[HIV and human rights: political action to achieve ZERO stigma]. / VIH y derechos humanos: acción política para alcanzar CERO estigma.

According to Sustainable Development Goals 10.2 and 10.3, it is imperative to promote the elimination of discriminatory laws, as well as implement policies and practices for the inclusion of vulnerable social groups on the social, economic and political fronts. In this regard, HIV-related discrimination and stigma remain unaddressed in many European Union countries. Fighting HIV-related stigma has been one of the main priorities of the Spanish Presidency of the Council of the European Union. This commitment was reflected in the High Level Meeting entitled HIV and Human Rights. Political action to achieve ZERO stigma. This meeting provided an opportunity to discuss a variety of strategies and agreements for eradicating stigma and discrimination associated with HIV in a variety of social, political, and institutional contexts.

Los objetivos de desarrollo sostenible 10.2 y 10.3 ponen de manifiesto la importancia de fomentar la eliminación de leyes discriminatorias, así como de implantar políticas y prácticas orientadas a la inclusión social, económica y política de los grupos sociales vulnerables. En este sentido, abordar la discriminación y el estigma asociados al VIH sigue siendo una asignatura pendiente dentro de los países que conforman la Unión Europea. De ahí que esta cuestión haya sido una prioridad política de la Presidencia española del Consejo de la Unión Europea, reflejada en la Reunión de Alto Nivel VIH y derechos humanos. Acción política para alcanzar CERO estigma. En esta reunión se abordaron diferentes estrategias y acuerdos para promover la eliminación del estigma y la discriminación asociada al VIH en diferentes ámbitos y dimensiones sociales, políticas e institucionales.

Life expectancy of people with HIV on antiretroviral therapy in Spain.

OBJECTIVE: To estimate life expectancy of people with HIV (PWH) and describe causes of death. DESIGN: Antiretroviral therapy (ART)-naive adults from the CoRIS cohort starting ART in 2004-2019. METHODS: We calculated life expectancy at age 40 for men and women according to their ART initiation period, and stratified by transmission category, CD4 + cell count and AIDS diagnosis. We estimated life expectancy in 10-year age bands using life tables constructed from mortality rates, estimated through Poisson models. RESULTS: Life expectancy increased from 65.8 [95% confidence interval (CI) 65.0-66.6] in 2004-2008 to 72.9 (72.2-73.7) in 2014-2019 in men [general population comparators (GPC): 79.1 and 81.2 years, respectively] and from 65.8 (65.0-66.6) to 72.5 (71.8-73.3) in women (GPC: 84.9 and 86.4, respectively). Non-AIDS-related deaths accounted for 68% of deaths among men and 78% among women. Life expectancy was longer when starting ART with higher CD4 + cell counts and without AIDS. For men acquiring HIV through sex with men, starting ART in 2014-2019 without AIDS, life expectancy was 75.0 (74.2-75.7) with CD4 + cell count less than 200 cells/µl, rising to 78.1 (77.5-78.8) with CD4 + cell count at least 350 cells/µl. Corresponding figures were 70.1 (69.4-70.9) and 76.0 (75.3-76.7) for men acquiring HIV heterosexually (HTX) and 61.5 (60.7-62.3) and 69.0 (68.2-69.8) for those acquiring HIV through injection drug use (IDU). For women starting ART from 2014 without AIDS, life expectancy increased from 71.7 (71.0-72.4) to 77.3 (76.7-77.9) among HTX and from 63.7 (62.9-64.5) to 70.7 (70.0-71.5) among IDU. CONCLUSION: Our findings confirm the progressive improvement of life expectancy in PWH in Spain over the last decades, supporting the insurability of PWH on suppressive ART in our current setting and time.

Drug Repurposing and Observational Studies: The Case of Antivirals for the Treatment of COVID-19.

