Sophie Abgrall - Academia.edu (original) (raw)

Papers by Sophie Abgrall

Research paper thumbnail of Diphtheria, tetanus, poliomyelitis, yellow fever and hepatitis B seroprevalence among HIV1-infected migrants. Results from the ANRS VIHVO vaccine sub-study

Vaccine, 2015

Few data are available on the seroprotection status of HIV1-infected patients with respect to vac... more Few data are available on the seroprotection status of HIV1-infected patients with respect to vaccine-preventable diseases. To describe, in a population of HIV1-infected migrants on stable, effective ART therapy, the seroprevalence of diphtheria, poliomyelitis, tetanus, yellow fever antibodies and serostatus for hepatitis B, and to identify factors associated with seroprotection. Vaccine responses against diphtheria, tetanus, poliomyelitis and yellow fever were also studied. Sub-Saharan African patients participating in the ANRS-VIHVO cohort were enrolled prior to travel to their countries of origin. Serologic analyses were performed in a central laboratory before and after the trip. Univariate and multivariate logistic regression was used to identify factors associated with initial seroprotection. 250 patients (99 men and 151 women) were included in the seroprevalence study. Median age was 45 years (IQR 39-52), median CD4 cell count was 440/μL (IQR 336-571), and 237 patients (95%) had undetectable HIV1 viral load. The initial seroprevalence rates were 69.0% (95%CI 63.2-74.7) for diphtheria, 70.7% (95%CI 65.0-76.3) for tetanus, and 85.9% (95%CI 81.6-90.2) for yellow fever. Only 64.4% (95%CI 58.5-70.3) of patients had protective antibody titers against all three poliomyelitis vaccine strains before travel. No serological markers of hepatitis B were found in 18.6% of patients (95%CI 13.7-23.3). Patient declaration of prior vaccination was the only factor consistently associated with initial seroprotection. We found a low prevalence of seroprotection against diphtheria, poliomyelitis, tetanus and hepatitis B. HIV infected migrants living in France and traveling to their native countries need to have their vaccine schedule completed.

Research paper thumbnail of Comparative effectiveness of immediate antiretroviral therapy versus CD4-based initiation in HIV-positive individuals in high-income countries: observational cohort study

The Lancet HIV, 2015

Recommendations have differed nationally and internationally with respect to the best time to sta... more Recommendations have differed nationally and internationally with respect to the best time to start antiretroviral therapy (ART). We compared effectiveness of three strategies for initiation of ART in high-income countries for HIV-positive individuals who do not have AIDS: immediate initiation, initiation at a CD4 count less than 500 cells per μL, and initiation at a CD4 count less than 350 cells per μL. We used data from the HIV-CAUSAL Collaboration of cohort studies in Europe and the USA. We included 55 826 individuals aged 18 years or older who were diagnosed with HIV-1 infection between January, 2000, and September, 2013, had not started ART, did not have AIDS, and had CD4 count and HIV-RNA viral load measurements within 6 months of HIV diagnosis. We estimated relative risks of death and of death or AIDS-defining illness, mean survival time, the proportion of individuals in need of ART, and the proportion of individuals with HIV-RNA viral load less than 50 copies per mL, as would have been recorded under each ART initiation strategy after 7 years of HIV diagnosis. We used the parametric g-formula to adjust for baseline and time-varying confounders. Median CD4 count at diagnosis of HIV infection was 376 cells per μL (IQR 222-551). Compared with immediate initiation, the estimated relative risk of death was 1·02 (95% CI 1·01-1·02) when ART was started at a CD4 count less than 500 cells per μL, and 1·06 (1·04-1·08) with initiation at a CD4 count less than 350 cells per μL. Corresponding estimates for death or AIDS-defining illness were 1·06 (1·06-1·07) and 1·20 (1·17-1·23), respectively. Compared with immediate initiation, the mean survival time at 7 years with a strategy of initiation at a CD4 count less than 500 cells per μL was 2 days shorter (95% CI 1-2) and at a CD4 count less than 350 cells per μL was 5 days shorter (4-6). 7 years after diagnosis of HIV, 100%, 98·7% (95% CI 98·6-98·7), and 92·6% (92·2-92·9) of individuals would have been in need of ART with immediate initiation, initiation at a CD4 count less than 500 cells per μL, and initiation at a CD4 count less than 350 cells per μL, respectively. Corresponding proportions of individuals with HIV-RNA viral load less than 50 copies per mL at 7 years were 87·3% (87·3-88·6), 87·4% (87·4-88·6), and 83·8% (83·6-84·9). The benefits of immediate initiation of ART, such as prolonged survival and AIDS-free survival and increased virological suppression, were small in this high-income setting with relatively low CD4 count at HIV diagnosis. The estimated beneficial effect on AIDS is less than in recently reported randomised trials. Increasing rates of HIV testing might be as important as a policy of early initiation of ART. National Institutes of Health.

Research paper thumbnail of A Multifaceted Intervention Designed to Improve Medical Management of Moderate to Advanced Chronic Kidney Disease in HIV-Infected Patients: A Cluster Randomized Trial

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 22, 2015

Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency vir... more Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol leve...

Research paper thumbnail of High prevalence of undiagnosed COPD in a cohort of HIV-infected smokers

The European respiratory journal, 2015

Research paper thumbnail of Visiting one's native country: the risks of nonadherence in HIV-infected sub-Saharan migrants--ANRS VIHVO study

Journal of the International Association of Providers of AIDS Care

The aim of this study was to evaluate to what extent travel-related factors may cause adherence f... more The aim of this study was to evaluate to what extent travel-related factors may cause adherence failure to antiretroviral therapy (ART) in otherwise adherent migrants when traveling back to Africa. HIV-infected sub-Saharian migrants living in France with a plasma HIV viral load < 200 copies/mL, with no change in ART for ≥3 months and who were about to visit their native country for between 2 weeks and 6 months were enrolled for the study. Patients completed a self-administered adherence questionnaire both at enrollment and during the week following their return to France. Adherence failure occurred in 23 (11.5%) of 200 patients. Negative perception about ART effectiveness (adjusted odds ratio = 4.3; 95% confidence interval = 1.3-13.7), unexpected traumatic events during their stay in their native country (7.8; 2.3-26.1), and a prolongation of their stay (5.2; 1.4-20.4) were independently associated with a higher likelihood of adherence failure. Owning/renting one's house in F...

