FACTORS INFLUENCING SURVIVAL AFTER AIDS - REPORT FROM THE MULTICENTER-AIDS-COHORT-STUDY (MACS)

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.