Remdesivir and molnupiravir were the only 2 repurposed antivirals that were approved for emergency use during the COVID-19 pandemic. Both drugs received their emergency use authorization on the basis of a single industry-funded phase 3 trial, which was launched after evidence of in vitro activity against SARS-CoV-2. In contrast, for tenofovir disoproxil fumarate (TDF), little in vitro evidence was generated, no randomized trials for early treatment were done, and the drug was not considered for authorization. Yet, by the summer of 2020, observational evidence suggested a substantially lower risk for severe COVID-19 in TDF users compared with nonusers. The decision-making process for the launching of randomized trials for these 3 drugs is reviewed. Observational data in favor of TDF was systematically dismissed, even though no viable alternative explanations were proposed for the lower risk for severe COVID-19 among TDF users. Lessons learned from the TDF example during the first 2 years of the COVID-19 pandemic are described, and the use of observational clinical data to guide decisions about the launch of randomized trials during the next public health emergency is proposed. The goal is that gatekeepers of randomized trials make better use of the available observational evidence for the repurposing of drugs without commercial value.

Daily tenofovir disoproxil fumarate/emtricitabine and hydroxychloroquine for pre-exposure prophylaxis of COVID-19: a double-blind placebo-controlled randomized trial in healthcare workers.

OBJECTIVES: To assess the effect of hydroxychloroquine (HCQ) and Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) as pre-exposure prophylaxis on COVID-19 risk. METHODS: EPICOS is a double-blind, placebo-controlled randomized trial conducted in Spain, Bolivia, and Venezuela. Healthcare workers with negative SARS-CoV-2 IgM/IgG test were randomly assigned to the following: daily TDF/FTC plus HCQ for 12 weeks, TDF/FTC plus HCQ placebo, HCQ plus TDF/FTC placebo, and TDF/FTC placebo plus HCQ placebo. Randomization was performed in groups of four. Primary outcome was laboratory-confirmed, symptomatic COVID-19. We also studied any (symptomatic or asymptomatic) COVID-19. We compared group-specific 14-week risks via differences and ratios with 95% CIs. RESULTS: Of 1002 individuals screened, 926 (92.4%) were eligible and there were 14 cases of symptomatic COVID-19: 220 were assigned to the TDF/FTC plus HCQ group (3 cases), 231 to the TDF/FTC placebo plus HCQ group (3 cases), 233 to the TDF/FTC plus HCQ placebo group (3 cases), and 223 to the double placebo group (5 cases). Compared with the double placebo group, 14-week risk ratios (95% CI) of symptomatic COVID-19 were 0.39 (0.00-1.98) for TDF + HCQ, 0.34 (0.00-2.06) for TDF, and 0.49 (0.00-2.29) for HCQ. Corresponding risk ratios of any COVID-19 were 0.51 (0.21-1.00) for TDF + HCQ, 0.81 (0.44-1.49) for TDF, and 0.73 (0.41-1.38) for HCQ. Adverse events were generally mild. DISCUSSION: The target sample size was not met. Our findings are compatible with both benefit and harm of pre-exposure prophylaxis with TDF/FTC and HCQ, alone or in combination, compared with placebo.

Tenofovir disoproxil fumarate/emtricitabine and severity of coronavirus disease 2019 in people with HIV infection.