Research paper thumbnail of CD4+ T-cell percentage is an independent predictor of clinical progression in AIDS-free antiretroviral-naive patients with CD4+ T-cell counts >200 cells/mm3

Antiviral therapy, 2009

The aim of this study was to evaluate the clinical prognostic value of the CD4+ T-cell percentage... more The aim of this study was to evaluate the clinical prognostic value of the CD4+ T-cell percentage (%CD4), the CD4+/CD8+ T-cell ratio or the CD8+ T-cell count, in addition to the CD4+ T-cell count and viral load (VL) in antiretroviral-naive HIV-infected patients with CD4+ T-cell counts >200 cells/mm(3). Antiretroviral-naive patients (n=9,740) who were AIDS-free and had a CD4+ T-cell count >200 cells/mm(3) at their first visit after January 1997 were followed-up until treatment initiation or clinical progression (mean follow-up 17 months and 13,660 person-years). Poisson regression was used for statistical analyses. Progression to AIDS-defining events (ADEs), serious ADEs and death occurred in 228 patients (crude rate 1.69 per 100 person-years), 105 patients (0.77 per 100 person-years) and 67 patients (0.49 per 100 person-years), respectively. Regarding progression to ADE, the data fit was improved when the model also included the %CD4 (Akaike's information criteria [AIC] 2,...

Research paper thumbnail of Later cART Initiation in Migrant Men from Sub-Saharan Africa without Advanced HIV Disease in France

PloS one, 2015

To compare the time from entry into care for HIV infection until combination antiretroviral thera... more To compare the time from entry into care for HIV infection until combination antiretroviral therapy (cART) initiation between migrants and non migrants in France, excluding late access to care. Antiretroviral-naïve HIV-1-infected individuals newly enrolled in the FHDH cohort between 2002-2010, with CD4 cell counts >200/μL and no previous or current AIDS events were included. In three baseline CD4 cell count strata (200-349, 350-499, ≥500/μL), we examined the crude time until cART initiation within three years after enrolment according to geographic origin, and multivariable hazard ratios according to geographic origin, gender and HIV-transmission group, with adjustment for baseline age, enrolment period, region of care, plasma viral load, and HBV/HBC coinfection. Among 13338 individuals, 9605 (72.1%) were French natives (FRA), 2873 (21.4%) were migrants from sub-Saharan Africa/non-French West Indies (SSA/NFW), and 860 (6.5%) were migrants from other countries. Kaplan-Meier probab...

Research paper thumbnail of A lupus-like glomerulonephritis following acute HIV-1 seroconversion in an African woman

Nephrology Dialysis Transplantation, 2005

Research paper thumbnail of Hospitalization Criteria in Imported Falciparum Malaria

Journal of Travel Medicine, 2008

Background . Controversy exists about the management of patients with imported Plasmodium falcipa... more Background . Controversy exists about the management of patients with imported Plasmodium falciparum malaria. We postulated that rapid parasite clearance supports ambulatory care, or, conversely, that factors associated with longer parasite clearance time (PCT) could be used as hospitalization criteria. Methods . Hospitalized patients with imported falciparum malaria recruited through one single travel clinic between 1993 and 2000. We used a linear regression to identify factors independently associated with PCT defi ned as the time in hours from antimalarial drug administration until the fi rst negative malaria smear. Results . Among 400 patients hospitalized with falciparum malaria, mean (range) PCT was 58 (1 -189) hours. In multivariate analysis, severe malaria, gastrointestinal signs, initial temperature greater than or equal to 40°C, parasitemia greater than or equal to 1%, and platelet counts less than 50,000/ L were associated with longer PCT. Offering ambulatory care to patients aged 15 to 64 years with none of the factors associated with longer PCT in the study would have resulted in 147 (37%) patients receiving outpatient care. Conclusion . Factors identifi ed in this model may help physicians determine which P falciparum malaria patients can be treated on an ambulatory basis, and contribute to revisions of national guidelines for imported malaria management.

Research paper thumbnail of Multidrug-Resistant Chronic Osteomyelitis Complicating War Injury in Iraqi Civilians

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

War-related orthopedic injury is frequently complicated by environmental contamination and delays... more War-related orthopedic injury is frequently complicated by environmental contamination and delays in management, placing victims at increased risk for long-term infectious complications. We describe, among Iraqi civilians with war-related chronic osteomyelitis, the bacteriology of infection at the time of admission. In the Médecins Sans Frontières Reconstructive Surgery Project in Amman, Jordan, we retrospectively reviewed baseline demographics and results of initial intraoperative surgical cultures among Iraqi civilians with suspected osteomyelitis. One hundred thirty-seven patients (90% male; median age, 35 years [interquartile range {IQR}, 28-46]; median time since initial injury, 19 months [IQR, 10-35]) were admitted with suspected chronic osteomyelitis after war-related injury. One hundred seven patients had a positive intraoperative culture. Before arrival, patients had undergone a median of 4 (IQR, 2-6) surgical procedures in Iraq. Fifty-nine (55%) of 107 patients with confirmed osteomyelitis had a multidrug-resistant (MDR) organism isolated at admission: cefepime-resistant Enterobacteriaceae (n = 40), methicillin-resistant Staphylococcus aureus (n = 16), and MDR Acinetobacter baumannii (n = 3). An association of borderline significance existed between a history of more than two prior surgical procedures in Iraq and an MDR isolate at program entry (multivariate: odds ratio, 5.3; 95% confidence interval, 0.9-30.6; p = 0.064). Health care actors, including Iraqi health facilities and humanitarian medical organizations, must be aware of the link between chronic war injury and antimicrobial drug resistance in this region and should be prepared for the management challenges involved with the treatment of chronic drug-resistant osteomyelitis.

