Frank de Wolf

Imperial College London, Londinium, England, United Kingdom

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Publications (251)1669.23 Total impact

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    ABSTRACT: Estimates of the size of the undiagnosed HIV-infected population are important to understand the HIV epidemic and to plan interventions, including "test-and-treat" strategies. We developed a multi-state back-calculation model to estimate HIV incidence, time between infection and diagnosis, and the undiagnosed population by CD4 count strata, using surveillance data on new HIV and AIDS diagnoses. The HIV incidence curve was modelled using cubic splines. The model was tested on simulated data and applied to surveillance data on men who have sex with men in The Netherlands. The number of HIV infections could be estimated accurately using simulated data, with most values within the 95% confidence intervals of model predictions. When applying the model to Dutch surveillance data, 15,400 (95% confidence interval [CI] = 15,000, 16,000) men who have sex with men were estimated to have been infected between 1980 and 2011. HIV incidence showed a bimodal distribution, with peaks around 1985 and 2005 and a decline in recent years. Mean time to diagnosis was 6.1 (95% CI = 5.8, 6.4) years between 1984 and 1995 and decreased to 2.6 (2.3, 3.0) years in 2011. By the end of 2011, 11,500 (11,000, 12,000) men who have sex with men in The Netherlands were estimated to be living with HIV, of whom 1,750 (1,450, 2,200) were still undiagnosed. Of the undiagnosed men who have sex with men, 29% (22, 37) were infected for less than 1 year, and 16% (13, 20) for more than 5 years. This multi-state back-calculation model will be useful to estimate HIV incidence, time to diagnosis, and the undiagnosed HIV epidemic based on routine surveillance data.This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
    Epidemiology (Cambridge, Mass.) 07/2015; 26(5). DOI:10.1097/EDE.0000000000000324 · 6.20 Impact Factor
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    ABSTRACT: The population infected with HIV is getting older and these people will increasingly develop age-related non-communicable diseases (NCDs). We aimed to quantify the scale of the change and the implications for HIV care in the Netherlands in the future. We constructed an individual-based model of the ageing HIV-infected population, which followed patients on HIV treatment as they age, develop NCDs-including cardiovascular disease (hypertension, hypercholesterolaemia, myocardial infarctions, and strokes), diabetes, chronic kidney disease, osteoporosis, and non-AIDS malignancies-and start co-medication for these diseases. The model was parameterised by use of data for 10 278 patients from the national Dutch ATHENA cohort between 1996 and 2010. We made projections up to 2030. Our model suggests that the median age of HIV-infected patients on combination antiretroviral therapy (ART) will increase from 43·9 years in 2010 to 56·6 in 2030, with the proportion of HIV-infected patients aged 50 years or older increasing from 28% in 2010 to 73% in 2030. In 2030, we predict that 84% of HIV-infected patients will have at least one NCD, up from 29% in 2010, with 28% of HIV-infected patients in 2030 having three or more NCDs. 54% of HIV-infected patients will be prescribed co-medications in 2030, compared with 13% in 2010, with 20% taking three or more co-medications. Most of this change will be driven by increasing prevalence of cardiovascular disease and associated drugs. Because of contraindications and drug-drug interactions, in 2030, 40% of patients could have complications with the currently recommended first-line HIV regimens. The profile of patients in the Netherlands infected with HIV is changing, with increasing numbers of older patients with multiple morbidities. These changes mean that, in the near future, HIV care will increasingly need to draw on a wide range of medical disciplines, in addition to evidence-based screening and monitoring protocols to ensure continued high-quality care. These findings are based on a large dataset of HIV-infected patients in the Netherlands, but we believe that the overall patterns will be repeated elsewhere in Europe and North America. The implications of such a trend for care of HIV-infected patients in high-burden countries in Africa could present a particular challenge. Medical Research Council, Bill & Melinda Gates Foundation, Rush Foundation, and Netherlands Ministry of Health, Welfare and Sport. Copyright © 2015 Elsevier Ltd. All rights reserved.