BACKGROUND: Effective, safe, and affordable antivirals are needed for coronavirus disease 2019 (COVID-19). Several lines of research suggest that tenofovir may be effective against COVID-19, but no large-scale human studies with appropriate adjustment for comorbidities have been conducted. METHODS: We studied HIV-positive individuals on antiretroviral therapy (ART) in 2020 at 69 HIV clinics in Spain. We collected data on sociodemographics, ART, CD4+ cell count, HIV-RNA viral-load, comorbidities and the following outcomes: laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, COVID-19 hospitalization, intensive care unit (ICU) admission and death. We compared the 48-week risks for individuals receiving tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), tenofovir alafenamide (TAF)/FTC, abacavir (ABC)/lamivudine (3TC), and other regimes. All estimates were adjusted for clinical and sociodemographic characteristics via inverse probability weighting. RESULTS: Of 51 558 eligible individuals, 39.6% were on TAF/FTC, 11.9% on TDF/FTC, 26.6% on ABC/3TC, 21.8% on other regimes. There were 2402 documented SARS-CoV-2 infections (425 hospitalizations, 45 ICU admissions, 37 deaths). Compared with TAF/FTC, the estimated risk ratios (RR) (95% confidence interval) of hospitalization were 0.66 (0.43, 0.91) for TDF/FTC and 1.29 (1.02, 1.58) for ABC/3TC, the RRs of ICU admission were 0.28 (0.11, 0.90) for TDF/FTC and 1.39 (0.70, 2.80) for ABC/3TC, and the RRs of death were 0.37 (0.23, 1.90) for TDF/FTC and 2.02 (0.88-6.12) for ABC/3TC. The corresponding RRs of hospitalization for TDF/FTC were 0.49 (0.24, 0.81) in individuals ≥50 years and 1.15 (0.59, 1.93) in younger individuals. DISCUSSION: Compared with other antiretrovirals, TDF/FTC lowers COVID-19 severity among HIV-positive individuals with virological control. This protective effect may be restricted to individuals aged 50 years and older.

Intersectionality of stigmas and health-related quality of life in people ageing with HIV in China, Europe, and Latin America.

People ageing with HIV face crucial challenges that can compromise their long-term health, one of which is stigma. HIV-related stigma can interact with other coexistent inequities to create a unique oppression system that results in traumatic experiences. This intersectionality of stigmas represents a new inequality that is greater than the sum of the original component inequalities. In this Series paper we review the literature regarding the intersectionality of HIV-related and ageing-related stigma and health-related quality of life among people ageing with HIV in China, Europe, and Latin America-three regions that represent distinct epidemiological and cultural trends in terms of HIV and ageing. Substantial gaps in the literature were identified, in particular a scarcity of data from Latin America. We also found inconsistencies between countries in terms of definitions and reporting practices related to people ageing with HIV. Research that fully considers the intersectional stigmas faced by this vulnerable population will contribute to advancing the United Nations 2030 Agenda for Sustainable Development.

Systematic review and meta-analysis of randomized trials of hydroxychloroquine for the prevention of COVID-19.

BACKGROUND: Recruitment into randomized trials of hydroxychloroquine (HCQ) for prevention of COVID-19 has been adversely affected by a widespread conviction that HCQ is not effective for prevention. In the absence of an updated systematic review, we conducted a meta-analysis of randomized trials that study the effectiveness of HCQ to prevent COVID-19. METHODS: A search of PubMed, medRxiv, and clinicaltrials.gov combined with expert consultation found 11 completed randomized trials: 7 pre-exposure prophylaxis trials and 4 post-exposure prophylaxis trials. We obtained or calculated the risk ratio of COVID-19 diagnosis for assignment to HCQ versus no HCQ (either placebo or usual care) for each trial, and then pooled the risk ratio estimates. RESULTS: The pooled risk ratio estimate of the pre-exposure prophylaxis trials was 0.72 (95% CI: 0.58-0.90) when using either a fixed effect or a standard random effects approach, and 0.72 (95% CI: 0.55-0.95) when using a conservative modification of the Hartung-Knapp random effects approach. The corresponding estimates for the post-exposure prophylaxis trials were 0.91 (95% CI: 0.72-1.16) and 0.91 (95% CI: 0.62-1.35). All trials found a similar rate of serious adverse effects in the HCQ and no HCQ groups. DISCUSSION: A benefit of HCQ as prophylaxis for COVID-19 cannot be ruled out based on the available evidence from randomized trials. However, the "not statistically significant" findings from early prophylaxis trials were widely interpreted as definite evidence of lack of effectiveness of HCQ. This interpretation disrupted the timely completion of the remaining trials and thus the generation of precise estimates for pandemic management before the development of vaccines.

SARS-CoV-2 infection and coronavirus disease 2019 severity in persons with HIV on antiretroviral treatment.

