Correspondence

Changes in the Mix of AIDS-Defining Conditions

N Engl J Med 1993; 329:1962December 23, 1993

Article

To the Editor:

Antiretroviral therapy and chemoprophylaxis are changing the natural history of infection with the human immunodeficiency virus (HIV), with a change in the pattern of initial AIDS-defining illnesses1,2 [see Hoover et al. elsewhere in this issue]. In the U.S. military, HIV screening is mandatory. We reviewed the AIDS-defining diagnoses at the Naval Medical Center in San Diego, California, in patients who had been identified as HIV-seropositive or had received a diagnosis of AIDS while on active duty. A trend analysis was performed with a simple linear regression.

AIDS was diagnosed in 198 patients during the period from 1984 through 1992 (Table 1Table 1Frequency of AIDS-Defining Diagnoses at the Naval Medical Center, San Diego, California.). The incidence of Pneumocystis carinii pneumonia decreased from 52 percent of AIDS-defining illnesses from 1984 through 1987 to just 5 percent in 1990 (P = 0.033) but has recently increased. In 1992 prophylaxis failed in six of the seven patients with P. carinii pneumonia; one patient declined prophylaxis. Primary prophylaxis against P. carinii pneumonia was instituted at our hospital in 1989. The recent rise in the incidence of this illness reflects the failure of second-line prophylactic agents in severely immunocompromised patients. The incidence of invasive fungal diseases declined over the period from 1990 through 1992 (P = 0.052) coincident with our use, starting in 1990, of fluconazole for suppression of thrush.

The incidence of the wasting syndrome and Mycobacterium avium complex bacteremia increased steadily to 31 percent (P<0.001) and 8 percent (P = 0.043), respectively, of AIDS-defining diagnoses in 1992. Others report similar trends1. The dramatic rise in the incidence of the wasting syndrome and the smaller increase in the incidence of M. avium complex bacteremia are most likely secondary to successful prophylaxis against the other common illnesses. The incidence of Kaposi's sarcoma decreased since 1987 through 1988 and has subsequently continued to account for a relatively low proportion of AIDS-defining diagnoses. Others have noted this trend as well1,2.

There were no clear time-dependent trends in the incidence of HIV encephalopathy or other diagnoses. Previous studies have noted a decreased incidence of HIV encephalopathy, perhaps because of early zidovudine therapy3. The unusually high and stable incidence of this illness in our study may result from a detection bias, since half our patients are enrolled in a detailed longitudinal study of the neuropsychiatric manifestations of HIV. Some evidence of HIV encephalopathy may have been detected in the absence of overt clinical impairment4.

Of the 26 patients in whom AIDS was first diagnosed in 1992, 20 (77 percent) had CD4+ T-cell counts under 200 per cubic millimeter before the onset of the AIDS-defining illness.

HIV screening, antiretroviral therapy, and chemoprophylaxis are changing the spectrum of AIDS-defining conditions. Revisions in the case definition cannot explain these changes, since all the diagnoses listed in Table 1 have been included in the definition of AIDS since 19875. The mix of AIDS-defining illnesses should continue to change as chemoprophylaxis improves and becomes available for a wider variety of infections. Given the recent change in the case definition,6 it is expected that in the future, most cases of AIDS in military patients will be established on the basis of the CD4+ T-cell count.

Peter J. Weiss, M.D.
Mark R. Wallace, M.D.
Patrick E. Olson, M.D.
Rita Rossetti, L.V.N.
Naval Medical Center, San Diego, CA 92134

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Citing Articles (10)

Citing Articles

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   Carl Grunfeld, Donald P. Kotler, Adrian Dobs, Marshall Glesby, Shalender Bhasin. (2006) Oxandrolone in the Treatment of HIV-Associated Weight Loss in Men. JAIDS Journal of Acquired Immune Deficiency Syndromes 41:3, 304-314
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   Christine Wanke. (2004) Pathogenesis and Consequences of HIV-Associated Wasting. JAIDS Journal of Acquired Immune Deficiency Syndromes 37:Supplement 1, S277-S279
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   Lawrence Cone. 2000. Wasting and AIDS in the Era of Highly Active Antiretroviral Therapy. .
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   Robert H. Lyles, Alice M. Tang, Ellen Smit, John W. Mellors, Joseph B. Margolick, Barbara R. Visscher, John P. Phair, Neil M. H. Graham. (1999) Virologic, Immunologic, and Immune Activation Markers as Predictors of HIV-Associated Weight Loss Prior to AIDS. Journal of Acquired Immune Deficiency Syndromes 22:4, 386
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   Robert H. Lyles, Alice M. Tang, Ellen Smit, John W. Mellors, Joseph B. Margolick, Barbara R. Visscher, John P. Phair, Neil M. H. Graham. (1999) Virologic, Immunologic, and Immune Activation Markers as Predictors of HIV-Associated Weight Loss Prior to AIDS. JAIDS Journal of Acquired Immune Deficiency Syndromes 22:4, 386
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   Franck Carbonnel, Caroline Maslo, Laurent Beaugerie, Fabrice Carrat, Edith Wirbel, Christian Aussel, Jean Gérard Gobert, Pierre Marie Girard, Jean Pierre Gendre, Jacques Cosnes, Willy Rozenbaum. (1998) Effect of indinavir on HIV-related wasting. AIDS 12:14, 1777-1784
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   David A. Wheeler, Cynthia L. Gibert, Cynthia A. Launer, Norma Muurahainen, Richard A. Elion, Donald I. Abrams, Glenn E. Bartsch. (1998) Weight Loss as a Predictor of Survival and Disease Progression in HIV Infection. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 18:1, 80-85
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   Seth Rivera, William Briggs, Dajun Qian, Fred R. Sattler. (1998) Levels of HIV RNA Are Quantitatively Related to Prior Weight Loss in HIV-Associated Wasting. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 17:5, 411-418
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   Kathleen Mulligan, Viva W. Tai, Morris Schambelan. (1997) Cross-Sectional and Longitudinal Evaluation of Body Composition in Men With HIV Infection. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 15:1, 43-48
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10. 10

    Camilla S. Graham, Brevick G. Graham, John A. Bartlett, Alison E. Heald, Susan S. Schiffman. (1995) Taste and smell losses in HIV infected patients. Physiology & Behavior 58:2, 287-293
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