    The Lancet Infectious Diseases 06/2015; 15(7). DOI:10.1016/S1473-3099(15)00056-0 · 22.43 Impact Factor
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    ABSTRACT: Certain non-AIDS-related diseases have been associated with immunodeficiency and HIV RNA levels in HIV-infected patients on combination antiretroviral therapy (cART). We aimed to investigate these associations in patients not yet on cART, when potential antiretroviral-drug-related effects are absent and variation in RNA levels is greater. Associations between, on the one hand, time-updated CD4 counts and plasma HIV RNA and, on the other hand, a composite non-AIDS-related endpoint, including major cardiovascular diseases, liver fibrosis/cirrhosis, and non-AIDS-related malignancies, were studied with multivariate Poisson regression models in 12 800 patients diagnosed with HIV infection from 1998 onwards while not yet treated with cART. During 18 646 person-years of follow-up, 203 non-AIDS-related events occurred. Compared with a CD4 count ≥ 500 cells/μL, adjusted relative risks (RRs) for the composite endpoint were 4.71 [95% confidence interval (CI) 2.98-7.45] for a CD4 count < 200 cells/μL, 2.06 (95% CI 1.38-3.06) for a CD4 count of 200-349 cells/μL, and 1.19 (95% CI 0.82-1.74) for a CD4 count of 350-499 cells/μL. There was no evidence for an independent association with HIV RNA. Other important covariates were age [RR 1.40 (95% CI 1.31-1.49) per 5 years older], hepatitis B virus coinfection [RR 5.66 (95% CI 3.87-8.28)] and hepatitis C virus coinfection [RR 9.26 (95% CI 6.04-14.2)]. In persons not yet receiving cART, a more severe degree of immunodeficiency rather than higher HIV RNA levels appears to be associated with an increased risk of our composite non-AIDS-related endpoint. Larger studies are needed to address these associations for individual non-AIDS-related events. © 2015 British HIV Association.
    HIV Medicine 01/2015; 16(5). DOI:10.1111/hiv.12202 · 3.99 Impact Factor
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    ABSTRACT: Little is known about the impact of acute HCV co-infection on HIV-1 disease progression. We investigated CD4 cell count and HIV RNA concentration changes after HCV infection in individuals chronically infected with HIV-1. We selected individuals that had a last negative and first positive HCV RNA test less than 1 year apart. Bivariate linear mixed effects regression was used to model trends in HIV RNA level and CD4 cell count from 2 years before the last negative HCV RNA test until the first of the following dates: start of anti-HCV medication, change in cART status and end of follow-up. At the estimated time of HCV co-infection, out of 89 individuals, 63 (71%) were cART-treated and 26 (29%) were not on cART. In persons on cART, median CD4 cell count declined from 587 to 508 cells/mm (p<0.0001) during the first 5 months after HCV infection and returned to 587 cells/mm after 2.2 years. Also, the probability of an HIV RNA >50 copies/ml peaked to 18.6% at HCV co-infection , with lower probabilities 6 months before (3.5%, p=0.006 compared to peak probability) and after (2.9%, p=0.009). In persons not on cART, no significant impact of HCV co-infection on trends in HIV RNA level or CD4 cell count were observed. Acute HCV infection in cART-treated, chronically HIV-infected patients was associated with a temporary decrease in CD4 cell counts and increased risk of HIV viraemia >50 copies/ ml. This may increase the risk of further HIV transmission.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2014; 68(5):1. DOI:10.1097/QAI.0000000000000514 · 4.56 Impact Factor
  • 20th International AIDS conference, Melbourne, Australia; 07/2014
