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Sabin C.A.,University College London | Cooper D.A.,University of New South Wales | Collins S.,HIV i Base | Schechter M.,Federal University of Rio de Janeiro
AIDS | Year: 2013

Guidelines for the initiation of combination antiretroviral therapy (cART) in those living with HIV are provided by several national and international treatment guidelines committees. Following recent changes to some of these guidelines, there is now considerable variation between the guidelines in terms of the recommendations for initiation of cART among asymptomatic individuals with high (>350 cells/μl) CD4 cell counts. In this review we compare the schemes used for rating evidence by the various committees and assess the strengths and weaknesses of the available evidence for initiating cART at higher CD4 cell counts. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Rosenfeld D.,Keele University | Ridge D.,University of Westminster | Catalan J.,South Kensington and Chelsea Mental Health Center | Delpech V.,Public Health England | And 3 more authors.
Journal of Aging Studies | Year: 2016

Studies of disclosure amongst older people living with HIV (PLWH) are uninformed by critical social-gerontological approaches that can help us to appreciate how older PLWH see and treat age as relevant to disclosure of their HIV status. These approaches include an ethnomethodologically-informed social constructionism that explores how 'the' life course (a cultural framework depicting individuals' movement through predictable developmental stages from birth to death) is used as an interpretive resource for determining self and others' characteristics, capacities, and social circumstances: a process Rosenfeld and Gallagher (2002) termed 'lifecoursing'. Applying this approach to our analysis of 74 life-history interviews and three focus groups with older (aged 50. +) people living with HIV in the United Kingdom, we uncover the central role that lifecoursing plays in participants' decision-making surrounding disclosure of their HIV to their children and/or older parents. Analysis of participants' accounts uncovered four criteria for disclosure: the relevance of their HIV to the other, the other's knowledge about HIV, the likelihood of the disclosure causing the other emotional distress, and the other's ability to keep the disclosed confidential. To determine if these criteria were met in relation to specific children and/or elders, participants engaged in lifecoursing, evaluating the other's knowledge of HIV, and capacity to appropriately manage the disclosure, by reference to their age. The use of assumptions about age and life-course location in decision-making regarding disclosure of HIV reflects a more nuanced engagement with age in the disclosure decision-making process than has been captured by previous research into HIV disclosure, including on the part of people aging with HIV. © 2016 Elsevier Inc.

Miners A.,London School of Hygiene and Tropical Medicine | Phillips A.,University College London | Kreif N.,London School of Hygiene and Tropical Medicine | Rodger A.,University College London | And 45 more authors.
The Lancet HIV | Year: 2014

Background: Combination antiretroviral therapy has substantially increased life-expectancy in people living with HIV, but the eff ects of chronic infection on health-related quality of life (HRQoL) are unclear. We aimed to compare HRQoL in people with HIV and the general population. Methods: We merged two UK cross-sectional surveys: the ASTRA study, which recruited participants aged 18 years or older with HIV from eight outpatient clinics in the UK between Feb 1, 2011, and Dec 31, 2012; and the Health Survey for England (HSE) 2011, which measures health and health-related behaviours in individuals living in a random sample of private households in England. The ASTRA study has data for 3258 people (response rate 64%) and HSE for 8503 people aged 18 years or older (response rate 66%). HRQoL was assessed with the Euroqol 5D questionnaire 3 level (EQ-5D-3L) instrument that measures health on fi ve domains, each with three levels. The responses are scored on a scale where a value of 1 represents perfect health and a value of 0 represents death, known as the utility score. We used multivariable models to compare utility scores between the HIV and general population samples with adjustment for several sociodemographic factors. Findings: 3151 (97%) of 3258 of participants in ASTRA and 7424 (87%) of 8503 participants in HSE had complete EQ-5D-3L data. The EQ-5D-3L utility score was lower for people with HIV compared with that in the general population (marginal eff ect in utility score adjusted for age, and sex/sexuality -0·11; 95% CI -0·13 to -0·10; p<0·0001). HRQoL was lower for people with HIV for all EQ-5D-3L domains, particularly for anxiety/depression. The diff erence in utility score was signifi cant after adjustment for several additional sociodemographic variables (ethnic origin, education, having children, and smoking status) and was apparent across all CD4 cell count, antiretroviral therapy, and viral load strata, but was greatest for those people diagnosed with HIV in earlier calendar periods. Reduction in HRQoL with age was not greater in people with HIV than in the general population (pinteraction>0·05). Interpretation: People living with HIV have signifi cantly lower HRQoL than do the general population, despite most HIV positive individuals in this study being virologically and immunologically stable. Although this diff erence could in part be due to factors other than HIV, this study provides additional evidence of the loss of health that can be avoided through prevention of further HIV infections. © Miners et al.

