New challenges in infectious diseases

1
New challenges in infectious diseases
Jan von Overbeck Chief Medical Officer Swiss Re
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AIDS
by Quarter-Year of Diagnosis/Death, United
States, 1985-1999
3
Pneumococcal septicemiabefore and after
penicillin
Relative mortality
1930
- 72
1965
Ann Inter Med 1964
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The HAART revolutionMortality from HIV/AIDS
Relative mortality
1992
- 84
1998
SHCS, 1999 JAMA 2822220
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The HAART revolution
S. pneumoniae Sepsis 1930-1965
AIDS, 1994-1998
AZT
Delta, ACTG 175
ddI/C
Caesar
3-TC
ACTG 320
IND

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Care prolongs productive life
Source Adapted from WHO/UNAIDS Statistics,
HIV/AIDS Surveillance in Europe, End- year report
2001, No. 66, CESES
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Swiss HIV Cohort Study (SHCS)

• 6547 patients enrolled
• observation period 1/1997 - 12/2001
• follow-up to death
• risk factors investigated
• gender, origin, age
• hepatitis C and B
• CD4 count and viral load
• therapy

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SHCS characteristics
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Swiss HIV Cohort Study
died
Number of patients / year
Year
Source SHCS 03/2001
10
Trend in use of antiretroviral therapy, SHCS,
1991-2000
100
No treatment
More than 3 drugs
80
60
of patients
Triple combination
40
20
Bi-therapy
Mono-therapy
0
91
92
93
94
95
96
97
98
99
00
Year
Source SHCS 03/2001
11
Decline in AIDS events after initiation of HAART
40
(183 events, 1457 pyrs)
35
30
25
Incidence per 100 pyrs
20
15
10
5
0
-6
-6
3
9
15
HAART
Months
Telenti et al.
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Mortality in patients with lt 200 CD4 cells (SHCS)
Year Relative Risk 1988/89 1
(Reference) 1990/91 0.9 1992/1993 0.88 1994/19
95 0.71 1996/1997 0.14
Egger et al. BMJ, 1998
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Selection of HIV risk groups
Jaggy et al., 2003 Lancet
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Selection of HIV risk groups - discrimination ?
100 6547
54
45
20
8
of original group
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Jaggy et al., 2003 Lancet
95 CI interval
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EDR by age - Difficulties due to limited data!
Number of observed deaths
17

• Swiss
• HCV-
• HAART

1
5
8
Jaggy et al., 2003 Lancet
95 CI interval
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What is mortality of HIV positive people?
Jaggy et al., 2003 Lancet
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Development of extra mortality over time

• Swiss
• HCV-
• HAART

12 12 6 4 1 of deaths
Jaggy et al., 2003 Lancet
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Risk selection is crucial - can it be managed
successfully?
Jaggy et al., 2003 Lancet
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HIV and Life Insurance

• HIV extra mortality quantifiable, though with
  considerable uncertainties (small sample)
• Sub-groups of HIV infected people with distinctly
  favourable mortality identified
• Positive impact of medical advances on HIV
  mortality
• Mortality experience with HAART therapy is
  limited in time!
• HAART therapy compliance? (risk management!)
• Size of favourable HIV sub-group?
  (discrimination!)

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Effects of interrupting HAART
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HIV and Survival
Set point and CD4 count before Treatment