International Journal of Epidemiology, Vol 28, 541-549, Copyright © 1999 by International Epidemiological Association
M Prins, RP Brettle, JR Robertson, I Hernandez Aguado, B Broers, N Carre, DJ Goldberg, R Zangerle, RA Coutinho and A van den Hoek
BACKGROUND: Human immunodeficiency virus (HIV) disease progression might
vary by geographical region due to differences in the spectrum of
HIV-related illnesses and (access to) health care. Therefore, the effect of
geographical region, next to the effect of other potential cofactors, on
disease progression in 664 injecting drug users (IDU) with documented HIV
seroconversion from eight cohorts in Europe was studied. METHODS:
Kaplan-Meier methods and Cox proportional hazards analysis were performed
to assess the effect of geographical region, other sociodemographics, drug
use and repeated HIV exposure on progression from HIV seroconversion to
immunosuppression, AIDS and death with AIDS. We considered the confounding
effect of study-design related factors (e.g. setting of follow-up), and
accounted for pre-AIDS death from natural causes by imputing when each
endpoint would have occurred, had they not died without AIDS. RESULTS:
Estimates of progression to AIDS and death with AIDS were substantially
faster after taking pre-AIDS mortality into account. Median incubation time
from seroconversion to the first CD4 count < 200 cells/microliter was
7.7 years (95% CI: 7.1-8.3) and to AIDS 10.4 years (95% CI: 9.8-infinity).
The 10-year survival was 70.3% (95% CI: 62.8-76.6). The relative hazards
(RH) of AIDS for IDU from central and southern Europe compared with IDU
from northern Europe was 1.9 (95% CI: 1.2-3.0) and 1.2 (95% CI: 0.6-2.3),
respectively, before, and 1.5 (95% CI: 0.7-3.2) and 1.1 (95% CI: 0.6-2.3)
after taking differences in study-design related factors into account.
Accounting for these factors, the RH of death with AIDS was 0.9 (95% CI:
0.3-2.5) for central and 1.2 (95% CI: 0.4- 3.4) for southern Europe
compared with northern Europe. For the first CD4 count < 200
cells/microliter these figures were 0.8 (95% CI: 0.5- 1.4) and 0.8 (95% CI:
0.5-1.4). Age at seroconversion was the strongest predictor of disease
progression. No statistically significant differences in disease
progression were found by gender, foreign nationality, drug use and
potential repeated HIV exposure. CONCLUSIONS: We found no evidence for
regional variability in HIV disease progression among European IDU. Future
studies evaluating geographical differences should consider the confounding
effect of study-design related factors and differential non-AIDS mortality.
As age is an important determinant of disease progression, it should be
considered in recommending treatment.
ARTICLES
Geographical variation in disease progression in HIV-1 seroconverted injecting drug users in Europe?
Municipal Health Service, Division of Public Health and Environment, Amsterdam, The Netherlands.
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