HIV prevalence has increased steadily as the use of highly active antiretroviral therapies (HAART) has become widespread and has prolonged the lives of HIV-infected individuals. With roughly stable HIV incidence, HIV prevalence is estimated to have increased each year by the difference between new AIDS diagnoses and deaths (23,600 in 1999, and 24,900 in 2000). Fleming now estimates that there are now between 850,000 and 950,000 Americans living with HIV and AIDS. In addition to updating overall prevalence estimates, researchers sought to determine how many of these HIV-infected individuals were aware of their infection status and had been linked to ongoing care. HIV testing and treatment are critical for the health of infected individuals, as well as for preventing the further spread of the epidemic. Findings suggest that between 42 and 59 percent of infected individuals (about 400,000 to 500,000) remain undiagnosed, untreated, or both. To examine the proportion of HIV-infected individuals who have been diagnosed, Fleming and colleagues analyzed data from 25 states with longstanding HIV and AIDS reporting in order to estimate the number of HIV diagnoses on a national level. Estimated HIV diagnoses (330,000) were then added to known AIDS prevalence (340,000) to determine that approximately 670,000 people have been diagnosed with HIV or AIDS or roughly 75 percent of those believed to be infected. Therefore, an estimated one-fourth of those infected (180,000 to 280,000) may be unaware of their full infection. Reported CD4 tests from 12 states with lab-based CD4 reporting were used as indicators of entrance into care among individuals with diagnosed HIV infection or AIDS. Study authors found that 7% of individuals with AIDS and 61% of individuals with HIV infection (but not AIDS) had no reported CD4 test. Thus, of the estimated 670,000 Americans with diagnosed HIV or AIDS, roughly one-third (225,000) may not be receiving ongoing care. According to Fleming, the new estimates point to the importance of efforts such as CDC's Serostatus Approach to Fighting the HIV Epidemic (SAFE), which focuses on reaching all HIV-infected individuals with voluntary testing, care, and services to help them establish and maintain safer behaviors. Because individuals with HIV are living longer than ever before, prevention efforts for both those at-risk of infection and those already infected are critical to slowing the U.S. epidemic. PROTEASE INHIBITORS ASSOCIATED WITH SMALL, BUT INCREASING RISK OF HEART ATTACK AMONG HIV PATIENTS Protease inhibitor use and adverse cardiovascular outcomes in ambulatory HIV patients, Dr. Scott Holmberg and colleagues - Abstract #698-T, Poster Session A new multi-city study suggests that protease inhibitors (PIs) may increase risk for heart attacks in HIV-infected patients. The study, by CDC epidemiologist, Scott Holmberg, M.D., and colleagues, analyzed the risk of myocardial infarction (heart attacks), angina (chest pain), and cerebrovascular accident (stroke), among 5,676 HIV-infected patients treated in nine HIV clinics between January 1993 and January 2001. While heart attacks were relatively uncommon throughout the study period (only 15 occurred), the incidence increased over time, and patients taking PIs were over five times more likely to experience heart attacks than other patients. Thirteen of 3,013 patients taking PIs, but only two of the 2,663 patients who did not take PIs experienced heart attacks. While heart attacks occurred most frequently in individuals with other cardiovascular risk factors (e.g. smoking, hypertension and diabetes), risk was significantly elevated among those using PIs even after controlling for these factors. However, risks of chest pain and stroke were not significantly increased among those taking PIs. According to Holmberg, this risk should be taken into consideration in decisions about the use of PIs among those with other cardiovascular risk factors. Physicians could consider other classes of HIV drugs if individuals have pre-existing risk factors for heart disease. While the risk of heart attack will not likely outweigh the benefits of PIs for patients already taking PIs, these patients should be advised to cease or treat other risks for heart disease. FORTY PERCENT OF HIV PATIENTS BEGIN TREATMENT LATE: DIFFERENCES IDENTIFIED BY RACE, RISK AND GENDER Factors associated with immunologic stage at which patients initiate antiretroviral therapy Forty percent of HIV patients initiated antiretroviral therapy (ART) "late" in a 10-city study of 4,379 patients treated from 1998 through 2000. The study, by CDC epidemiologist A.D. McNaghten, Ph.D. and colleagues, defined "late" ART treatment as treatment starting after CD4 levels fell below 200 or after a person had developed an AIDS-defining illness. Current treatment guidelines recommend that generally treatment should be offered to asymptomatic patients when CD4 counts drop below 350, but before they reach 200, as delaying treatment past this point has been shown to markedly increase a patient's risk of death. Overall, 26 percent of patients initiated ART as recommended (CD4>200 but <350), 33 percent of patients percent initiated early (CD4 >350), and 40 percent initiated late (CD4<200). By race, Latino and African-American patients were significantly more likely to initiate therapy late compared to white patents. By risk, injection drug users and heterosexuals were significantly more likely to initiate therapy late compared to men who have sex with men. According to study authors, the findings point to the better understand and address factors resulting in late initiation of treatment, especially among people of color, injection drug users, and heterosexuals. It will be important to determine if those individuals were diagnosed late in the course of their disease or if treatment was delayed despite early diagnosis. In addition to timing of treatment, choice of first treatment regimen has also been shown to play a role in patient outcomes. This study therefore analyzed the type of initial treatment regimen prescribed, and found that over half of patients (58 percent) were started initially on a highly active antiretroviral regimen (HAART), 27 percent were started on dual ART and 15 percent an other regimens. The proportion of patients prescribed HAART as their initial regimen increased overtime. Researchers were encouraged by the high level of HAART use as first regimen in this large, diverse patient population, given the clinical benefits of maximally suppressive regimens. STUDY EXAMINES SHIFT IN CONDITIONS PRESENT AT DEATH AMONG HIV-INFECTED Deaths with non AIDS-related diseases have increased as a proportion of deaths of HIV-Infected persons since the advent of HAART, Dr. Mitchell Wolfe and colleagues -- Abstract #l4, Oral Abstract Session 5 As deaths among HIV patients with tuberculosis (TB), pneumocystis pneumonia, and other opportunistic illnesses (OIs) have declined, there has been an increasing proportion of deaths among HIV-infected individuals with liver and kidney disease, according to a new six-city study. The study, conducted by CDC epidemiologist Mitchell Wolfe, M.D. and colleagues, analyzes medical information provided for HIV-infected individuals who died before (1992-1995) and after (1996-2000) the widespread availability of HAART. A specific cause of death was not always noted in the information provided by the sites, therefore, study authors noted diseases present at the time of death as probable causes of death. According to study authors, examining what diseases might be emerging as leading causes of death among HIV-infected individuals in treatment may be useful for devising new strategies to prolong life for people living with HIV and AIDS. In the HAART era, HIV-infected individuals were significantly less likely to die with TB, pneumocystis pneumonia, non-TB mycobacterial infections, or toxoplasmosis (see table below). Wolfe attributes these declines to improvements in HIV suppressive treatments and prophylaxis for opportunistic illnesses. The study also shows an increase in the proportion of non-AIDS-related causes of death, with HIV-infected individuals significantly more likely to die with liver disease and kidney disease in the HAART era (see table below). The absolute number of deaths with these causes did not increase, and further research will be needed to determine if underlying factors, such as adverse treatment outcomes or an aging HIV-infected population, are playing a role in these non-AIDS related causes of death.
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