title: AIDS and non-AIDS severe morbidity associated with hospitalizations among HIV-infected patients in two regions with universal access to care and antiretroviral therapy, France and Brazil, 2000-2008: hospital-based cohort studies.
abstract: BACKGROUND
  In high-income settings, the spectrum of morbidity and mortality experienced by Human Immunodeficiency Virus (HIV)-infected individuals receiving combination antiretroviral therapy (cART) has switched from predominantly AIDS-related to non-AIDS-related conditions. In the context of universal access to care, we evaluated whether that shift would apply in Brazil, a middle-income country with universal access to treatment, as compared to France.
  
  
  METHODS
  Two hospital-based cohorts of HIV-infected individuals were used for this analysis: the ANRS CO3 Aquitaine Cohort in South Western France and the Evandro Chagas Research Institute (IPEC) Cohort of the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Severe morbid events (AIDS- and non-AIDS-related) were defined as all clinical diagnoses associated with a hospitalization of ≥48 hours. Trends in the incidence rate of events and their determinants were estimated while adjusting for within-subject correlation using generalized estimating equations models with an auto-regressive correlation structure and robust standard errors.
  
  
  RESULTS
  Between January 2000 and December 2008, 7812 adult patients were followed for a total of 41,668 person-years (PY) of follow-up. Throughout the study period, 90% of the patients were treated with cART. The annual incidence rate of AIDS and non-AIDS events, and of deaths significantly decreased over the years, from 6.2, 21.1, and 1.9 AIDS, non-AIDS events, and deaths per 100 PY in 2000 to 4.3, 14.9, and 1.5/100 PY in 2008. The annual incidence rates of non-AIDS events surpassed that of AIDS-events during the entire study period. High CD4 cell counts were associated with a lower incidence rate of AIDS and non-AIDS events as well as with lower rates of specific non-AIDS events, such as bacterial, hepatic, viral, neurological, and cardiovascular conditions. Adjusted analysis showed that severe morbidity was associated with lower CD4 counts and higher plasma HIV RNAs but not with setting (IPEC versus Aquitaine).
  
  
  CONCLUSIONS
  As information on severe morbidities for HIV-infected patients remain scarce, data on hospitalizations are valuable to identify priorities for case management and to improve the quality of life of patients with a chronic disease requiring life-long treatment. Immune restoration is highly effective in reducing AIDS and non-AIDS severe morbid events irrespective of the setting.
authors.affiliation: Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro 21040, Rio de Janeiro, Brasil. luzpaulamendes@gmail.com.
authors.forename: Paula Mendes
authors.initials: PM
authors.lastname: Luz
authors.forename: Mathias
authors.initials: M
authors.lastname: Bruyand
authors.forename: Sayonara
authors.initials: S
authors.lastname: Ribeiro
authors.forename: Fabrice
authors.initials: F
authors.lastname: Bonnet
authors.forename: Ronaldo Ismério
authors.initials: RI
authors.lastname: Moreira
authors.forename: Mojgan
authors.initials: M
authors.lastname: Hessamfar
authors.forename: Dayse Perreira
authors.initials: DP
authors.lastname: Campos
authors.forename: Carine
authors.initials: C
authors.lastname: Greib
authors.forename: Charles
authors.initials: C
authors.lastname: Cazanave
authors.forename: Valdilea Gonçalves
authors.initials: VG
authors.lastname: Veloso
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.forename: Beatriz
authors.initials: B
authors.lastname: Grinsztejn
authors.forename: Geneviève
authors.initials: G
authors.lastname: Chêne
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000150:complications / Q000453:epidemiology*; D000328:Adult; D001938:Brazil / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D005602:France / Q000453:epidemiology; D015658:HIV Infections / Q000150:complications; D006760:Hospitalization; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D011788:Quality of Life