• Causes of Death Among HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy (HAART). Aquitaine Cohort (France), 1998-1999 (Poster 299)
  Authored by F. Bonnet, P. Morlat, G. Chene, P. Mercie, D. Neau, I. Chossat, M. Decoin, C. Lewden, D. Malvy, J. L. Pellegrin, J. M. Ragnaud, M. Dupon, F. Dabis, J. Beylot, and the GECSA
  View the original abstract

The prognosis of HIV infection has dramatically improved since the introduction of HAART in the mid 90s. In spite of that, HIV and AIDS is still a terrible disease. Treatments are complicated and have many side effects, and although less frequently than before (fortunately), patients are still dying of complications related to HIV or AIDS.

The study of Bonnet et al. looked at the causes of death in HIV-infected patients in a large cohort (2,200 patients) followed in a single clinic in southwest France. They reviewed all the deaths in the years 1999 and 2000. There were a total of 107 deaths, and they were able to review 101 of them. It was interesting to notice that although most patients who died did so with very low CD4 cell counts (41% had counts less than 50 cells per mm³), a quarter of the deaths were among patients with higher CD4 counts (>200). 32% of the patients died with an undetectable viral load.

It was also very interesting to see the distribution of the causes of death, and compare it to my experience in an 850-patient clinic in St. Louis. Twenty percent of the patients died of liver failure (cirrhosis, related in most instances to chronic hepatitis C). Non-Hodgkin's lymphoma was the cause of death in 14% of the subjects and another 14% died of other cancers. Central nervous system problems (PML) was present in 13 cases and late opportunistic infections -- like CMV and MAI -- in another 10%. It was really sad to see that up to 11% of the patients died of complications of using HAART, including lactic acidosis and hepatotoxicity.

The distribution looked awfully familiar to me.

The study is important because it shows trends and identifies areas on which we should focus our efforts to improve the management of HIV infection:

• We need to look at hepatitis C and its treatment in HIV co-infected patients. We have several studies that have started to look at this issue and at the role of pegylated interferon in the management of hepatitis C in HIV infection. These studies will be, without any doubt, one of the major topics for next year's conference.

• We also need to take a particular look at lymphomas and other cancers and evaluate if we seeing more of them or if it is just because there is no opportunistic infections that it looks that way. Unfortunately, the National Cancer Institute and the ACTG stopped last year a large cohort study "Oncogenic Viral Pathogenesis and Cancer Risk Factors Among Patients with Acquired Immunodeficiency Syndrome" that was specifically going to look at these issues in patients with HIV infection in the era of HAART. I do not know all the details about that decision, but it looks like it was short-sighted.

• It is sobering that 11% of the patients died of complications directly related to therapy. This should be a reminder for everybody about how toxic these drugs really are, the need for expertise in the management of these complicated patients, and the need for better and less-toxic drugs.