The relative susceptibility of people with HIV (PWH) to Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is debated. Numerous studies have been published with apparently contradictory findings, but comparisons are difficult because they have been conducted in populations with different characteristics (e.g. age, prevalence comorbidities) and have used different comparison groups (e.g. HIV-negative cohorts, coronavirus disease 2019 (COVID-19) hospitalized patients, general population), and because of challenges to measure the most important confounders. Here, we review the evidence regarding risk and severity of SARS-CoV-2 infection in PWH compared with persons without HIV. Publications originate largely from high-income settings where the majority of the PWH are on antiretroviral therapy (ART). Despite early evidence supporting higher frequency of SARS-CoV-2 testing in PWH on ART, HIV infection is not associated with SARS-CoV-2 infection, once confounding by socioeconomic characteristic is taken into account. Most publications identify increased COVID-19 severity in PWH compared with people without HIV from the general population or compared with COVID-19 hospitalized patients. The only study with an adequate comparison group to reduce confounding, has not identified differences in COVID-19 disease severity by HIV. Publications consistently identify that COVID-19 severity in PWH is not homogeneous and increases with age and baseline comorbidities. As PWH have a higher prevalence of comorbidities than people without HIV, examining their respective contribution to poor health outcomes is not straight forward as comorbidities could mediate the effect of HIV on COVID-19 outcomes.

The impact of coronavirus disease 2019 on people with HIV.

PURPOSE OF REVIEW: The COVID-19 pandemic materialized in 2020, the year the international community had expected to meet the interim targets to end AIDS by 2030. Forty years into the HIV pandemic, the COVID-19 pandemic challenges the achievements made in HIV and may even reverse some of them. RECENT FINDINGS: This article provides an overview of the impact of COVID-19 on people with, and at risk of, HIV infection. It addresses where the global response to HIV was expected to be by 2020, analyzes the impact of COVID-19 on HIV-related outcomes and reviews the impact of HIV on COVID-19 related outcomes. SUMMARY: The COVID-19 pandemic has had a profound impact on the response to HIV infection through disruption of prevention, testing, and access to antiretroviral treatment, as well as on the management of long-term HIV and mental health. This negative impact has been unequal throughout the world and across populations and deepens inequities in health. HIV does not increase Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) susceptibility once confounders are taken into account and inconsistencies are reported regarding its direct role on clinical severity. In post-COVID-19 scenarios, new models for HIV testing and care are likely to be consolidated. Monitoring responses needs high-quality epidemiological data and collaborative research.

[Development of the Agreement of the Council of Ministers approving instructions to update the catalogue of medical causes of exclusion in access to public employment.] / Desarrollo del acuerdo del Consejo de Ministros por el que se aprueban instrucciones para actualizar el catálogo de las causas médicas de exclusión en el acceso al empleo público.

The Agreement of the Council of Ministers of November 30, 2018 approving instructions to eliminate certain medical causes of exclusion in access to public employment, such as HIV, diabetes, celiac disease and psoriasis, has meant an important advance in the protection of the labor rights of people in these conditions. Since then, the tables of medical exclusions have been revised and modified for the National Police, National Police, the Civil Guard, the Customs Surveillance Corps, the Corps of Penitentiary Institutions Assistants, the Military Training Centers, the Training Centers, for the incorporation to the Troops and Marines scales and the National School of Police. In addition, the repeal of the Orders of the National Police (Order of January 11, 1988) and the regulatory modification of the Civil Guard (Order PCI/155/2019) guarantee that the diagnosis of HIV, diabetes, celiac disease and psoriasis, will continue without being an impediment for access to the National Police and the Civil Guard in the calls for the next exercises. So, that the mere diagnosis of a disease such as HIV, diabetes, celiac disease and psoriasis will not be a generic cause for exclusion from public employment, but will take into account medical advances and existing scientific evidence, as well as the health situation of each person.

El Acuerdo del Consejo de Ministros de 30 de noviembre de 2018, por el que se aprueban instrucciones para eliminar ciertas causas médicas de exclusión en el acceso al empleo público, como el VIH, la diabetes, la enfermedad celíaca y la psoriasis, ha supuesto un importante avance en la protección de los derechos laborales de las personas con estas condiciones. Desde entonces, se han revisado y modificado los cuadros de exclusiones médicas de convocatorias para el ingreso en la Policía Nacional, la Guardia Civil, los Cuerpos de Vigilancia Aduanera, el Cuerpo de Ayudantes de Instituciones Penitenciarias, los Centros Docentes de Formación Militar, los Centros Docentes de Formación para la incorporación a las Escalas de Tropa y Marinería y la Escuela Nacional de Policía. Además, la derogación de la Orden de la Policía Nacional (Orden de 11 de enero de 1988) y la modificación de la Orden de la Guardia Civil (Orden PCI/155/2019) garantizan que el diagnóstico del VIH, la diabetes, la enfermedad celíaca y la psoriasis dejarán de ser un impedimento para el acceso a la Policía Nacional y a la Guardia Civil en las convocatorias de los próximos ejercicios. Así, el mero diagnóstico de una enfermedad como el VIH, la diabetes, la enfermedad celíaca y la psoriasis, no será una causa genérica de exclusión de un empleo público, sino que se tendrán en cuenta los avances médicos y la evidencia científica existente, así como la situación de salud de cada persona.

Prevalence and undiagnosed fraction of hepatitis C infection in 2018 in Spain: results from a national population-based survey.

BACKGROUND: A national strategy against hepatitis C virus (HCV) was implemented in Spain in 2015 with the aim of reducing associated morbidity and mortality. In order to improve our understanding of the epidemiology of HCV, we analysed the prevalence of HCV antibodies and active infection overall and by age and sex in the general population aged 20-80 years. We also aimed to report the undiagnosed fraction. METHODS: A national population-based seroprevalence survey was conducted in 2017-2018. A representative sample from the general population was selected using two-stage sampling. The prevalence of total HCV antibodies and of HCV RNA was calculated using inverse probability weighting based on bootstrapping. RESULTS: Overall, we approached 17 496 persons; 9103 agreed to participate and met the eligibility criteria and 7675 were aged 20-80. We obtained a prevalence of HCV antibodies of 0.85% [95% confidence interval (CI): 0.64-1.08%] and of active infection of 0.22% (95% CI: 0.12-0.32%). The prevalence of active HCV infection was highest in men aged 50-59 (0.86%; 95% CI: 0.28-1.57%) and in men aged 60-69 years (0.72%; 95% CI: 0.27-1.28%). Prevalence was below 0.20% in the remaining age groups. The undiagnosed fraction for active HCV infection was 29.4%. CONCLUSION: This study shows that prevalence of HCV in the general population in Spain is low and reflects the impact of scaling up treatment with direct acting antivirals, together with other prevention strategies, from 2015 onwards. The data reported can guide subsequent public health actions.

Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV.

Health systems have improved their abilities to identify, diagnose, treat and, increasingly, achieve viral suppression among people living with HIV (PLHIV). Despite these advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV. Stigma and discrimination further exacerbate these poor outcomes. A global multidisciplinary group of HIV experts developed a consensus statement identifying key issues that health systems must address in order to move beyond the HIV field's longtime emphasis on viral suppression to instead deliver integrated, person-centered healthcare for PLHIV throughout their lives.

[Guideline on hepatitis C testing in Spain. An interdisciplinary work with a Public Health approach.] / La guía de cribado de la infección por el VHC en España. Un proceso interdisciplinar con enfoque de salud pública.

Within the framework of the Global health sector strategy on viral hepatitis and the Strategic Plan for tackling hepatitis C in the Spanish National Health System, the Secretariat of the National Plan on HIV and STIs and the Unit for Screening Programs in the Ministry of Health have coordinated the policies around the screening of hepatitis C virus (HCV) in Spain. This paper describes the experience and learnings arisen around it. The key points of the process include interdisciplinary work through a Technical Group made up of experts from the different fields involved; the availability of scientific evidence for decision-making, highlighting the 2nd Seroprevalence Study in the general population; and a public health approach along the entire process. As a result, the recently published Guideline on hepatitis C testing includes the indication for HCV testing for people with risk exposures and situations, as well as the main recommendations to improve screening and linkage to care in the most affected populations. We hope that this Guideline and the continuation of joint work will be a step towards equitable access to the diagnosis and treatment of HCV infection in Spain.

