IMPACT OF OPPORTUNISTIC DISEASE ON SURVIVAL IN PATIENTS WITH HIV-INFECTION

Objective: To assess the impact of opportunistic diseases on survival in patients with HIV disease. Methods: A cohort of 2081 patients follo wed for a mean of 30 months was studied. Time-dependent Cox proportion al hazards analyses were performed using incident opportunistic diseas es and CD4 cell counts as independent variables. Results: During follo w-up, 730 (35%) patients died. The occurrence of Pneumocystis carinii pneumonia (PCP), cytomegalovirus (CMV) disease, Mycobacterium avium co mplex (MAC) disease, Candida esophagitis, Kaposi's sarcoma, lymphoma, progressive multifocal leukoencephalopathy (PML), dementia, wasting, t oxoplasmosis, and cryptosporidiosis were all significantly associated with death, independently of CD4 cell count (all P < 0.001 for opportu nistic diseases controlling for CD4 cell count). The magnitude of incr eased risk was greatest for lymphoma [relative hazard (RH), 7.2], PML (RH, 3.9), MAC (RH, 3.0) and CMV (RH, 2.2). Cryptococcosis (RH, 0.94) and herpes zoster (RH, 0.85) were not associated with death. In a mult ivariate Cox proportional hazards analysis, MAC [RH, 2.56; 95% confide nce interval (CI), 2.1-3.1], CMV (RH, 1.63; 95% CI, 1.3-2.1), toxoplas mosis (RH, 1.85; 95% CI, 1.3-2.6), PCP (RH, 1.29; 95% CI, 1.1-1.5), an d CD4 cell count were significantly associated with death. Patients wh o had opportunistic diseases had significantly greatly monthly decline s in CD4 counts (-11 x 10(6)/l per month) than those who did not (-6 x 10(6)/l per month; P < 0.001). Conclusion: Most opportunistic disease s increase the risk of death independently of CD4 cell count. These da ta support the hypothesis that opportunistic diseases enhance HIV path ogenesis and further underscore the importance of prophylaxis.