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Lethal DMAC persists among patients with HIV
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Despite the availability of effective ART, disseminated Mycobacterium avium complex, or DMAC, is still a mortal danger to patients with HIV/AIDS, according to researchers.
DMAC, a late-stage complication of HIV, also disproportionately affects minorities and is the result of delayed and inconsistent treatment, they wrote in Open Forum Infectious Diseases.
“In the modern era of ART — which is increasingly effective, safe and available — the persistence of DMAC as a complication in patients with HIV/AIDS represents a profound breakdown in the HIV treatment cascade,” Lauren F. Collins, MD, an internal medicine resident at the Duke University Medical Center, and colleagues wrote. “We believe two key interventions will be necessary to improve outcomes in this high-risk population: (a) More available and de-stigmatized outreach and testing in high-risk groups to diagnose HIV earlier, and (b) intensive interventions for patients with known HIV who develop DMAC, using this potentially lethal diagnosis as a stimulus to more consistently engage in care.”
The researchers performed an observational retrospective study of 330 HIV–infected patients newly infected with DMAC who were treated in the Duke University Health System between 1992 and 2015. In all, 75.2% of patients were men, and 69.1% were non-Hispanic black. The median patient age was 37 years.
The researchers found that the incidence of DMAC has “dramatically declined” since the advent of ART in 1996 and has stabilized since 2005. Specifically, DMAC incidence declined from 65.3 cases per 1,000 population in 1992 to two per 1,000 population in 2015.
For 144 patients with DMAC who received ART, the standardized mortality ratios at years 1 to 5 post-DMAC diagnosis, respectively, were 69 (95% CI, 42-94), 58 (95% CI, 44-70), 27 (95% CI, 21-33), 5.90 (95% CI, 4.50-7.3) and 6.80 (95% CI, 4.80-8.7).
For patients with DMAC who never received ART, the ratios were 275 (95% CI, 245-298), 280 (95% CI, 246-303), 236 (95% CI, 167-278), 0 (95% CI, 0-283) and 99 (95% CI,41-143). The researchers stressed that none of the four patients alive at the start of year 4 died by year’s end, accounting for the 0 ratio.
Among the 135 patients diagnosed with DMAC since 2000, 20% were newly diagnosed with HIV within the 3 months leading up to the presentation of DMAC, the researchers said.
The 107 patients with an established HIV diagnosis (made more than 3 months before DMAC presentation) had a median time from HIV diagnosis to DMAC diagnosis of 7 years (interquartile range, 4-10 years; range, 4 months to 22 years).
Additionally, patients with a long history of HIV at the time of DMAC diagnosis were more likely to be black. In all, 84% of patients with an established HIV diagnosis and 64% of those newly diagnosed with HIV were black (P = .008).
The researchers said clinicians must focus on linking patients with HIV and DMAC to appropriate care.
“Patients with HIV who develop DMAC are at very high risk of death and hospitalization for several years after diagnosis,” they concluded. “Encouragingly, we demonstrate that long-term survival may be achieved with ART, even for patients with delayed presentation to care and/or those who fail to engage in care. Continued prioritization of strategy development and implementation to link and engage this [medically and behaviorally] complex population of patients in HIV care is critically needed.” – by Joe Green
Disclosure: The researchers report no relevant financial disclosures.
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