Research paper thumbnail of Tuberculosis-Associated Immune Restoration Syndrome in HIV-1-Infected Patients Involves Tuberculin-Specific CD4 Th1 Cells and KIR-Negative    T Cells

The Journal of Immunology, 2009

Tuberculosis (TB)-associated immune restoration syndrome (IRS) is a frequent event (10 to 30%) in... more Tuberculosis (TB)-associated immune restoration syndrome (IRS) is a frequent event (10 to 30%) in HIV-1-infected patients receiving antiretroviral treatment and is associated with an increased number of IFN-gamma-producing tuberculin-specific cells. To further understand the immune mechanisms of TB-IRS and to identify predictive factors, we prospectively analyzed the Th1 and TCRgammadelta T cells known to be involved in mycobacterial defenses and dendritic cells at baseline and after antiretroviral and TB treatment in 24 HIV-1(+) patients, 11 with and 13 without IRS. At baseline, these two groups differed by significantly lower proportions of TCRgammadelta and Vdelta2(+) T cells displaying the inhibitory receptors CD94/NKG2 and CD158ah,b in IRS patients. The two groups did not differ in the baseline characteristics of CD8 or CD4 T cells or TLR-2 expression on monocytes or myeloid/plasmacytoid dendritic cells. During IRS, the increase in tuberculin-specific IFN-gamma-producing cells involved only highly activated effector memory multifunctional (IFN-gamma(+)TNF-alpha(+)IL-2(-)) CD4 T cells, whereas activated HLA-DR(+) CD4(+) T cells also increased during IRS. In contrast, dendritic cells decreased significantly during IRS and there were no changes in TLR-2 expression. Finally, the Vdelta2(+) T cells, mostly killer Ig-related receptor (KIR) (CD94/NKG2(-) and CD158(-)), significantly peaked during IRS but not in non-IRS patients. In conclusion, IRS is associated with an increase in the number of activated tuberculin-specific effector memory CD4 T cells and of KIR(-)Vdelta2(+) TCRgammadelta(+) T cells. Higher proportions of Vdelta2(+)TCRgammadelta(+) T cells lacking KIR expression are present as baseline and distinguish patients who will develop IRS from those who will not.

Research paper thumbnail of Spondylitis Due to Mycobacterium xenopi in a Human Immunodeficiency Virus Type 1-Infected Patient: Case Report and Review of the Literature

Journal of Clinical Microbiology, 2005

Nontuberculous mycobacterial infections are well known to occur in patients with human immunodefi... more Nontuberculous mycobacterial infections are well known to occur in patients with human immunodeficiency virus infection. However, spondylitis due to mycobacteria other than Mycobacterium tuberculosis is uncommon. We report a case of biopsy-and culture-proven Mycobacterium xenopi spondylitis in an AIDS patient and discuss approaches to diagnosis and therapy. This case serves to highlight the potential pathogenic role of this usually environmental commensal organism in severely immunosuppressed AIDS patients and uncertainties in their management, given the scarce data on appropriate therapy for this organism.

Research paper thumbnail of Impact of Late Presentation on the Risk of Death Among HIV-Infected People in France (2003–2009)

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2013

A recent consensus defines &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more A recent consensus defines &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;late presentation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (LP) during the course of HIV infection as presentation with AIDS whatever the CD4 cell count or with CD4 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;350 cells per cubic millimeter. Here, using this new definition, we examined the frequency and predictors of LP and its impact on mortality. In antiretroviral-naive patients enrolled in the French Hospital Database on HIV between 2003 and 2009, we studied risk factors for LP by multivariable logistic regression. The impact of LP on mortality was analyzed according to the level of immunodeficiency by using Cox multivariable models adjusted for potential confounders, with follow-up categorized into 0-6, 6-12, and 12-48 months. There were 11,038 (53.9%) late presenters among the 20,496 patients included in the study. Compared with patients presenting for care with CD4 ≥350 cells per cubic millimeter, patients presenting with AIDS had a very high risk of death with crude hazard ratio ranging from 48.3 during the first 6 months of follow-up to 4.8 during months 12-48; the corresponding values among AIDS-free patients with CD4 ≤200 cells per cubic millimeter were 8.1 and 2.3. Importantly, patients presenting with CD4 between 200 and 350 cells per cubic millimeter also had a significantly increased risk of death beyond 6 months of follow-up (hazard ratio: 3.0 and 1.8 for months 6-12 and 12-48, respectively). Results were similar after adjustment. LP with HIV infection is still very frequent in France and is associated with higher mortality, even among patients with only moderate immunodeficiency. Encouraging early testing and access to care is still urgently needed.

Research paper thumbnail of Pneumocystis carinii Pneumonia Recurrence in HIV Patients on Highly Active Antiretroviral Therapy: Secondary Prophylaxis

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2001

... Abgrall, Sophie*; Matheron, Sophie†; Le Moing, Vincent†; Dupont, Caroline‡; Costagliola, Domi... more ... Abgrall, Sophie*; Matheron, Sophie†; Le Moing, Vincent†; Dupont, Caroline‡; Costagliola, Dominique*; Clinical Epidemiology Group from the French Hospital Database on HIV. Article Outline. Collapse Box Author Information. ...