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    ABSTRACT: The emergence of CXCR4-using HIV variants (X4-HIV) is associated with accelerated disease progression in the absence of antiretroviral therapy. However, the effect of X4-HIV variants on the treatment response remains unclear. Here we determined whether the presence of X4-HIV variants influenced the time to undetectable viral load and CD4+ T cell reconstitution after initiation of cART in 732 patients. The presence of X4-HIV variants was determined by MT-2 assay prior to cART initiation and viral load and CD4+ T cell counts were analyzed every 3 to 6 months during a three year follow-up period. Kaplan-Meier and Cox proportional hazard analyses were performed to compare time to viral suppression and the absolute CD4+ T cell counts and increases in CD4+ T cell counts during follow-up were compared for patients with and without X4-HIV at start of cART. Patients harboring X4-HIV variants at baseline showed a delay in time to achieve viral suppression below the viral load detection limit. This delay in viral suppression was independently associated with high viral load and the presence of X4-HIV variants. Furthermore, the absolute CD4+ T cell counts were significantly lower in patients harboring X4-HIV variants at all time points during follow-up. However, no differences were observed in the increase in absolute CD4+ T cell numbers after treatment initiation, indicating that the reconstitution of CD4+ T cells is independent of the presence of X4-HIV variants. The emergence of X4-HIV has been associated with an accelerated CD4+ T cell decline during the natural course of infection and therefore, patients who develop X4-HIV variants may benefit from earlier treatment initiation in order to obtain faster reconstitution of the CD4+ T cell population to normal levels.
    PLoS ONE 10/2013; 8(10):e76255. DOI:10.1371/journal.pone.0076255 · 3.23 Impact Factor
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    ABSTRACT: BACKGROUND: Few studies consider the incidence of individual AIDS-defining illnesses (ADIs) at higher CD4 counts, relevant on a population level for monitoring and resource allocation. METHODS: Individuals from the Collaboration of Observational HIV Epidemiological Research Europe (COHERE) aged ≥14 years with ≥1 CD4 count of ≥200 µL between 1998 and 2010 were included. Incidence rates (per 1000 person-years of follow-up [PYFU]) were calculated for each ADI within different CD4 strata; Poisson regression, using generalized estimating equations and robust standard errors, was used to model rates of ADIs with current CD4 ≥500/µL. RESULTS: A total of 12 135 ADIs occurred at a CD4 count of ≥200 cells/µL among 207 539 persons with 1 154 803 PYFU. Incidence rates declined from 20.5 per 1000 PYFU (95% confidence interval [CI], 20.0-21.1 per 1000 PYFU) with current CD4 200-349 cells/µL to 4.1 per 1000 PYFU (95% CI, 3.6-4.6 per 1000 PYFU) with current CD4 ≥ 1000 cells/µL. Persons with a current CD4 of 500-749 cells/µL had a significantly higher rate of ADIs (adjusted incidence rate ratio [aIRR], 1.20; 95% CI, 1.10-1.32), whereas those with a current CD4 of ≥1000 cells/µL had a similar rate (aIRR, 0.92; 95% CI, .79-1.07), compared to a current CD4 of 750-999 cells/µL. Results were consistent in persons with high or low viral load. Findings were stronger for malignant ADIs (aIRR, 1.52; 95% CI, 1.25-1.86) than for nonmalignant ADIs (aIRR, 1.12; 95% CI, 1.01-1.25), comparing persons with a current CD4 of 500-749 cells/µL to 750-999 cells/µL. DISCUSSION: The incidence of ADIs was higher in individuals with a current CD4 count of 500-749 cells/µL compared to those with a CD4 count of 750-999 cells/µL, but did not decrease further at higher CD4 counts. Results were similar in patients virologically suppressed on combination antiretroviral therapy, suggesting that immune reconstitution is not complete until the CD4 increases to >750 cells/µL.
    Clinical Infectious Diseases 10/2013; 57(7):1038-1047. DOI:10.1093/cid/cit423 · 8.89 Impact Factor
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    ABSTRACT: Document progress in HIV-treatment in the Netherlands since 1996 by reviewing changing patterns of cART use and relating those to trends in patients' short-term clinical outcomes between 1996 and 2010. 1996-2010 data from 10,278 patients in the Dutch ATHENA national observational cohort were analysed. The annual number of patients starting a type of regimen was quantified. Trends in the following outcomes were described: i) recovery of 150 CD4 cells/mm(3) within 12 months of starting cART; ii) achieving viral load (VL) suppression ≤1,000 copies/ml within 12 months of starting cART; iii) switching from first-line to second-line regimen within three years of starting treatment; and iv) all-cause mortality rate per 100 person-years within three years of starting treatment. Between 1996 and 2010, first-line regimens changed from lamivudine/zidovudine-based or lamivudine/stavudine-based regimens with unboosted-PIs to tenofovir with either emtricitabine or lamivudine with NNRTIs. Mortality rates did not change significantly over time. VL suppression and CD4 recovery improved over time, and the incidence of switching due to virological failure and toxicity more than halved between 1996 and 2010. These effects appear to be related to the use of new regimens rather than improvements in clinical care. The use of first-line cART in the Netherlands closely follows changes in guidelines, to the benefit of patients. While there was no significant improvement in mortality, newer drugs with better tolerability and simpler dosing resulted in improved immunological and virological recovery and reduced incidences of switching due to toxicity and virological failure.
    PLoS ONE 09/2013; 8(9):e76071. DOI:10.1371/journal.pone.0076071 · 3.23 Impact Factor
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    ABSTRACT: Background: We estimated the impact of loss to follow-up (LTFU) on the mortality rate amongst HIV-1 infected patients in Curaçao. Methods: A total of 214 therapy-naïve HIV-1 infected patients aged 15 years or older upon entering into HIV care between January 2005 and July 2009 were included. Persons who discontinued follow-up for more than 365 days were defined as LTFU and traced with the aim of registering their vital status. If no personal contact could be made, data were matched with the Curaçao National Death Registry. Mortality rates were estimated before and after starting combined antireteroviral therapy (cART). We used log-rank tests to compare survival rates amongst patients LTFU and patients who experienced continuous follow-up. Results: Pre-cART mortality in patients LTFU was similar to pre-cART mortality in those with continuous follow-up (p=0.79). All pre-cART deaths occurred within 6 months after entry. Late diagnosis was predictive for a shorter time to death after entry. Adjusting for those who were LTFU, the mortality rate after starting cART increased from 4.3 to 5.5 per 100 person years of observation (p=0.06). Mortality after starting cART was highest in the first 2 months after starting cART, especially for those who had late disease stage. Mortality rates were lower in patients with continuous follow-up compared to LTFUs (p<0.001). Conclusion: Mortality rates in HIV-1 infected patients who have started cART in Curaçao are underestimated as a result of inefficient patient administration combined with people starting cART at very late disease stage. Monitoring HIV treatment could help reducing the risk of LTFU and may improve the effect of treatment.
    AIDS research and human retroviruses 08/2013; 29(10). DOI:10.1089/AID.2012.0362 · 2.33 Impact Factor
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    ABSTRACT: Background. Our objective was to assess differences in all-cause mortality, as well as AIDS and non-AIDS death rates, among patients started on antiretroviral therapy (ART) according to their geographical origin and ethnicity/race in Europe, Canada, and the United States.Methods. This was a collaboration of 19 cohort studies of human immunodeficiency virus-positive subjects who have initiated ART (ART Cohort Collaboration) between 1998 and 2009. Adjusted mortality hazard ratios (AHRs) were estimated using Cox regression. A competing risk framework was used to estimate adjusted subdistribution hazard ratios for AIDS and non-AIDS mortality.Results. Of 46 648 European patients, 16.3% were from sub-Saharan Africa (SSA), 5.1% Caribbean and Latin America, 1.6% North Africa and Middle East, and 1.7% Asia/West; of 1371 patients from Canada, 14.9% were First Nations and 22.4% migrants, and of 7742 patients from North America, 55.5% were African American and 6.6% Hispanic. Migrants from SSA (AHR, 0.79; 95% confidence interval [CI],. 68-.92) and Asia/West (AHR, 0.62; 95% CI,. 41-.92) had lower mortality than Europeans; these differences appeared mainly attributable to lower non-AIDS mortality. Compared with white Canadians, mortality in Canadian First Nations people (AHR, 1.48; 95% CI,. 96-2.29) was higher, both for AIDS and non-AIDS mortality rates. Among US patients, when compared with whites, African Americans had higher AIDS and non-AIDS mortality, and hazard ratios for all-cause mortality increased with time on ART.Conclusions. The lower mortality observed in migrants suggests "healthy migrant" effects, whereas the higher mortality in First Nations people and African Americans in North America suggests social inequality gaps. © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved.
