title: An internationally generalizable risk index for mortality after one year of antiretroviral therapy.
abstract: OBJECTIVE
  Despite the success of antiretroviral therapy (ART), excess mortality continues for those with HIV infection. A comprehensive approach to risk assessment, addressing multiorgan system injury on ART, is needed. We sought to develop and validate a practical and generalizable mortality risk index for HIV-infected individuals on ART.
  
  
  METHODS
  The Veterans Aging Cohort Study (VACS) was used to develop the VACS Index, based on age, CD4 cell count, HIV-1 RNA, hemoglobin, aspartate and alanine transaminase, platelets, creatinine and hepatitis C status, and a Restricted Index based on age, CD4 cell count and HIV-1 RNA with an outcome of death up to 6 years after ART initiation. Validation was in six independent cohorts participating in the ART Cohort Collaboration (ART-CC).
  
  
  RESULTS
  In both the development (4932 patients, 656 deaths) and validation cohorts (3146 patients, 86 deaths) the VACS Index had better discrimination than the Restricted Index (c-statistics 0.78 and 0.72 in VACS, 0.82 and 0.78 in ART-CC). The VACS Index also demonstrated better discrimination than the Restricted Index for HIV deaths and non-HIV deaths, in men and women, those younger and older than 50 years, with and without detectable HIV-1 RNA, and with or without HCV coinfection.
  
  
  CONCLUSIONS
  Among HIV-infected patients treated with ART, the VACS Index more accurately discriminates mortality risk than traditional HIV markers and age alone. By accounting for multiorgan system injury, the VACS Index may prove a useful tool in clinical care and research.
authors.affiliation: Yale University School of Medicine, West Haven, CT, USA. Janet.Tate2@va.gov
authors.forename: Janet P
authors.initials: JP
authors.lastname: Tate
authors.forename: Amy C
authors.initials: AC
authors.lastname: Justice
authors.forename: Michael D
authors.initials: MD
authors.lastname: Hughes
authors.forename: Fabrice
authors.initials: F
authors.lastname: Bonnet
authors.forename: Peter
authors.initials: P
authors.lastname: Reiss
authors.forename: Amanda
authors.initials: A
authors.lastname: Mocroft
authors.forename: Jacob
authors.initials: J
authors.lastname: Nattermann
authors.forename: Fiona C
authors.initials: FC
authors.lastname: Lampe
authors.forename: Heiner C
authors.initials: HC
authors.lastname: Bucher
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Sterling
authors.forename: Heidi M
authors.initials: HM
authors.lastname: Crane
authors.forename: Mari M
authors.initials: MM
authors.lastname: Kitahata
authors.forename: Margaret
authors.initials: M
authors.lastname: May
authors.forename: Jonathan A C
authors.initials: JA
authors.lastname: Sterne
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000410:Alanine Transaminase / Q000097:blood; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001219:Aspartate Aminotransferases / Q000097:blood; D015415:Biomarkers / Q000097:blood; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005060:Europe / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000097:blood* / Q000188:drug therapy / Q000401:mortality*; D006454:Hemoglobins; D006526:Hepatitis C / Q000097:blood / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000097:blood / Q000401:mortality; D010976:Platelet Count; D011237:Predictive Value of Tests; D012367:RNA, Viral; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D015415:Biomarkers; D006454:Hemoglobins; D012367:RNA, Viral; D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase