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AIDS survival in San Francisco by era of ART therapy

July 17 2015

San Francisco was in the eye of the AIDS storm when first described in 1981. Kpandja Djawe and colleagues compared survival after a diagnosis of AIDS over 3 eras of antiretroviral therapy (ART) - 1981-1986 (pre-ART), 1987-1996 (mono or dual ART) and 1997-2012 (HAART or triple combination ART). Outcomes improved dramatically during the third era, as is well recognized, but the longer term survival after each infection of cancer is not so well documented.

Of 20,858 AIDS patients with at least one opportunistic infection, 14.4% were in the pre-ART era, 67.6% in the second era and 18% in the HAART era. The overall survival rates by year are shown in the figure, compared with those for the 39% (8,163) who presented with Pneumocystis pneumonia (PCP), 6.6% (1,381) with oesophageal candidiasis and 4.2% (883) who developed cryptococcal meningitis.

The relative rates of PCP, oesophageal candidiasis and cryptococcosis in the pre-ART and HAART era were 55% to 30%, 3% to 10% and 3.5% to 5.8%, for reasons that are not immediately apparent. PCP prophylaxis was introduced in 1989 but fails to reach those who do not know their HIV status or choose not to take it.

What all the survival curves demonstrate is the immediate death rates after presentation with AIDS have not materially changed over time, and that there is continuing mortality for all patients who present with AIDS. These survival curves are worse than many other countries such as Thailand for similar AIDS presentations. The outcomes for those with oesophageal candidiasis and especially cryptococcosis is substantially worse than for PCP. Indeed the outcomes for cryptococcosis in the HAART era is as bad as immunoblastic lymphoma.

Editorial "Opportunistic Infections & Mortality: Still room for improvement ": Masur H &  Read SW JID 2015:212, 1348