    Clinical Infectious Diseases 05/2013; 56(12):1800-1809. DOI:10.1093/cid/cit111 · 8.89 Impact Factor
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    ABSTRACT: The advent of effective combination antiretroviral therapy (ART) in 1996 resulted in fewer patients experiencing clinical events, so that some prognostic analyses of individual cohort studies of human immunodeficiency virus-infected individuals had low statistical power. Because of this, the Antiretroviral Therapy Cohort Collaboration (ART-CC) of HIV cohort studies in Europe and North America was established in 2000, with the aim of studying the prognosis for clinical events in acquired immune deficiency syndrome (AIDS) and the mortality of adult patients treated for HIV-1 infection. In 2002, the ART-CC collected data on more than 12,000 patients in 13 cohorts who had begun combination ART between 1995 and 2001. Subsequent updates took place in 2004, 2006, 2008, and 2010. The ART-CC data base now includes data on more than 70 000 patients participating in 19 cohorts who began treatment before the end of 2009. Data are collected on patient demographics (e.g. sex, age, assumed transmission group, race/ethnicity, geographical origin), HIV biomarkers (e.g. CD4 cell count, plasma viral load of HIV-1), ART regimen, dates and types of AIDS events, and dates and causes of death. In recent years, additional data on co-infections such as hepatitis C; risk factors such as smoking, alcohol and drug use; non-HIV biomarkers such as haemoglobin and liver enzymes; and adherence to ART have been collected whenever available. The data remain the property of the contributing cohorts, whose representatives manage the ART-CC via the steering committee of the Collaboration. External collaboration is welcomed. Details of contacts are given on the ART-CC website (
    International Journal of Epidemiology 04/2013; 43(3). DOI:10.1093/ije/dyt010 · 9.18 Impact Factor
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    ABSTRACT: Background. Low CD4+ T-cell counts are the main factor leading to clinical progression in human immunodeficiency virus type 1 (HIV-1) infection. We aimed to investigate factors affecting CD4+ T-cell counts after triple-class virological failure. Methods. We included individuals from the COHERE database who started antiretroviral therapy from 1998 onward and who experienced triple-class virological failure. CD4+ T-cell counts obtained after triple-class virologic failure were analyzed using generalized estimating equations. Results. The analyses included 2424 individuals with a total of 23 922 CD4+ T-cell count measurements. In adjusted models (excluding current viral load and year), CD4+ T-cell counts were higher with regimens that included boosted protease inhibitors (increase, 22 cells/µL [95% confidence interval {CI}, 3.9–41]; P = .017) or drugs from the new classes (increase, 39 cells/µL [95% CI, 15–62]; P = .001), compared with nonnucleoside reverse-transcriptase inhibitor–based regimens. These associations disappeared when current viral load and/or calendar year were included. Compared with viral levels of <2.5 log10 copies/mL, levels of 2.5–3.5, 3.5–4.5, 4.5–5.5, and >5.5 log10 copies/mL were associated with CD4+ T-cell count decreases of 51, 84, 137, and 186 cells/µL, respectively (P < .001). Conclusions. The approximately linear inverse relationship between log10 viral load and CD4+ T-cell count indicates that there are likely immunologic benefits from lowering viral load even by modest amounts that do not lead to undetectable viral loads. This is important for patients with low CD4+ T-cell counts and few drug options.
