Prognosis in HIV and AIDS #213

Abstract

Introduction

The prognosis of adults in the developed world with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS) who are adherent with combination antiretroviral therapy (cART) is now approaching that of the general population.^1,2 This is attributable to the decreased incidence of AIDS opportunistic infections (OIs) from cART use and improved care for those with HIV-related complications.^3–5 Worldwide, the availability of cART is estimated to have saved nearly 8 million people between 2000 and 2014.⁶ Consequently, an increased proportion of deaths in HIV patients is due to organ failure, non-AIDS malignancies, substance abuse, and limitations in healthcare access. This Fast Fact provides prognostic information on the nonmalignant complications of the syndrome. Fast Fact #214 covers prognosis on AIDS-related malignancies.

Prognostic Principles

• Certain factors are correlated with a worse prognosis from AIDS-related conditions: African American or mixed races, the number of OIs, poor functional and nutritional status, anemia, active substance abuse, a low CD4+ count, and a high HIV viral load.^7–10

• For patients who do not receive cART with a CD4 count <50 cells/mm³, survival ranges between 12 and 27 months; those with CD4+ counts <20 cells/mm³ have a median survival of 11 months.²

• Many patients die with HIV or AIDS, not from it. In one large hospital-based study, 78% of the deaths were non-AIDS related.¹¹ Surprisingly, these deaths were more closely associated with cART use, a higher CD4+ count, and a suppressed HIV viral load.¹

• Hospice eligibility criteria include absence of cART, decreased performance status (Palliative Performance Scale <50%), a CD4+ count <25 cells/mcL, and a viral load >100,000 copies/mL plus either CNS lymphoma, AIDS wasting syndrome (>10% weight loss not attributable to another condition); Mycobacterium avium complex (MAC); progressive multifocal leukoencephalopathy (PML); systemic lymphoma; visceral Kaposi's sarcoma, renal failure in the absence of dialysis, cryptosporidium infection, or toxoplasmosis.

• Some experts have described a “Lazarus effect,” wherein AIDS patients appear to be imminently dying, only to experience a dramatic medical recovery with (re)institution of cART.

• Because the field of HIV medicine is rapidly evolving, close collaboration with the treating HIV specialist is recommended regarding prognosis and treatment options.

OIs and Nonmalignant HIV-Related Conditions

Not only has the incidence of OIs declined dramatically since the early 1990s, but also the five year survival after an AIDS defining OI is now 65%.¹² Hereunder are prognostic data for the most common OIs and HIV-related conditions in descending incidence during 2000–2015:

• Pneumocystis jiroveci pneumonia (PCP): incident mortality rate 9.7–11.6%. Poor prognostic indicators include age >50, respiratory failure, ICU admission, anemia, low albumin, and new HIV diagnosis.¹³ Following successful treatment of PCP, one year survival is 94% and five year survival is 73%.¹⁴

• AIDS Wasting Syndrome: five year mortality rate is 23%.¹⁵

• Cryptococcal meningitis: 90 day mortality rate is 10–19%. One year mortality rate is 16–26%. Increased age, intracranial pressure >25 cm H₂O, positive CSF cultures after two weeks therapy, cryptococcemia, and absence of cART are risk factors for mortality.^16–19

• HIV-associated dementia: one year survival is about 65%.^19–20

• Disseminated MAC infection: median survival 10 months, mortality rate is fourfold that of MAC negative matched HIV+ patients.¹⁵

• Cryptosporidial enteritis: five year survival is 81%.^3,21

• Cytomegalovirus disease including retinitis: median survival is 13–35 months.^22–23

• Toxoplasma encephalitis: 77–90% survival at 12 months if on cART, with most deaths occurring within six months.^19,24

• PML: median survival without cART is four months, overall one year survival is 50–63%. Predictors of survival beyond one year include cART adherence and CD4 + > 100 cells/mm³ at diagnosis.^25–27

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