Research paper thumbnail of Dual Nucleoside Reverse Transcriptase Inhibitor Therapy in the Combination Antiretroviral Therapy Era and Predictors of Discontinuation or Switch to Combination Antiretroviral Therapy

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2008

Contrary to current HIV/AIDS management guidelines, and despite the arrival of potent combination... more Contrary to current HIV/AIDS management guidelines, and despite the arrival of potent combination antiretroviral therapy (cART) many years ago, some patients are still treated with dual nucleoside reverse transcriptase inhibitor (NRTI) regimens. We selected 5222 patients who received dual NRTI therapy for at least 6 months during 1998 to 2002, representing 9.9% of the 52,981 ARV-treated patients recorded in the French Hospital Database on HIV. Factors associated with switching to cART or with ARV discontinuation were identified by using Cox models. The 3-year probabilities of switching to cART and of antiretroviral (ARV) drug discontinuation were 55.2% (95% confidence interval [CI]: 53.8 to 56.7) and 10.9% (95% CI: 10.1 to 11.8), respectively, whereas 1591 patients (30.5%) kept the dual NRTI therapy during all the study period. Place of birth and region of care did not influence the choice of treatment strategy. After adjustment, the likelihood of switching to cART was lower among women, intravenous drug users, and patients with an undetectable plasma viral load (pVL) on at least 1 occasion during follow-up; in contrast, it was higher among patients with AIDS and those with a low CD4 cell count at enrollment or at the last follow-up visit. The likelihood of ARV discontinuation was higher among women and intravenous drug users and lower among patients with a low CD4 cell count at inclusion or at the last follow-up visit and among patients with an undetectable pVL on at least 1 occasion during follow-up. The likelihood of switching to cART or discontinuing ARV drugs was higher among patients receiving zidovudine/zalcitabine or didanosine/stavudine than among those receiving zidovudine/lamivudine. In France, until recent years, some patients (mainly women and intravenous drug users) were still receiving dual NRTI therapy despite free access to care and to highly effective ARV regimens. Dual NRTI therapy is gradually being replaced by cART, although some patients with satisfactory immunovirologic status are discontinuing all ARV drugs.

Research paper thumbnail of Silicone in HIV-1-infected patients: a cause of misdiagnosed granulomatous disease

International Journal of Infectious Diseases, 2010

Research paper thumbnail of Cohort Profile: French hospital database on HIV (FHDH-ANRS CO4)

International Journal of Epidemiology, 2014

The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort with inclu... more The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort with inclusions ongoing since 1989. The research objectives focus mainly on mid- and long-term clinical outcomes and therapeutic strategies, as well as severe AIDS and non-AIDS morbidities, and public health issues relative to HIV infection. FHDH also serves to describe HIV-infected patients receiving hospital care in France. FHDH includes data on more than 120,000 HIV-infected patients from 70 French general or university hospitals distributed throughout France. Patients are eligible for inclusion if they are infected by HIV-1 or HIV-2 and give their written informed consent. Standardized variables are collected at each outpatient visit or hospital admission during which a new clinical manifestation is diagnosed, a new treatment is prescribed or a change in biological markers is noted, and/or at least every 6 months. Since its inception, variables collected in FHDH include demographic characteristics, HIV-related biological markers, the date and type of AIDS and non AIDS-defining events, antiretroviral treatments and the date and causes of death, as reported in the medical records. Since 2005, data have also been collected on: co-infection with hepatitis B or C virus; alcohol and tobacco use; and non HIV-related biomarkers. Anyone can submit a research project by completing a standardized form available on the FHDH website (http://www.ccde.fr/_fold/fl-1385734776-429.pdf) or from the corresponding author, describing the context and objectives of the study. All projects are reviewed by the scientific committee.

Research paper thumbnail of Impact of risk factors for specific causes death in the first and subsequent years of ART among HIV-infected patients

Clinical Infectious Diseases, 2014

Background. Patterns of cause-specific mortality in individuals infected with human immunodeficie... more Background. Patterns of cause-specific mortality in individuals infected with human immunodeficiency virus type 1 (HIV-1) are changing dramatically in the era of antiretroviral therapy (ART).

Research paper thumbnail of Scedosporium apiospermum Lung Infection with Fatal Subsequent Postoperative Outcome in an Immunocompetent Host

Clinical Infectious Diseases, 2007

Research paper thumbnail of Maintaining Antiretroviral Therapy Reduces the Risk of AIDS-Defining Events in Patients with Uncontrolled Viral Replication and Profound Immunodeficiency

Clinical Infectious Diseases, 2008

The benefits of continuing antiretroviral therapy are questionable in human immunodeficiency viru... more The benefits of continuing antiretroviral therapy are questionable in human immunodeficiency virus (HIV) type 1-infected patients with profound immunodeficiency and multiple treatment failure due to viral resistance. From the French Hospital Database on HIV, we selected 12,765 patients with a CD4(+) cell count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;200 cells/mm(3) who received a combination antiretroviral therapy (cART) during 2000-2005. Three groups of patients were defined: patients who interrupted cART at least once, patients who had at least 2 consecutive detectable viral loads (VLs) while receiving cART, and patients who had undetectable VL during treatment with cART. Incidence rates and risks of new acquired immunodeficiency syndrome-defining events (ADEs) were assessed among the 3 groups of patients, overall and after CD4(+) cell count stratification (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 and 50-200 cells/mm(3)). The estimated incidence rates +/- standard deviation of ADEs were 18.5+/-1.9, 14.5+/-0.7, and 4.9+/-0.5, respectively, for patients who interrupted cART, patients who had detectable VL during treatment with cART, and patients who had undetectable VL during treatment with cART. These differences were observed in both CD4(+) cell count strata. Overall, after adjustment, risks of a new ADE in patients who had detectable VL and in patients who had undetectable VL while receiving cART were 22% and 62% lower, respectively, than in patients who stopped cART. Among patients with CD4(+) cell count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 cells/mm(3), the risk of a new ADE was 22% lower in patients who continued to receive a failing cART regimen than in patients who stopped treatment with cART. Likewise, among patients with a CD4(+) cell count of 50-200 cells/mm(3), the risk was 34% lower in patients who continued to receive a failing cART regimen than in those who stopped taking cART. Even when effective virological control is no longer achievable, cART still reduces the risk of ADEs in profoundly immunodeficient HIV-infected patients.