Lundgren J.D.,Copenhagen University | Babiker A.G.,University College London | Gordin F.,George Washington University | Emery S.,University of New South Wales | And 15 more authors.
New England Journal of Medicine | Year: 2015

Background Data from randomized trials are lacking on the benefits and risks of initiating antiretroviral therapy in patients with asymptomatic human immunodeficiency virus (HIV) infection who have a CD4+ count of more than 350 cells per cubic millimeter. Methods We randomly assigned HIV-positive adults who had a CD4+ count of more than 500 cells per cubic millimeter to start antiretroviral therapy immediately (immediate-initiation group) or to defer it until the CD4+ count decreased to 350 cells per cubic millimeter or until the development of the acquired immunodeficiency syndrome (AIDS) or another condition that dictated the use of antiretroviral therapy (deferred-initiation group). The primary composite end point was any serious AIDS-related event, serious non-AIDS-related event, or death from any cause. Results A total of 4685 patients were followed for a mean of 3.0 years. At study entry, the median HIV viral load was 12,759 copies per milliliter, and the median CD4+ count was 651 cells per cubic millimeter. On May 15, 2015, on the basis of an interim analysis, the data and safety monitoring board determined that the study question had been answered and recommended that patients in the deferred-initiation group be offered antiretroviral therapy. The primary end point occurred in 42 patients in the immediate-initiation group (1.8%; 0.60 events per 100 personyears), as compared with 96 patients in the deferred-initiation group (4.1%; 1.38 events per 100 person-years), for a hazard ratio of 0.43 (95% confidence interval [CI], 0.30 to 0.62; P<0.001). Hazard ratios for serious AIDS-related and serious non-AIDS-related events were 0.28 (95% CI, 0.15 to 0.50; P<0.001) and 0.61 (95% CI, 0.38 to 0.97; P = 0.04), respectively. More than two thirds of the primary end points (68%) occurred in patients with a CD4+ count of more than 500 cells per cubic millimeter. The risks of a grade 4 event were similar in the two groups, as were the risks of unscheduled hospital admissions. Conclusions The initiation of antiretroviral therapy in HIV-positive adults with a CD4+ count of more than 500 cells per cubic millimeter provided net benefits over starting such therapy in patients after the CD4+ count had declined to 350 cells per cubic millimeter. Copyright © 2015 Massachusetts Medical Society.

McDonnell J.,University College London | Haddow L.,University College London | Daskalopoulou M.,University College London | Lampe F.,University College London | And 12 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Background: To determine the prevalence of neurocognitive impairment (NCI) in UK HIV-positive and HIV-negative men who have sex with men (MSM).Methods: HIV-positive and HIV-negative participants were recruited to a cross-sectional study from 2 London clinics and completed computerassisted neuropsychological tests and questionnaires of depression, anxiety, and activities of daily living. Published definitions of HIVassociated neurocognitive disorders (HAND) and global deficit scores were used. Age- and education-adjusted neuropsychological test scores were directly compared with reference population data.Results: A total of 248 HIV-positive and 45 HIV-negative MSM participated. In the HIV-positive group, median time since diagnosis was 9.4 years, median CD4+ count was 550 cells per cubic millimeter, and 88% were on antiretroviral therapy. Prevalence of HAND was 21.0% in HIV-positive MSM (13.7% asymptomatic neurocognitive impairment, 6.5% mild neurocognitive disorder, and 0.8% HIVassociated dementia). Using a global deficit score threshold of 0.5, the prevalence of NCI was 31.5% (when averaged over 5 neuropsychological domains) and 40.3% (over 10 neuropsychological test scores). These results were not significantly different from the HIV-negative study sample. No consistent pattern of impairment was seen in HIVpositive patients relative to general male population data (n = 380).Conclusions: We found a prevalence of HAND and degree of impairment on neuropsychological testing of HIV-positive MSM that could represent a normal population distribution. These findings suggest that NCI may be overestimated in HIV-positive MSM, and that the attribution of NCI to HIV infection implied by the term HAND requires revision. Copyright © 2014 by Lippincott Williams & Wilkins.

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