• Continued Benefit From Highly Active Antiretroviral Therapy: Trends in AIDS-Related Opportunistic Illnesses in a Public Health Care System, 1990-2001 (ThOrC1443)
  Authored by D.L. Cohn, P.S. Breese, W.J. Burman, D.L. Lopez, B.L. Barth, C.A. Rietmeijer, A.J. Davidson
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The spectacular reductions in HIV-related opportunistic infections that have occurred due to combination antiretroviral therapy began in 1996. However, there has been some concern that this decline is beginning to reverse, a concern fueled by widespread reports of high rates of poor adherence, drug resistance, drug complications, virologic failure, and the significant social and medical challenges faced by many people with HIV. This analysis of opportunistic infection data from Denver provides some reassurance that the benefits of antiretroviral therapy are continuing.

Data were derived from Denver Health, an integrated public health care system which is the largest HIV care provider in Colorado. As participants in the U.S. Center for Disease Prevention's Adult Spectrum of Disease Project, patients in this care system have had chart reviews conducted every six months since 1990. The goal of this study was to compare the rates of opportunistic infections and malignancies from the period 1990-1995 to 1997-2001.

The study included 3,975 persons with HIV. The group was 91 percent male, 18 percent black, and 19 percent Hispanic. Mode of HIV acquisition was 57 percent MSM, 12 percent IDU, and 2.5 percent heterosexual. The presenting author pointed out that this demographic differs somewhat from the urban poor in other parts of the United States, which have higher proportions of non-whites, women, and those who acquired HIV through IDU. Nonetheless, he stated that in this group more than half carried psychiatric diagnoses and/or a history of substance abuse.

The rates of change -- all highly significant -- for each complication are listed below:

None of the conditions showed any reversal in the downward trend -- that is, rates declined and remained very low. In addition, there has been a 72 percent overall decline in deaths, and a 47 percent decline in HIV-related hospitalizations. Hospitalizations for non-HIV related causes have remained stable.

These data are reassuring about the continued benefits of antiretroviral therapy, even as we struggle with adherence, lipodystrophy, and drug resistance. They furthermore highlight the marked immunologic benefit accrued by treatment -- even in the absence of virologic suppression, since numerous studies of patient populations such as this one generally show suppression rates of 50 percent or lower. It is particularly gratifying that the diseases associated with the most severe and advanced forms of AIDS -- disseminated M. avium complex and CMV -- have declined the most, as these conditions are both devastating to people who have them and particularly difficult to treat.