Research paper thumbnail of Diphtheria, tetanus, poliomyelitis, yellow fever and hepatitis B seroprevalence among HIV1-infected migrants. Results from the ANRS VIHVO vaccine sub-study

Vaccine, 2015

Few data are available on the seroprotection status of HIV1-infected patients with respect to vac... more Few data are available on the seroprotection status of HIV1-infected patients with respect to vaccine-preventable diseases. To describe, in a population of HIV1-infected migrants on stable, effective ART therapy, the seroprevalence of diphtheria, poliomyelitis, tetanus, yellow fever antibodies and serostatus for hepatitis B, and to identify factors associated with seroprotection. Vaccine responses against diphtheria, tetanus, poliomyelitis and yellow fever were also studied. Sub-Saharan African patients participating in the ANRS-VIHVO cohort were enrolled prior to travel to their countries of origin. Serologic analyses were performed in a central laboratory before and after the trip. Univariate and multivariate logistic regression was used to identify factors associated with initial seroprotection. 250 patients (99 men and 151 women) were included in the seroprevalence study. Median age was 45 years (IQR 39-52), median CD4 cell count was 440/μL (IQR 336-571), and 237 patients (95%) had undetectable HIV1 viral load. The initial seroprevalence rates were 69.0% (95%CI 63.2-74.7) for diphtheria, 70.7% (95%CI 65.0-76.3) for tetanus, and 85.9% (95%CI 81.6-90.2) for yellow fever. Only 64.4% (95%CI 58.5-70.3) of patients had protective antibody titers against all three poliomyelitis vaccine strains before travel. No serological markers of hepatitis B were found in 18.6% of patients (95%CI 13.7-23.3). Patient declaration of prior vaccination was the only factor consistently associated with initial seroprotection. We found a low prevalence of seroprotection against diphtheria, poliomyelitis, tetanus and hepatitis B. HIV infected migrants living in France and traveling to their native countries need to have their vaccine schedule completed.

Research paper thumbnail of Comparative effectiveness of immediate antiretroviral therapy versus CD4-based initiation in HIV-positive individuals in high-income countries: observational cohort study

The Lancet HIV, 2015

Recommendations have differed nationally and internationally with respect to the best time to sta... more Recommendations have differed nationally and internationally with respect to the best time to start antiretroviral therapy (ART). We compared effectiveness of three strategies for initiation of ART in high-income countries for HIV-positive individuals who do not have AIDS: immediate initiation, initiation at a CD4 count less than 500 cells per μL, and initiation at a CD4 count less than 350 cells per μL. We used data from the HIV-CAUSAL Collaboration of cohort studies in Europe and the USA. We included 55 826 individuals aged 18 years or older who were diagnosed with HIV-1 infection between January, 2000, and September, 2013, had not started ART, did not have AIDS, and had CD4 count and HIV-RNA viral load measurements within 6 months of HIV diagnosis. We estimated relative risks of death and of death or AIDS-defining illness, mean survival time, the proportion of individuals in need of ART, and the proportion of individuals with HIV-RNA viral load less than 50 copies per mL, as would have been recorded under each ART initiation strategy after 7 years of HIV diagnosis. We used the parametric g-formula to adjust for baseline and time-varying confounders. Median CD4 count at diagnosis of HIV infection was 376 cells per μL (IQR 222-551). Compared with immediate initiation, the estimated relative risk of death was 1·02 (95% CI 1·01-1·02) when ART was started at a CD4 count less than 500 cells per μL, and 1·06 (1·04-1·08) with initiation at a CD4 count less than 350 cells per μL. Corresponding estimates for death or AIDS-defining illness were 1·06 (1·06-1·07) and 1·20 (1·17-1·23), respectively. Compared with immediate initiation, the mean survival time at 7 years with a strategy of initiation at a CD4 count less than 500 cells per μL was 2 days shorter (95% CI 1-2) and at a CD4 count less than 350 cells per μL was 5 days shorter (4-6). 7 years after diagnosis of HIV, 100%, 98·7% (95% CI 98·6-98·7), and 92·6% (92·2-92·9) of individuals would have been in need of ART with immediate initiation, initiation at a CD4 count less than 500 cells per μL, and initiation at a CD4 count less than 350 cells per μL, respectively. Corresponding proportions of individuals with HIV-RNA viral load less than 50 copies per mL at 7 years were 87·3% (87·3-88·6), 87·4% (87·4-88·6), and 83·8% (83·6-84·9). The benefits of immediate initiation of ART, such as prolonged survival and AIDS-free survival and increased virological suppression, were small in this high-income setting with relatively low CD4 count at HIV diagnosis. The estimated beneficial effect on AIDS is less than in recently reported randomised trials. Increasing rates of HIV testing might be as important as a policy of early initiation of ART. National Institutes of Health.

Research paper thumbnail of A Multifaceted Intervention Designed to Improve Medical Management of Moderate to Advanced Chronic Kidney Disease in HIV-Infected Patients: A Cluster Randomized Trial

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Jan 22, 2015

Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency vir... more Chronic kidney disease (CKD) is frequent in individuals infected with human immunodeficiency virus (HIV). Progression to end-stage renal disease can be slowed by appropriate medical management. To assess whether active promotion of guidelines improves CKD management, we conducted a cluster randomized controlled trial within the French Hospital Database on HIV (FHDH-ANRS CO4). We randomized 46 centers participating in the FHDH to either simple information on guideline availability or active promotion with a multifaceted and repeated intervention comprising reminders and audit feedback and targeting of local opinion leaders carried out between April 2009 and April 2010. Outcome measure was CKD management adequacy assessed before and 2 years after the beginning of the intervention in HIV-infected patients with moderate to severe CKD. CKD management was considered adequate in case of referral to a nephrologist or if proteinuria, blood pressure, low-density lipoprotein cholesterol leve...

Research paper thumbnail of High prevalence of undiagnosed COPD in a cohort of HIV-infected smokers

The European respiratory journal, 2015

Research paper thumbnail of Visiting one's native country: the risks of nonadherence in HIV-infected sub-Saharan migrants--ANRS VIHVO study

Journal of the International Association of Providers of AIDS Care

The aim of this study was to evaluate to what extent travel-related factors may cause adherence f... more The aim of this study was to evaluate to what extent travel-related factors may cause adherence failure to antiretroviral therapy (ART) in otherwise adherent migrants when traveling back to Africa. HIV-infected sub-Saharian migrants living in France with a plasma HIV viral load < 200 copies/mL, with no change in ART for ≥3 months and who were about to visit their native country for between 2 weeks and 6 months were enrolled for the study. Patients completed a self-administered adherence questionnaire both at enrollment and during the week following their return to France. Adherence failure occurred in 23 (11.5%) of 200 patients. Negative perception about ART effectiveness (adjusted odds ratio = 4.3; 95% confidence interval = 1.3-13.7), unexpected traumatic events during their stay in their native country (7.8; 2.3-26.1), and a prolongation of their stay (5.2; 1.4-20.4) were independently associated with a higher likelihood of adherence failure. Owning/renting one's house in F...

