title: Critical importance of long-term adherence to care in HIV infected patients in the cART era: new insights from Pneumocystis jirovecii pneumonia cases over 2004-2011 in the FHDH-ANRS CO4 cohort.
abstract: OBJECTIVE
  To describe characteristics and outcomes of HIV-infected patients with Pneumocystis jirovecii pneumonia (PCP) over 2004-2011 in France, in particular in those previously enrolled (PE) in the French Hospital Database on HIV (FHDH).
  
  
  METHODS
  PE patients with an incident PCP were compared with patients with an inaugural PCP revealing HIV infection (reference). Adequate adherence to care was defined as a CD4 measurement at least every 6 months. Immune reconstitution (CD4≥200/mm3) and risk of death were studied using Kaplan-Meier estimates and multivariable Cox proportional hazards models.
  
  
  RESULTS
  In a context of a decreasing incidence of PCP, 1259 HIV-infected patients had a PCP diagnosis, and 593 (47%) were PE patients of whom 161 (27%) have had a prior history of AIDS-defining clinical illness (prior ADI). Median time since enrolment was 8 years for PE patients; 74% had received cART. Median proportion of time with adequate adherence to care was 85% (IQR, 66-96) for all FHDH enrollees, but only 45% (IQR, 1-81) for PE patients during the 2 years before PCP. Median CD4 cell count (38/mm3) and HIV viral load (5.2 log10 copies/ml) at PCP diagnosis did not differ between PE patients and the reference group. Three year mortality rate of 25% was observed for PE prior ADI group, higher than in PE non-prior ADI group (8%) and the reference group (9%) (p<0.0001). In the PE prior ADI group, poor prognosis remained even after adjustment for virological control and immune reconstitution (HR, 2.4 [95%CI, 1.5-3.7]).
  
  
  CONCLUSIONS
  Almost 50% of PCP diagnoses in HIV-infected patients occurred presently in patients already in care, mainly with a previous cART prescription but with waning adherence to care. Having repeated ADI is contributing to the risk of death beyond its impact on immune reconstitution and viral suppression: special efforts must be undertaken to maintain those patients in care.
authors.affiliation: Inserm UMRS 1136, Paris, France; UPMC Univ Paris 06 UMRS 1136, Paris, France.
authors.forename: Blandine
authors.initials: B
authors.lastname: Denis
authors.affiliation: Inserm UMRS 1136, Paris, France; UPMC Univ Paris 06 UMRS 1136, Paris, France.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Guiguet
authors.affiliation: Service de maladies infectieuses et tropicales, CHU Saint Louis, AP-HP, Paris, France; Université Paris Diderot, Paris, France.
authors.forename: Nathalie
authors.initials: N
authors.lastname: de Castro
authors.affiliation: Service de maladies infectieuses et tropicales, CHU Avicenne AP-HP, Bobigny, France.
authors.forename: Frédéric
authors.initials: F
authors.lastname: Mechaï
authors.affiliation: Service de maladies infectieuses et tropicales, CHU Rennes, Rennes, France.
authors.forename: Matthieu
authors.initials: M
authors.lastname: Revest
authors.affiliation: Service de maladies infectieuses et tropicales, CHU Cayenne, Cayenne, France; EA 3595, Univ Antilles-Guyane, Cayenne, France.
authors.forename: Aba
authors.initials: A
authors.lastname: Mahamat
authors.affiliation: Service de maladies infectieuses et tropicales, CHU Saint Louis, AP-HP, Paris, France; Université Paris Diderot, Paris, France.
authors.forename: Giovanna Melica
authors.initials: GM
authors.lastname: Gregoire
authors.affiliation: CHU Necker-Enfants malades, AP-HP, Centre d'Infectiologie Necker Pasteur, Paris, France; Université Paris Descartes, Institut Imagine, Paris, France; Institut Pasteur, Centre National de Référence Mycoses Invasives et Antifongiques, Paris, France; CNRS URA 3012, Paris, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Lortholary
authors.affiliation: Inserm UMRS 1136, Paris, France; UPMC Univ Paris 06 UMRS 1136, Paris, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Costagliola
mesh_terms: D015704:CD4 Antigens / Q000378:metabolism; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D053208:Kaplan-Meier Estimate; D010349:Patient Compliance / Q000706:statistics & numerical data*; D045363:Pneumocystis carinii / Q000472:pathogenicity*; D011014:Pneumonia / Q000453:epidemiology*
chemical_list: D015704:CD4 Antigens
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