En el marco de la Estrategia Mundial del sector de la salud contra las hepatitis víricas y el Plan Estratégico de Abordaje de la Hepatitis C en el Sistema Nacional de Salud (SNS), la Secretaría del Plan Nacional sobre el Sida, junto a la Unidad de Programas de Cribado del Ministerio de Sanidad, han coordinado entre 2019 y 2020 las políticas estatales en torno al cribado de la infección por el virus de la hepatitis C (VHC) en España. En este artículo se describe la experiencia y reflexiones surgidas en torno a ella. Como puntos clave del proceso destacan el trabajo interdisciplinar a través de un Grupo Técnico en el que han participado personas expertas de los diferentes ámbitos implicados; la disponibilidad de evidencia científica para la toma de decisiones, especialmente el 2º Estudio de Seroprevalencia del VHC en población general; y el enfoque de salud pública transversal a todo el proceso. El resultado se muestra en la recién publicada Guía de cribado de infección por el VHC, en la que se indica el cribado a personas con exposiciones y situaciones de riesgo para la infección, así como se recogen las principales recomendaciones para mejorar el cribado y la vinculación al seguimiento y tratamiento. Esperamos que esta Guía y la continuación del trabajo conjunto supongan un impulso al acceso equitativo al diagnóstico y tratamiento de la infección por el VHC en España.

Incidence and Severity of COVID-19 in HIV-Positive Persons Receiving Antiretroviral Therapy : A Cohort Study.

BACKGROUND: The incidence and severity of coronavirus disease 2019 (COVID-19) among HIV-positive persons receiving antiretroviral therapy (ART) have not been characterized in large populations. OBJECTIVE: To describe the incidence and severity of COVID-19 by nucleos(t)ide reverse transcriptase inhibitor (NRTI) use among HIV-positive persons receiving ART. DESIGN: Cohort study. SETTING: HIV clinics in 60 Spanish hospitals between 1 February and 15 April 2020. PARTICIPANTS: 77 590 HIV-positive persons receiving ART. MEASUREMENTS: Estimated risks (cumulative incidences) per 10 000 persons and 95% CIs for polymerase chain reaction-confirmed COVID-19 diagnosis, hospitalization, intensive care unit (ICU) admission, and death. Risk and 95% CIs for COVID-19 diagnosis and hospital admission by use of the NRTIs tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC), tenofovir alafenamide (TAF)/FTC, abacavir (ABC)/lamivudine (3TC), and others were estimated through Poisson regression models. RESULTS: Of 77 590 HIV-positive persons receiving ART, 236 were diagnosed with COVID-19, 151 were hospitalized, 15 were admitted to the ICU, and 20 died. The risks for COVID-19 diagnosis and hospitalization were greater in men and persons older than 70 years. The risk for COVID-19 hospitalization was 20.3 (95% CI, 15.2 to 26.7) among patients receiving TAF/FTC, 10.5 (CI, 5.6 to 17.9) among those receiving TDF/FTC, 23.4 (CI, 17.2 to 31.1) among those receiving ABC/3TC, and 20.0 (CI, 14.2 to 27.3) for those receiving other regimens. The corresponding risks for COVID-19 diagnosis were 39.1 (CI, 31.8 to 47.6), 16.9 (CI, 10.5 to 25.9), 28.3 (CI, 21.5 to 36.7), and 29.7 (CI, 22.6 to 38.4), respectively. No patient receiving TDF/FTC was admitted to the ICU or died. LIMITATION: Residual confounding by comorbid conditions cannot be completely excluded. CONCLUSION: HIV-positive patients receiving TDF/FTC have a lower risk for COVID-19 and related hospitalization than those receiving other therapies. These findings warrant further investigation in HIV preexposure prophylaxis studies and randomized trials in persons without HIV. PRIMARY FUNDING SOURCE: Instituto de Salud Carlos III and National Institutes of Health.