Research paper thumbnail of CD4+ T-cell percentage is an independent predictor of clinical progression in AIDS-free antiretroviral-naive patients with CD4+ T-cell counts >200 cells/mm3

Antiviral therapy, 2009

The aim of this study was to evaluate the clinical prognostic value of the CD4+ T-cell percentage... more The aim of this study was to evaluate the clinical prognostic value of the CD4+ T-cell percentage (%CD4), the CD4+/CD8+ T-cell ratio or the CD8+ T-cell count, in addition to the CD4+ T-cell count and viral load (VL) in antiretroviral-naive HIV-infected patients with CD4+ T-cell counts >200 cells/mm(3). Antiretroviral-naive patients (n=9,740) who were AIDS-free and had a CD4+ T-cell count >200 cells/mm(3) at their first visit after January 1997 were followed-up until treatment initiation or clinical progression (mean follow-up 17 months and 13,660 person-years). Poisson regression was used for statistical analyses. Progression to AIDS-defining events (ADEs), serious ADEs and death occurred in 228 patients (crude rate 1.69 per 100 person-years), 105 patients (0.77 per 100 person-years) and 67 patients (0.49 per 100 person-years), respectively. Regarding progression to ADE, the data fit was improved when the model also included the %CD4 (Akaike's information criteria [AIC] 2,...

Research paper thumbnail of Later cART Initiation in Migrant Men from Sub-Saharan Africa without Advanced HIV Disease in France

PloS one, 2015

To compare the time from entry into care for HIV infection until combination antiretroviral thera... more To compare the time from entry into care for HIV infection until combination antiretroviral therapy (cART) initiation between migrants and non migrants in France, excluding late access to care. Antiretroviral-naïve HIV-1-infected individuals newly enrolled in the FHDH cohort between 2002-2010, with CD4 cell counts >200/μL and no previous or current AIDS events were included. In three baseline CD4 cell count strata (200-349, 350-499, ≥500/μL), we examined the crude time until cART initiation within three years after enrolment according to geographic origin, and multivariable hazard ratios according to geographic origin, gender and HIV-transmission group, with adjustment for baseline age, enrolment period, region of care, plasma viral load, and HBV/HBC coinfection. Among 13338 individuals, 9605 (72.1%) were French natives (FRA), 2873 (21.4%) were migrants from sub-Saharan Africa/non-French West Indies (SSA/NFW), and 860 (6.5%) were migrants from other countries. Kaplan-Meier probab...

Research paper thumbnail of A lupus-like glomerulonephritis following acute HIV-1 seroconversion in an African woman

Nephrology Dialysis Transplantation, 2005

Research paper thumbnail of Hospitalization Criteria in Imported Falciparum Malaria

Journal of Travel Medicine, 2008

Background . Controversy exists about the management of patients with imported Plasmodium falcipa... more Background . Controversy exists about the management of patients with imported Plasmodium falciparum malaria. We postulated that rapid parasite clearance supports ambulatory care, or, conversely, that factors associated with longer parasite clearance time (PCT) could be used as hospitalization criteria. Methods . Hospitalized patients with imported falciparum malaria recruited through one single travel clinic between 1993 and 2000. We used a linear regression to identify factors independently associated with PCT defi ned as the time in hours from antimalarial drug administration until the fi rst negative malaria smear. Results . Among 400 patients hospitalized with falciparum malaria, mean (range) PCT was 58 (1 -189) hours. In multivariate analysis, severe malaria, gastrointestinal signs, initial temperature greater than or equal to 40°C, parasitemia greater than or equal to 1%, and platelet counts less than 50,000/ L were associated with longer PCT. Offering ambulatory care to patients aged 15 to 64 years with none of the factors associated with longer PCT in the study would have resulted in 147 (37%) patients receiving outpatient care. Conclusion . Factors identifi ed in this model may help physicians determine which P falciparum malaria patients can be treated on an ambulatory basis, and contribute to revisions of national guidelines for imported malaria management.

Research paper thumbnail of Multidrug-Resistant Chronic Osteomyelitis Complicating War Injury in Iraqi Civilians

The Journal of Trauma: Injury, Infection, and Critical Care, 2011

War-related orthopedic injury is frequently complicated by environmental contamination and delays... more War-related orthopedic injury is frequently complicated by environmental contamination and delays in management, placing victims at increased risk for long-term infectious complications. We describe, among Iraqi civilians with war-related chronic osteomyelitis, the bacteriology of infection at the time of admission. In the Médecins Sans Frontières Reconstructive Surgery Project in Amman, Jordan, we retrospectively reviewed baseline demographics and results of initial intraoperative surgical cultures among Iraqi civilians with suspected osteomyelitis. One hundred thirty-seven patients (90% male; median age, 35 years [interquartile range {IQR}, 28-46]; median time since initial injury, 19 months [IQR, 10-35]) were admitted with suspected chronic osteomyelitis after war-related injury. One hundred seven patients had a positive intraoperative culture. Before arrival, patients had undergone a median of 4 (IQR, 2-6) surgical procedures in Iraq. Fifty-nine (55%) of 107 patients with confirmed osteomyelitis had a multidrug-resistant (MDR) organism isolated at admission: cefepime-resistant Enterobacteriaceae (n = 40), methicillin-resistant Staphylococcus aureus (n = 16), and MDR Acinetobacter baumannii (n = 3). An association of borderline significance existed between a history of more than two prior surgical procedures in Iraq and an MDR isolate at program entry (multivariate: odds ratio, 5.3; 95% confidence interval, 0.9-30.6; p = 0.064). Health care actors, including Iraqi health facilities and humanitarian medical organizations, must be aware of the link between chronic war injury and antimicrobial drug resistance in this region and should be prepared for the management challenges involved with the treatment of chronic drug-resistant osteomyelitis.

