US EPA

6985555 

Journal Article 

Natural history of opportunistic disease in an HIV-infected urban clinical cohort (Reprinted from Annals of Internal Medicine, vol 124, pg 633-642, 1996) 

Moore, RD; Chaisson, RE 

1997 

Yes 

Formulary
ISSN: 1082-801X 

32 

S32-S42 

WOS:A1997WC57300004 

Objective. To determine the effect of contemporary clinical care on the natural history of opportunistic disease in an urban population infected with the human immunodeficiency virus (HIV). Setting. Urban university HIV clinic. Design. Retrospective and prospective observational study. Patients. One thousand two hundred forty-six HIV-infected patients with CD4(+) counts of 300 cells/mm(3) or less. Measurements. Incidence rates and Kaplan-Meier estimates of the probability of developing opportunistic disease, and the association between preventive drug therapies and the occurrence of opportunistic infection. Results. The most common opportunistic disease was Candida esophagitis, which had an incidence of 13.3 events per 100 person-years and a 3-year Kaplan-Meier probability of 0.30. Pneumocystis carinii pneumonia. Mycobacterium avium complex bacteremia, cytomegalovirus, and the acquired immunodeficiency syndrome dementia complex occurred at rates of 5 to 9 events per 100 person-years and 3-year Kaplan-Meier probabilities of 0.15 to 0.22. Non-Hodgkin lymphoma, M. tuberculosis infection, progressive multifocal leukoencephalopathy, and cryptosporidiosis were the least common disorders, with an incidence of about 1 to 2 events per 100 person-years and a 3-year pneumonia, and herpes zoster decreased (p < 0.05) between 1989-1992 and 1993-1995. Fluconazole use was associated with a decreased relative rate of 0.49 (p = 0.06) for cryptococcal meningitis and a decreased relative rate of 0.61 (p = 0.005) for esophageal candidiasis. Rifabutin use was associated with a decreased relative rate of 0.37 (p = 0.002) for M. avium complex bacteremia, and trimethoprim-sulfamethoxazole use was associated with decreased relative rates of 0.33 (p = 0.02) for secondary P. carinii pneumonia and 0.55 (p = 0.08) for primary P. carinii pneumonia. Candidiasis, herpes zoster, and M. tuberculosis infection first occurred at a median CD4(+) count greater than 100 cells/mm(3), but all other opportunistic diseases first occurred at a median CD4(+) count less than 50 cells/mm(3). Median survival after diagnosis varied from 35 days for non-Hodgkin lymphoma to 680 days for herpes zoster. Conclusions. In the patients studied, the incidences of secondary P. carinii pneumonia, cryptococcal meningitis, and herpes zoster have declined in the past 5 years. The incidences of primary P. carinii pneumonia and Kaposi sarcoma appear to be declining compared with historical estimates. However, although these and other opportunistic diseases continue to be relatively frequent complications of HIV infection, they are first occurring at more advanced immunosuppression than in the past. Continued efforts are needed to develop effective strategies for preventing opportunistic disease in very advanced HIV infection.