HIV This Week

Månsson F, Alves A, Silva ZJ, Dias F, Andersson S, Biberfeld G, Fenyö EM, Norrgren H .Trends of HIV-1 and HIV-2 prevalence among pregnant women in Guinea-Bissau, West Africa: possible effect of the civil war 1998 1999. Sex Transm Infect. 2007 Oct;83(6):463-7.

Sentinel surveys in Bissau, the capital of Guinea-Bissau, have shown low prevalence of HIV-1 but high HIV-2 prevalence before 1998. Guinea-Bissau experienced a civil war in 1998-1999. Månsson and colleagues aimed to examine specifically the trends of HIV prevalence from antenatal surveys in Bissau, Guinea-Bissau in 1987-2004, and whether the civil war in 1998-1999 could have an effect on HIV prevalence levels after the conflict. Since 1987, anonymous HIV testing in delivering women has been performed at the maternity clinic, Simão Mendes National Hospital, Bissau, as part of the national sentinel surveillance programme. Consecutive sampling was performed for approximately 3 months between September and December each year. Serological analyses were performed at the National Public Health Laboratory in Guinea-Bissau. A total of 20 422 women were tested for HIV between 1987 and 2004. The total HIV-1 prevalence increased from 0.0% in 1987 to 4.8% in 2004 and the total HIV-2 prevalence decreased from 8.3% in 1987 to 2.5% in 2004. The HIV-1 prevalence increased from 2.5% in 1997 to 5.2% in 1999, but stabilized in subsequent years. There was a significant increase in HIV-1 prevalence in the years 1987-2004 and a significant decline in HIV-2 prevalence over the same period. The civil war in 1998-1999 may have sparked HIV-1 transmission, as HIV-1 prevalence more than doubled between 1997 and 1999, but there is no evidence of a long-term effect on the trends of HIV-1 or HIV-2 prevalence.

Editors’ note : Civil war can provoke changed sexual behaviour, including increased commercial sex, transitory sexual relations, and sexual abuse, as well as weakened health structures leading to unsafe injections and blood transfusion. These may increase HIV transmission if HIV is present; however, there are examples of HIV transmission slowing during conflicts related to reduced mobility and other factors. Long-term monitoring helps determine trends and reduces the risk of jumping to conclusions. In this case, it is unclear whether the war had an effect but peace time certainly has been associated with stability in HIV prevalence.

Muga R, Langohr K, Tor J, Sanvisens A, Serra I, Rey-Joly C, Muñoz A. Survival of HIV-infected injection drug users (IDUs) in the highly active antiretroviral therapy era, relative to sex- and age-specific survival of HIV-uninfected IDUs. Clin Infect Dis. 2007 Aug 1;45(3):370-6.

In the era of highly active antiretroviral therapy (HAART), it remains unclear whether human immunodeficiency virus (HIV)-infected injection drug users (IDUs) have durations of survival similar to those for comparable HIV-uninfected IDUs. The goal of this study was to compare survival durations of HIV-infected and HIV-uninfected IDUs for the period 1987-2004. Demographic data, drug use characteristics, and biological markers were obtained at the time of admission to a substance abuse treatment program. The outcome of interest was the duration of survival after admission, and the primary exposure was HIV infection. Vital status was ascertained by means of the mortality register by the end of 2004. Three calendar periods, which were defined on the basis of use of specific therapies, were considered: 1987-1991 (the antiretroviral monotherapy era), 1992-1996 (the dual combination therapy era and the era when methadone was introduced in Spain), and 1997-2004 (the era of HAART and of established methadone programs). Muga and colleagues used Cox regression methods allowing for late entries to handle the contribution of persons who survived a given period and entered the following period with nonzero time. The authors compared HIV-uninfected and HIV-infected IDUs with adjustments for age, sex, and duration of follow-up after admission. A total of 1209 IDUs were admitted to the hospital during the period from January 1987 through December 2004, and 1181 were eligible for the study. The majority (81.3%) of patients were men. The mean age (+/- standard deviation) at admission was 27.8+/-5.6 years, and the mean duration of injection drug use (+/- standard deviation) was 7.6+/-5.0 years. The prevalences of HIV and hepatitis C virus infections were 59.0% and 92.3%, respectively, and the total duration of follow-up was 10,116 person-years. Although survival duration for HIV-uninfected IDUs in 1997-2004 was similar to the duration in earlier periods, the duration for HIV-infected IDUs improved significantly since 1997 (P<.01). Furthermore, among patients admitted in the last period, the survival durations for HIV-uninfected and HIV-infected IDUs were virtually the same (relative hazard, 0.89; 95% confidence interval, 0.44-1.81). The duration of survival of HIV-infected IDUs has improved substantially since 1997, reaching rates similar to the rates for HIV-seronegative IDUs who accessed the health care system in the era of HAART.

Editors’ note: Antiretroviral treatment has had dramatic effects on survival for injecting drug users, a fact that is not well appreciated. In Spain, improved survival was likely also related to access to methadone substitution therapy, prophylaxis for opportunistic infections, harm reduction intervention, and regular clinical care.