Research paper thumbnail of Tuberculosis-Associated Immune Restoration Syndrome in HIV-1-Infected Patients Involves Tuberculin-Specific CD4 Th1 Cells and KIR-Negative    T Cells

The Journal of Immunology, 2009

Tuberculosis (TB)-associated immune restoration syndrome (IRS) is a frequent event (10 to 30%) in... more Tuberculosis (TB)-associated immune restoration syndrome (IRS) is a frequent event (10 to 30%) in HIV-1-infected patients receiving antiretroviral treatment and is associated with an increased number of IFN-gamma-producing tuberculin-specific cells. To further understand the immune mechanisms of TB-IRS and to identify predictive factors, we prospectively analyzed the Th1 and TCRgammadelta T cells known to be involved in mycobacterial defenses and dendritic cells at baseline and after antiretroviral and TB treatment in 24 HIV-1(+) patients, 11 with and 13 without IRS. At baseline, these two groups differed by significantly lower proportions of TCRgammadelta and Vdelta2(+) T cells displaying the inhibitory receptors CD94/NKG2 and CD158ah,b in IRS patients. The two groups did not differ in the baseline characteristics of CD8 or CD4 T cells or TLR-2 expression on monocytes or myeloid/plasmacytoid dendritic cells. During IRS, the increase in tuberculin-specific IFN-gamma-producing cells involved only highly activated effector memory multifunctional (IFN-gamma(+)TNF-alpha(+)IL-2(-)) CD4 T cells, whereas activated HLA-DR(+) CD4(+) T cells also increased during IRS. In contrast, dendritic cells decreased significantly during IRS and there were no changes in TLR-2 expression. Finally, the Vdelta2(+) T cells, mostly killer Ig-related receptor (KIR) (CD94/NKG2(-) and CD158(-)), significantly peaked during IRS but not in non-IRS patients. In conclusion, IRS is associated with an increase in the number of activated tuberculin-specific effector memory CD4 T cells and of KIR(-)Vdelta2(+) TCRgammadelta(+) T cells. Higher proportions of Vdelta2(+)TCRgammadelta(+) T cells lacking KIR expression are present as baseline and distinguish patients who will develop IRS from those who will not.

Research paper thumbnail of Spondylitis Due to Mycobacterium xenopi in a Human Immunodeficiency Virus Type 1-Infected Patient: Case Report and Review of the Literature

Journal of Clinical Microbiology, 2005

Nontuberculous mycobacterial infections are well known to occur in patients with human immunodefi... more Nontuberculous mycobacterial infections are well known to occur in patients with human immunodeficiency virus infection. However, spondylitis due to mycobacteria other than Mycobacterium tuberculosis is uncommon. We report a case of biopsy-and culture-proven Mycobacterium xenopi spondylitis in an AIDS patient and discuss approaches to diagnosis and therapy. This case serves to highlight the potential pathogenic role of this usually environmental commensal organism in severely immunosuppressed AIDS patients and uncertainties in their management, given the scarce data on appropriate therapy for this organism.

Research paper thumbnail of Impact of Late Presentation on the Risk of Death Among HIV-Infected People in France (2003–2009)

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2013

A recent consensus defines &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;a... more A recent consensus defines &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;late presentation&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; (LP) during the course of HIV infection as presentation with AIDS whatever the CD4 cell count or with CD4 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;350 cells per cubic millimeter. Here, using this new definition, we examined the frequency and predictors of LP and its impact on mortality. In antiretroviral-naive patients enrolled in the French Hospital Database on HIV between 2003 and 2009, we studied risk factors for LP by multivariable logistic regression. The impact of LP on mortality was analyzed according to the level of immunodeficiency by using Cox multivariable models adjusted for potential confounders, with follow-up categorized into 0-6, 6-12, and 12-48 months. There were 11,038 (53.9%) late presenters among the 20,496 patients included in the study. Compared with patients presenting for care with CD4 ≥350 cells per cubic millimeter, patients presenting with AIDS had a very high risk of death with crude hazard ratio ranging from 48.3 during the first 6 months of follow-up to 4.8 during months 12-48; the corresponding values among AIDS-free patients with CD4 ≤200 cells per cubic millimeter were 8.1 and 2.3. Importantly, patients presenting with CD4 between 200 and 350 cells per cubic millimeter also had a significantly increased risk of death beyond 6 months of follow-up (hazard ratio: 3.0 and 1.8 for months 6-12 and 12-48, respectively). Results were similar after adjustment. LP with HIV infection is still very frequent in France and is associated with higher mortality, even among patients with only moderate immunodeficiency. Encouraging early testing and access to care is still urgently needed.

Research paper thumbnail of Pneumocystis carinii Pneumonia Recurrence in HIV Patients on Highly Active Antiretroviral Therapy: Secondary Prophylaxis

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2001

... Abgrall, Sophie*; Matheron, Sophie†; Le Moing, Vincent†; Dupont, Caroline‡; Costagliola, Domi... more ... Abgrall, Sophie*; Matheron, Sophie†; Le Moing, Vincent†; Dupont, Caroline‡; Costagliola, Dominique*; Clinical Epidemiology Group from the French Hospital Database on HIV. Article Outline. Collapse Box Author Information. ...