Cause-specific mortality after diagnosis of cancer among HIV-positive patients: A collaborative analysis of cohort studies.

People living with HIV (PLHIV) are more likely than the general population to develop AIDS-defining malignancies (ADMs) and several non-ADMs (NADMs). Information is lacking on survival outcomes and cause-specific mortality after cancer diagnosis among PLHIV. We investigated causes of death within 5 years of cancer diagnosis in PLHIV enrolled in European and North American HIV cohorts starting antiretroviral therapy (ART) 1996-2015, aged ≥16 years, and subsequently diagnosed with cancer. Cancers were grouped: ADMs, viral NADMs and nonviral NADMs. We calculated cause-specific mortality rates (MR) after diagnosis of specific cancers and compared 5-year survival with the UK and France general populations. Among 83,856 PLHIV there were 4,436 cancer diagnoses. Of 603 deaths after ADM diagnosis, 292 (48%) were due to an ADM. There were 467/847 (55%) and 74/189 (39%) deaths that were due to an NADM after nonviral and viral NADM diagnoses, respectively. MR were higher for diagnoses between 1996 and 2005 versus 2006-2015: ADMs 102 (95% CI 92-113) per 1,000 years versus 88 (78-100), viral NADMs 134 (106-169) versus 111 (93-133) and nonviral NADMs 264 (232-300) versus 226 (206-248). Estimated 5-year survival for PLHIV diagnosed with liver (29% [19-39%]), lung (18% [13-23%]) and cervical (75% [63-84%]) cancer was similar to general populations. Survival after Hodgkin's lymphoma diagnosis was lower in PLHIV (75% [67-81%]). Among ART-treated PLHIV diagnosed with cancer, MR and causes of death varied by cancer type, with mortality highest for liver and lung cancers. Deaths within 5 years of NADM diagnoses were more likely to be from cancer than AIDS.

Parameter estimates for trends and patterns of excess mortality among persons on antiretroviral therapy in high-income European settings.

INTRODUCTION: HIV cohort data from high-income European countries were compared with the UNAIDS Spectrum modelling parameters for these same countries to validate mortality rates and excess mortality estimates for people living with HIV (PLHIV) on antiretroviral therapy (ART). METHODS: Data from 2000 to 2015 were analysed from the Antiretroviral Therapy Cohort Collaboration (ART-CC) for Austria, Denmark, France, Italy, the Netherlands, Spain, and Switzerland. Flexible parametric models were used to compare all-cause mortality rates in the ART-CC and Spectrum. The percentage of AIDS-related deaths and excess mortality (both are the same within Spectrum) were compared, with excess mortality defined as that in excess of the general population mortality. RESULTS: Analyses included 94 026 PLHIV with 585 784 person-years of follow-up, from which there were 5515 deaths. All-cause annual mortality rates in Spectrum for 2000-2003 were 0.0121, reducing to 0.0078 in 2012-2015, whilst the ART-CC's corresponding annual mortality rates were 0.0151 [95% confidence interval (95% CI): 0.0130-0.0171] reducing to 0.0049 (95% CI: 0.0039-0.0060). The percentage of AIDS-related deaths in Spectrum was 74.7% in 2000-2003, dropping to 43.6% in 2012-2015. In the ART-CC, AIDS-related mortality constitutes 45.3% (95% CI: 38.4-52.9%) of mortality in 2000-2003 and 26.7% (95% CI: 19-46%) between 2012 and 2015. Excess mortality in the ART-CC was broadly similar to the Spectrum estimates, dropping from 75.3% (95% CI: 60.3-95.2%) in 2000-2003 to 30.7% (95% CI: 25.5-63.7%) in 2012-2015. CONCLUSION: All-cause mortality assumptions for PLHIV on ART in high-income European settings should be adjusted in Spectrum to be higher in 2000-2003 and decline more quickly to levels currently captured for recent years.