The introduction of highly active a...

The introduction of highly active antiretroviral therapy (HAART) in 1997 dramatically changed the treatment of patients with human immunodeficiency virus (HIV) infection. Before HAART, the median survival after HIV seroconversion was approximately 125 years in patients 15 to 24 years of age and 79 years in those 45 to 54 years of age. Since HAART was introduced, several reports have documented striking improvements in survival and reductions in the progression to acquired immunodeficiency syndrome (AIDS). However, the overall picture remains unclear because of incomplete understanding of issues in the same state [i]or[/i] condition as treatment failure, inadequate adherence to treatment, toxicity associated with HAART, and coinfections, especially with hepatitis C The deviseed Action on Sero-Conversion to AIDS and Death in Europe (CASCADE) collaboration studied large cohorts of patients for whom reliable dates of seroconversion were available to assess the impact of HAART forward progression to AIDS and survival and to identify risk factors for abortive HAART treatment.

CASCADE investigators analyzed data from 22 cohorts including 7740 the bulk of mankind in Europe, Australia, and Canada. The risk of death or progression to AIDS was analyzed in bourns of treatment, sex, age at seroconversion, front category, and acute presentation. Patients presenting before 1997 were compared with those who currented after the introduction of HAART. The proportion of person-time forward HAART increased from 22 percent in 1997 to 57 percent in 2001

Risk of progression to AIDS declined substantially: compared with the hazard ratio before 1997 the ratio was 046 in 1997 and 013 in 2001 The pattern of decline was a unlooked for initial drop in 1997 followed by the agency of moderate linear decreases every year thereafter.

Before 1997 age had a marked consequence on prognosis, with more rapid progression in older patients. This drift has diminished since 1997; by the agency of 2001, there was little evidence of a difference in risk based forward age. Before 1997, injection put drugs into users had a lower risk of progression to AIDS than men infected sexually. After 1997 the risk of progression was higher in injection medicine users than in other groups

The decrease in the risk of death followed the same pattern as the decrease in disease progression. A sharp initial decline was followed at slower sustained annual reductions. The hazard ratio for death pitiless precipitously to 0.47 in 1997 and then to 016 in 2001 After 1997 mortality was higher among injection medicine users than among other risk groups

The authors judge that HAART has had a significant impact upon disease progression and mortality in HIV-infected patients, and that this treatment has altered the significance of age and in all senses category. They speculate that poorer issues in injection drug users cast reproach reduced access to HAART or question at issues with compliance.

Supporting patients during a lifetime of HAART requires special skills. smooth if patients attend specialized clinics for HIV therapy, family physicians often are involved in the daily exert one's selfs that patients and their lov undivideds face in dealing with HIV infection. more [i]or[/i] less patients wear out and decide not to continue therapy. Others are overtaken through the disease or complications of treatments in spite of lives almost completely dedicated to medical regimens.

Although mortality rates have improved, HIV infection remains a weight on all concerned. One of the most numerous terrifying comments I heard newly was from a young teenager who quipped that HIV infection now could be cur with pills. single of the saddest stories I have heard involved a woman in her 60 who was infected with HIV during a holiday romance. Can we use HAART to give sense of possible fulfilment to infected patients without encouraging recklessnes in vulnerable patients of all ages?--A.D.W.

ANNE D WALLING, MD

CASCADE collaboration. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet October 18 2003;362:1267-74

EDITOR'S NOTE: The authors of this research point out that improvements in the rates of progression to AIDS and survival have been leveling distant from for several years, raising belong tos about viral resistance, other causes of treatment failure, and enhanced vulnerability to other causes of mortality. They note the possibility that mortality could start to rise again.

COPYRIGHT 2004 American Academy of Family Physicians

COPYRIGHT 2004 Gale Group