Aj. Saah et al., FACTORS INFLUENCING SURVIVAL AFTER AIDS - REPORT FROM THE MULTICENTER-AIDS-COHORT-STUDY (MACS), Journal of acquired immune deficiency syndromes, 7(3), 1994, pp. 287-295
The objective of this study was to determine if clinical signs, sympto
ms, laboratory variables, and use of therapeutic or prophylactic agent
s have prognostic associations with survival after diagnosis of clinic
al AIDS. A total of 2,168 homosexual men, seropositive for human immun
odeficiency virus type 1 (HIV-1) participated in a longitudinal cohort
study of the greater metropolitan areas of Baltimore, Maryland, Washi
ngton, D.C., Chicago, Illinois, Pittsburgh, Pennsylvania, and Los Ange
les, California, U.S.A.-the Multicenter AIDS Cohort Study (MACS). Vari
ables within 6 months prior to AIDS diagnosis included age, CD4(+) lym
phocyte counts, hemoglobin, and self-reported thrush, fever, anti-retr
oviral therapy (ART) beginning prior to AIDS onset, and ART beginning
after AIDS (as a time-dependent covariate) were analyzed as mutually e
xclusive categories, as was prophylaxis for Pneumocystis carinii pneum
onia (PCP). Univariate and multivariate survival models of time from A
IDS to death were fit. In univariate analysis, younger age, higher cou
nts of CD4(+) lymphocytes, hemoglobin, and absence of thrush or fever
prior to AIDS onset were associated with longer survival after AIDS. T
hose who began ART within 3 months after AIDS onset had longer median
survival (1.75 years), from 3 months after AIDS, when compared with th
ose who began ART prior to AIDS (1.18 years). This comparison is not i
nfluenced by the bias that those who survive longer have a greater lik
elihood to subsequently receive ART, Prophylaxis for PCP beginning aft
er AIDS onset was also associated with longer post-AIDS survival when
compared with beginning prophylaxis prior to AIDS or never using proph
ylaxis. In multivariate analysis, age <37 years at AIDS onset, higher
hemoglobin level, and higher CD4(+) lymphocyte count remained prognost
ically beneficial for survival after AIDS (relative hazards 0.78, 0.91
per g/dL and 0.80 per 100 cells x 10(6)/L, respectively). When PCP pr
ophylaxis and ART were started only after AIDS onset (considered as ti
me-dependent covariates, they reduced the hazard of death by 40% and 5
0%, respectively. The hazard of death after AIDS was 26% lower in thos
e using ART prior to AIDS than in those never using ART (p = 0.095). C
linical variables such as younger age, higher hemoglobin level, and hi
gher CD4(+) count are prognostically beneficial for survival after AID
S. Pre-AIDS ART and pneumocystis prophylaxis are presently the standar
d of care in treating those with HIV-1 infection and have been shown t
o delay the onset of AIDS. Survival after AIDS onset was longer for me
n who received pre-AIDS ART compared with those who never received ART
, but it was shorter in the former group than in those initiating ART
after AIDS, This finding suggests a transient beneficial effect from A
RT that is not completely attenuated at AIDS in the pre-AIDS ART recip
ient.