title: Pneumocystis jirovecii pneumonia in HIV-1-infected patients in the late-HAART era in developed countries.
abstract: BACKGROUND
  In developed countries with free access to health care, primary chemoprophylaxis with co-trimoxazole, and antiretroviral treatment, Pneumocystis pneumonia (PCP) in HIV-infected subjects should be restricted to undiagnosed late presenters.
  
  
  METHODS
  We retrospectively identified confirmed PCP hospital admissions in HIV-1 patients (period 1986-2010) and examined their characteristics and factors associated with mortality.
  
  
  RESULTS
  Three hundred and twelve episodes (median CD4 27 cells/μl) were identified during 3 periods: pre-HAART (1986-1995), 49%; early-HAART (1996-1999), 17.3%; and late-HAART (2000-2010), 33.7%. PCP was the initial AIDS-defining diagnosis in only 86 (27.6%). Thirty-four (10.9%) patients died during their hospital stay, without a significant reduction in mortality in recent periods (p = 0.311). However, the 12-month mortality decreased through the periods (33.3% to 16.2%; p = 0.003). Drug users (p = 0.001) and those naïve to HAART (p < 0.001) decreased in the late-HAART era, while heterosexuals (p = 0.001), immigrants (p < 0.001), and HAART initiation before hospital discharge (p < 0.001) increased. A partial pressure of oxygen (PaO2) ≤ 55 (p = 0.04), intensive care admission (p < 0.001), and the absence of HAART initiation before discharge (p = 0.02) were correlated with mortality.
  
  
  CONCLUSIONS
  The epidemiology and 12-month mortality of HIV-1-infected subjects with PCP have changed significantly in the late-HAART era, while mortality during hospital stay has remained unchanged. HIV diagnosed individuals lost to follow-up in care have emerged as the main driver of PCP in developed countries. Like HIV late presenters, they are more likely to have AIDS-defining illnesses, to be hospitalized, and to die. This finding has important implications for the design of better strategies to retain HIV-1-infected individuals in care.
authors.affiliation: University Hospital Germans Trias i Pujol, Badalona, Barcelona, Universitat Autònoma de Barcelona , Barcelona, Spain. jmllibre@flsida.org
authors.forename: Josep M
authors.initials: JM
authors.lastname: Llibre
authors.forename: Boris
authors.initials: B
authors.lastname: Revollo
authors.forename: Samuel
authors.initials: S
authors.lastname: Vanegas
authors.forename: Juan J
authors.initials: JJ
authors.lastname: Lopez-Nuñez
authors.forename: Arelly
authors.initials: A
authors.lastname: Ornelas
authors.forename: Joan M
authors.initials: JM
authors.lastname: Marin
authors.forename: Jose R
authors.initials: JR
authors.lastname: Santos
authors.forename: Paola
authors.initials: P
authors.lastname: Marte
authors.forename: Marta
authors.initials: M
authors.lastname: Morera
authors.forename: Paola
authors.initials: P
authors.lastname: Zuluaga
authors.forename: Jordi
authors.initials: J
authors.lastname: Tor
authors.forename: Bonaventura
authors.initials: B
authors.lastname: Clotet
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D019049:Developed Countries; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000188:drug therapy* / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification; D006801:Humans; D008297:Male; D045363:Pneumocystis carinii / Q000302:isolation & purification*; D011020:Pneumonia, Pneumocystis / Q000453:epidemiology* / Q000401:mortality; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis