Among the 1042 deaths reported by 168 wards, 889 were identified by 117 wards that also participated in 2000 survey. The distribution of causes of death reported in 2005 by the wards that participated in the 2 surveys (2000 and 2005) was similar to the overall distribution. The 153 cases documented and reported by new participating wards were more frequently related to AIDS (39% vs 36%), to non-AIDS non-hepatitis-related cancers (24% vs 15%), and to liver disease (17% vs 14%), and less frequently related to cardiovascular disease (4% vs 9%) (P = 0.006).
In 2005, individuals who died of non-AIDS non-hepatitis-related cancers and of cardiovascular disease were older than others (Table 1). Women, people nonnative from France, and those in poor socioeconomic conditions were more frequently represented in individuals who died of AIDS than in those who died of other causes. Median duration since HIV diagnosis was shorter in those who died of AIDS because 20% of them had HIV diagnosed within 6 months of death compared with 4% of those who died of other causes. Individuals who died of liver disease had the longest duration since HIV diagnosis. CD4 cell count was lower and HIV RNA higher in people who died of an AIDS-defining cause. The median CD4 cell count was 77/mm3 (10th-90th percentile: 5-443) in patients who died of NHL and 74/mm3 (10th-90th percentile: 12-384) in those who died of PML. Among those who died of cardiovascular cause, 29% had dyslipidemia that had justified medical care. More than half of individuals who died of non-AIDS-related causes were smokers compared with 44% of those who died of AIDS. Half of those who died of liver disease had excessive alcohol consumption. In 2000, these trends in the characteristics of patients according to the cause of death were similar and median CD4 cell counts tended to be lower for all main causes of death.2
Among 94 individuals who died within 6 months of HIV diagnosis, the diagnosis of HIV was done before death, the most frequent cause of death was AIDS (76%) and the most frequent AIDS-defining illnesses were Pneumocystis jiroveci pneumonia (27%), NHL (21%), and PML (20%) (Fig. 2).
Taking into account gender and age, the frequency of the 5 main underlying causes of death differed significantly between 2000 and 2005 (P = 0.001). These changes differed according to age (Table 2). Below 30 years, 2 in 3 deaths were AIDS related in both 2000 and 2005. The proportion of AIDS-related deaths decreased mainly above 40 years, from half in 2000 to 1 in 3 cases in 2005. From 2000 to 2005, the proportion of liver-related deaths decreased in the 30-40 years' age strata and increased from 15% to 20% in the 40-50 years' age strata. The increase in the proportion of cancer-related deaths was higher when age was higher. The increase in the proportion of cardiovascular-related deaths was moderate and mainly in the 40-50 years' age strata.
Between 2000 and 2005, the proportion of AIDS-related deaths continued to decrease among HIV-infected adults, but it remained the most frequent underlying cause of death, mainly related to NHL. The distribution of other causes of death was heterogeneous, whereas 3 causes increased and accounted for 40% of them: non-AIDS-defining cancer, liver-related diseases, and cardiovascular deaths. Our results may be a consequence of a suboptimal detection or management of both HIV infection and viral hepatitis coinfections, and also aging of HIV-infected individuals and a high prevalence of traditional determinants predisposing to cancers or cardiovascular diseases.
Other recent studies have reported that AIDS remains the most frequent cause of death,1,8,10,17 whereas HIV-related causes of death decrease in the cART period.7,9,18 The distribution of non-AIDS-defining causes of death largely varies according to specific characteristics of the studied population. Among individuals followed after the onset of AIDS in New York, substance abuse was the most frequent non-HIV-related cause of death between 1999 and 2004,7 whereas until 2004, cancer was the most frequent non-AIDS-defining cause of death in the Australian HIV Observational Database8 and in the US HIV Outpatient Study.9 Liver disease was the most frequent non-AIDS-defining cause of death in the cART period among HIV-infected individuals with hemophilia in Canada and in the DAD international collaboration (23% and 67% infected with HCV, respectively).5,19
In our study, 1 in 3 deaths (344, 33%) was related to a cancer, either AIDS or non-AIDS-defining cancer. When taking into account the age at death, this was not statistically different from the proportion of 27% reported in 2000. In the French general population, 39% of the deaths between the age of 35 and 54 years were related to cancer in 2004, but their localizations were different than those in HIV-infected individuals.20 Among HIV-infected individuals, NHL remains the most frequent AIDS-defining event leading to death. The use of cART is associated with an overall decrease in the risk of NHL,21,22 although to a lesser extent than other AIDS-defining events.23 The risk of NHL decreases as the CD4 cell count increases,24 although the level of CD4 allowing HIV-infected people to reach the risk of NHL reported in the general population is not known.25,26 After diagnosis, the prognosis of NHL in cART-treated patients seems to be exclusively associated with tumor-related factors.27
Among other cancers, 38% of non-AIDS non-hepatitis-related cancers were located in the respiratory tract. The risk of cancer is higher in HIV-infected adults than in the general population,25,28 and smoking plays a major role, as around half of HIV-infected adults are current smokers, a proportion that remains stable over time.29,30 Adapted smoking cessation programs in HIV-infected persons still have to be evaluated,29,31 and the benefit of specific targeted screening of cancers too.32 However, HIV itself may play a specific role in the occurrence of lung cancer, regardless of smoking status, as reported among drug users in the United States.33
