Important note: Information in this article was accurate in 2003. The state of the art may have changed since the publication date.
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Lancet (10.18.03) Vol. 362: P. 1267-1274 - Monday, December 22, 2003
CASCADE Collaboration
Using Cox models, the scientists compared the effects of age at seroconversion, exposure category, sex, and presentation during acute HIV-1 infection pre-1997 (pre-HAART), in 1997- 1998 (limited HAART use) and 1999-2001 (widespread HAART use). They found that overall, the risk of progression to AIDS fell substantially after 1996. Reductions in the risk of disease progression and reductions in the risks of death were very similar: an initial sharp drop in 1998 with smaller year-by- year reductions until 2001.
The researchers found strong evidence that the effect of exposure category on AIDS prognosis changed over calendar time. "Before 1997, injecting drug users had lower risk of progression to AIDS than did men infected through having sex with men; however, this trend was reversed in 1999-2001." There was no difference in the risk of progression to AIDS between injecting drug users and people infected by sex between men and women before 1997. By 1999-2001, however, injecting drug users had a much higher risk than did the other group.
Before 1997, age had a strong effect on prognosis, with people older than 45 at higher risk of AIDS. This effect was much smaller by 1999-2001.
The authors found that in the developed world, early survival improvements after the introduction of HAART have continued to increase, although not at the same rate after 1997- 1998. "Although survival times have continued to improve between 1997 and 2001, they have not matched the early reductions in risk of death or disease progression noted soon after the introduction of HAART," they wrote. "The changing balance between increased frequency of resistance, which leads to higher rates of treatment failure, variation in the circulation of subtypes, availability of new drugs or drug classes, and other changes in clinical management policies make the longer-term effect of HAART difficult to predict. Increased survival for people with HIV infection means that non-HIV causes of death are becoming increasingly important, and high quality information on cause of death is vital to assess the effect of interventions against HIV infection. Longer follow-up of persons with known duration of HIV infection is crucial to assess whether there is a persistent leveling off in the reduction in mortality rates, or even whether mortality will begin to rise again, and to accurately estimate whether older persons do still have a poorer survival with the availability of HAART," the report concluded.
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