Research paper thumbnail of Dual Nucleoside Reverse Transcriptase Inhibitor Therapy in the Combination Antiretroviral Therapy Era and Predictors of Discontinuation or Switch to Combination Antiretroviral Therapy

JAIDS Journal of Acquired Immune Deficiency Syndromes, 2008

Contrary to current HIV/AIDS management guidelines, and despite the arrival of potent combination... more Contrary to current HIV/AIDS management guidelines, and despite the arrival of potent combination antiretroviral therapy (cART) many years ago, some patients are still treated with dual nucleoside reverse transcriptase inhibitor (NRTI) regimens. We selected 5222 patients who received dual NRTI therapy for at least 6 months during 1998 to 2002, representing 9.9% of the 52,981 ARV-treated patients recorded in the French Hospital Database on HIV. Factors associated with switching to cART or with ARV discontinuation were identified by using Cox models. The 3-year probabilities of switching to cART and of antiretroviral (ARV) drug discontinuation were 55.2% (95% confidence interval [CI]: 53.8 to 56.7) and 10.9% (95% CI: 10.1 to 11.8), respectively, whereas 1591 patients (30.5%) kept the dual NRTI therapy during all the study period. Place of birth and region of care did not influence the choice of treatment strategy. After adjustment, the likelihood of switching to cART was lower among women, intravenous drug users, and patients with an undetectable plasma viral load (pVL) on at least 1 occasion during follow-up; in contrast, it was higher among patients with AIDS and those with a low CD4 cell count at enrollment or at the last follow-up visit. The likelihood of ARV discontinuation was higher among women and intravenous drug users and lower among patients with a low CD4 cell count at inclusion or at the last follow-up visit and among patients with an undetectable pVL on at least 1 occasion during follow-up. The likelihood of switching to cART or discontinuing ARV drugs was higher among patients receiving zidovudine/zalcitabine or didanosine/stavudine than among those receiving zidovudine/lamivudine. In France, until recent years, some patients (mainly women and intravenous drug users) were still receiving dual NRTI therapy despite free access to care and to highly effective ARV regimens. Dual NRTI therapy is gradually being replaced by cART, although some patients with satisfactory immunovirologic status are discontinuing all ARV drugs.

Research paper thumbnail of Silicone in HIV-1-infected patients: a cause of misdiagnosed granulomatous disease

International Journal of Infectious Diseases, 2010

Research paper thumbnail of Cohort Profile: French hospital database on HIV (FHDH-ANRS CO4)

International Journal of Epidemiology, 2014

The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort with inclu... more The French Hospital Database on HIV (FHDH) is a hospital-based multicentre open cohort with inclusions ongoing since 1989. The research objectives focus mainly on mid- and long-term clinical outcomes and therapeutic strategies, as well as severe AIDS and non-AIDS morbidities, and public health issues relative to HIV infection. FHDH also serves to describe HIV-infected patients receiving hospital care in France. FHDH includes data on more than 120,000 HIV-infected patients from 70 French general or university hospitals distributed throughout France. Patients are eligible for inclusion if they are infected by HIV-1 or HIV-2 and give their written informed consent. Standardized variables are collected at each outpatient visit or hospital admission during which a new clinical manifestation is diagnosed, a new treatment is prescribed or a change in biological markers is noted, and/or at least every 6 months. Since its inception, variables collected in FHDH include demographic characteristics, HIV-related biological markers, the date and type of AIDS and non AIDS-defining events, antiretroviral treatments and the date and causes of death, as reported in the medical records. Since 2005, data have also been collected on: co-infection with hepatitis B or C virus; alcohol and tobacco use; and non HIV-related biomarkers. Anyone can submit a research project by completing a standardized form available on the FHDH website (http://www.ccde.fr/_fold/fl-1385734776-429.pdf) or from the corresponding author, describing the context and objectives of the study. All projects are reviewed by the scientific committee.

Research paper thumbnail of Impact of risk factors for specific causes death in the first and subsequent years of ART among HIV-infected patients

Clinical Infectious Diseases, 2014

Background. Patterns of cause-specific mortality in individuals infected with human immunodeficie... more Background. Patterns of cause-specific mortality in individuals infected with human immunodeficiency virus type 1 (HIV-1) are changing dramatically in the era of antiretroviral therapy (ART).

Research paper thumbnail of Scedosporium apiospermum Lung Infection with Fatal Subsequent Postoperative Outcome in an Immunocompetent Host

Clinical Infectious Diseases, 2007

Research paper thumbnail of Maintaining Antiretroviral Therapy Reduces the Risk of AIDS-Defining Events in Patients with Uncontrolled Viral Replication and Profound Immunodeficiency

Clinical Infectious Diseases, 2008

The benefits of continuing antiretroviral therapy are questionable in human immunodeficiency viru... more The benefits of continuing antiretroviral therapy are questionable in human immunodeficiency virus (HIV) type 1-infected patients with profound immunodeficiency and multiple treatment failure due to viral resistance. From the French Hospital Database on HIV, we selected 12,765 patients with a CD4(+) cell count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;200 cells/mm(3) who received a combination antiretroviral therapy (cART) during 2000-2005. Three groups of patients were defined: patients who interrupted cART at least once, patients who had at least 2 consecutive detectable viral loads (VLs) while receiving cART, and patients who had undetectable VL during treatment with cART. Incidence rates and risks of new acquired immunodeficiency syndrome-defining events (ADEs) were assessed among the 3 groups of patients, overall and after CD4(+) cell count stratification (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 and 50-200 cells/mm(3)). The estimated incidence rates +/- standard deviation of ADEs were 18.5+/-1.9, 14.5+/-0.7, and 4.9+/-0.5, respectively, for patients who interrupted cART, patients who had detectable VL during treatment with cART, and patients who had undetectable VL during treatment with cART. These differences were observed in both CD4(+) cell count strata. Overall, after adjustment, risks of a new ADE in patients who had detectable VL and in patients who had undetectable VL while receiving cART were 22% and 62% lower, respectively, than in patients who stopped cART. Among patients with CD4(+) cell count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;50 cells/mm(3), the risk of a new ADE was 22% lower in patients who continued to receive a failing cART regimen than in patients who stopped treatment with cART. Likewise, among patients with a CD4(+) cell count of 50-200 cells/mm(3), the risk was 34% lower in patients who continued to receive a failing cART regimen than in those who stopped taking cART. Even when effective virological control is no longer achievable, cART still reduces the risk of ADEs in profoundly immunodeficient HIV-infected patients.