    The Journal of Infectious Diseases 03/2013; 207(5):759-767. DOI:10.1093/infdis/jis752 · 6.00 Impact Factor
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    ABSTRACT: Abstract Retention in care is one of the major challenges to scaling up and maximizing the effectiveness of combination antiretroviral therapy (cART). High attrition rates have been reported in the Caribbean region, varying from 6% to 23%. We studied the incidence of and risk factors for intermittent care in a cohort of adult HIV-1-positive patients, who entered into care in Curaçao between January 2005 and July 2009. A total of 214 therapy-naïve HIV-1-infected patients aged 15 years or older, entered HIV care between January 2005 and July 2009. Intermittent care was defined as at least one period of 365 days or longer in which there was no HIV care contact in Curaçao. Cox regression models were used to identify characteristics associated with time to intermittent care. In all, 203 (95%) patients could be classified as having intermittent or continuous care. The incidence of intermittent care before starting cART was 25.4 per 100 person years observation (PYO), whilst it was 6.1 per 100 PYO after starting cART. Being born outside Curaçao was associated with intermittent care before and after starting cART. Time from diagnosis to entry into care was an independent predictor for intermittent care before starting cART. Younger age was independently associated with intermittent care after starting cART. Half of the patients returned to care after intermitting care. Upon returning to care, median CD4 count was 264 cells/mm(3) (IQR, 189-401) for those who intermitted care before starting cART, and 146 cells/mm(3) (IQR, 73-436) in those who intermitted care after starting cART. In conclusion, the incidence of intermitting care is high in Curaçao, especially before starting cART, and intermitting care before starting cART is an independent predictor for starting cART late.
    AIDS Care 02/2013; 25(11). DOI:10.1080/09540121.2013.772276 · 1.60 Impact Factor
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    ABSTRACT: Background: In HIV-negative patients, radiotherapy (RT) decreases CD4 T-cell counts. We studied the effects of RT in HIV-1 positive patients. Methods: HIV-1 positive patients with a subsequent diagnosis of a solid tumor were selected from the Dutch national observational HIV cohort, Aids Therapy Evaluation in the Netherlands (ATHENA). The patients were grouped according to whether they had received RT or not. Primary endpoint of the study was the time from baseline to reaching CD4 cell counts higher than those at baseline. Kaplan-Meier estimates of the percentage of patients reaching the endpoint were calculated. Results: Ninety patients were included of whom 36 received RT and 54 did not. Median duration of RT was 46 [interquartile range (IQR) 30-63] days. Median first CD4 cell count after stopping RT was 150 (IQR 30-270) × 10/L lower compared with baseline. In 13 of the 36 patients receiving RT, CD4 cell counts recovered to baseline, after a median of 469 (IQR 345-595) days. In 35 of the 54 patients without RT, the CD4 cell count recovered to baseline or higher, after a median of 112 (IQR 42-182) days. After 3 years, in 39% of patients who had RT compared with 71% of patients without RT, CD4 cell counts recovered to baseline or higher (P < 0.0001). In a Cox regression adjusted for potential confounders, RT was associated with a longer (hazard ratio 0.29; 95% confidence interval 0.13 to 0.63) and combination antiretroviral therapy use with a shorter time to return to baseline [hazard ratio 2.46 (95% confidence interval 1.11 to 5.48)]. Conclusions: RT resulted in a significant and prolonged decrease in CD4 cell counts.
    JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2013; 62(5). DOI:10.1097/QAI.0b013e318285d934 · 4.56 Impact Factor
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    ABSTRACT: Background and objective: HIV-associated Pneumocystis jirovecii pneumonia (PJP) remains one of the commonest opportunistic infections in Western countries. Although it has been suggested that racial differences in PJP incidence exist, early studies report conflicting results. This study aimed to investigate differences in PJP incidence in a developed country among patients originating from sub-Saharan Africa compared with other regions of origin. Design and methods: A retrospective observational cohort study was performed among 13,844 HIV-infected patients from the Dutch ATHENA cohort. The main outcome measure was occurrence of PJP. Results: A total number of 1055 PJP infections were diagnosed. Patients originating from sub-Saharan Africa had a significantly lower risk of having PJP at the time of HIV diagnosis after adjustment of confounders compared with patients from Western origin [Western Europe, Australia and New Zealand; adjusted odds ratio (aOR) 0.21 (95% confidence interval (CI) 0.15-0.29)]. Other factors associated with higher PJP risk were increasing age [aOR 1.01 per year (95% CI 1.00-1.02)], a low CD4 count at HIV diagnosis [CD4 <50 versus >350 cells/μl aOR 123.3 (95% CI 77.8-195.5)] and a high plasma HIV-RNA (>100,000 copies/ml) at HIV diagnosis [aOR 1.41 (95% CI 1.19-1.66)]. Moreover, a clearly lower risk for PJP acquisition later during follow-up was observed among sub-Saharan Africans versus Western patients [adjusted hazard ratio 0.60 (95% CI 0.39-0.90)]. Conclusion: Among HIV-infected patients living in the Netherlands, PJP occurrence is substantially lower in patients originating from sub-Saharan Africa, as compared to Western patients. Differences in genetic susceptibility may partially explain the lower PJP incidence in these patients.
    AIDS (London, England) 12/2012; 27(7). DOI:10.1097/QAD.0b013e32835e2c90 · 5.55 Impact Factor
  • Netherlands Conference on HIV Pathogenesis, Epidemiology, Prevention and Treatment, Amsterdam, The Netherlands; 11/2012

Publication Stats

12k Citations
1,669.23 Total Impact Points


  • 2001–2015
    • Imperial College London
      • • Department of Infectious Disease Epidemiology
      • • Department of Medicine
      Londinium, England, United Kingdom
    • University of Oxford
      Oxford, England, United Kingdom
  • 1986–2013
    • University of Amsterdam
      • • Faculty of Medicine AMC
      • • Department of Clinical Epidemiology and Biostatistics
      • • Department of Internal Medicine
      Amsterdamo, North Holland, Netherlands
  • 2012
    • Amsterdam Institute for Global Health and Development
      Amsterdamo, North Holland, Netherlands
  • 2011–2012
    • Stichting Waterproef, Netherlands, Edam
      Эдам, North Holland, Netherlands
    • The University of Calgary
      • Section of Infectious Diseases
      Calgary, Alberta, Canada
  • 1988–2001
    • Academisch Medisch Centrum Universiteit van Amsterdam
      • • Department of Human Retrovirology
      • • Department of Internal Medicine
      • • Department of Virology
      Amsterdamo, North Holland, Netherlands
  • 2000
    • Medicines Evaluation Board, Netherlands
      Utrecht, Utrecht, Netherlands
  • 1998
    • Sapienza University of Rome
      Roma, Latium, Italy
    • Onze Lieve Vrouwe Gasthuis
      Amsterdamo, North Holland, Netherlands
  • 1991–1998
    • Hong Kong Red Cross Blood Transfusion Service
      Hong Kong, Hong Kong
  • 1996
    • Cairo University
      • Department of Medical Oncology (NCI)
      Al Qāhirah, Muḩāfaz̧at al Qāhirah, Egypt
  • 1993
    • University of Gothenburg
      Goeteborg, Västra Götaland, Sweden
  • 1990
    • Gemeentelijke Geneeskundige en Gezondheidsdienst
      Utrecht, Utrecht, Netherlands
  • 1989
    • Gezond Amsterdam
      Amsterdamo, North Holland, Netherlands