Hepatitis C virus was involved in 78% of liver-related deaths, and the proportion of hepatocarcinoma increased over time (16% in 2000 and 24% in 2005). Excessive alcohol consumption was reported in half of these cases, and two-thirds were infected by HIV through injecting drug use. In France, 90% of HIV-infected adults contaminated through injecting drug use are HCV infected.15 Despite improvement in the management of HIV-HCV coinfection, not all HIV/HCV-coinfected patients who would be eligible actually receive treatment for HCV.34,35 An improvement is expected in the future because new treatments are currently evaluated. Anti-HCV treatment should be largely proposed even in patients with cirrhosis, provided that they have no decompensation because early HCV viral kinetics allows to predict sustained virological response and to stop therapy in case of defavorable prognosis factors. In addition, most French HIV-infected patients are coinfected by genotype 4 that is associated with poorer outcome.36
The proportion of cardiovascular-related deaths only slightly increased. Improvement of antiretroviral strategies and management of dyslipidemia may have slowed an initially worse trend.12 Nevertheless, the relative contribution of HIV infection, antiretrovirals, and traditional risk factors in the occurrence of metabolic-related diseases is still debated.37
Although our observations have been made in the French context of free access to care, we believe that some characteristics of deceased patients reflect suboptimal management. The proportion of patients who died within 6 months of HIV diagnosis (9%) remained stable between 2000 and 2005. In London between 1998 and 2003, around one-fifth of all deaths occurred among individuals who had first been diagnosed with HIV within the 6 months before death.10 In France, more than 1 in 3 patients attending HIV care for the first time have advanced HIV infection,38 and delayed access to care was more frequent in migrants, as reported in other settings.39 In addition, 1 in 3 HIV-infected adults who died in 2005 was in poor socioeconomic conditions. The association between socioeconomic conditions and premature mortality is a constant in the general population40 and applies to HIV-infected populations.41
Over time, the latest CD4 cell count before death increased, as also reported by others.9 Nevertheless, despite 81% of our series had received cART, latest CD4 cell count was less than 200/mm3 among half of them. Median latest CD4 cell count was lower in people who died of AIDS and was around 200/mm3 in those who died of non-AIDS non-hepatitis-related cancers and of ESLD. Recent communications underlined that the risk of serious non-AIDS-defining events is higher with lower CD4 cell counts,42-44 and mortality rates in treated HIV-infected adults may reach those of the general population in the long term only when CD4 cell counts are above 500/mm3.45 Even if they are mostly treated, patients still experience immunodeficiency. In 2005, median CD4 cell count of patients followed in the French hospital database on HIV (n = 48,410) was 443/mm3 and 11% had CD4 less than 200/mm3.46
A larger number of wards participated in the current study compared with 2000. Nevertheless, we compared the distribution of causes of death regardless of participating wards. The overall distribution of the underlying causes of death in 2005 did not differ in the subgroup of wards that participated in the 2 surveys. Therefore, selecting only these wards would not have changed the results. Wards that participated in the Mortalité 2005 survey represented around 78,000 HIV-infected patients, whereas based on currently available data,47-49 we may consider that 100,000 individuals were living with HIV in France in 2005.
Few surveys like Mortalité 2000 and Mortalité 2005 are specifically implemented to analyze the causes of death in HIV-infected individuals. This survey is based on specific declarations of physicians and active monitoring and has advantages over existing observational cohorts. First, it may be more representative of the population of HIV-infected patients who died than studies of the causes of death in observational cohorts, which may select the patients under follow-up. Second, the determination of causes of death is based on detailed and standardized documentation that is rarely available in cohorts.
Given the confirmed emergence of heterogeneous causes of death and their link with specific characteristics of patients, surveillance of the causes of death over time among HIV-infected individuals across different geographical areas is important to adapt recommendations to specific context. In addition, it seems highly desirable to implement collection of all causes of severe morbidity in existing observational studies on HIV to allow earlier interventions in HIV case management. Indeed, there is still a potential to improve antiretroviral management in HIV-infected individuals because AIDS-related deaths still occur. Prevention and early detection of serious morbidity may include improved strategies to diagnose HIV infection earlier, particularly in migrants and people with poor socioeconomic conditions; maintaining efforts to reach high levels of CD4 cell count to prevent both persistent AIDS and non-AIDS-defining events related to immune suppression and including a proactive identification of obstacles to optimal response to treatment; implementing active prevention of the most frequent cancers, particularly through the promotion of smoking cessation programs; evaluating the benefits of targeted screening of cancers in patients at risk; improving HCV treatment coverage and efficacy; and improving prevention and management of diabetes and dyslipidemia to limit the occurrence of cardiovascular disease. The implementation of these recommendations will be especially important in the context of an aging HIV-infected population.
1. CASCADE Collaboration. Effective therapy has altered the spectrum of cause-specific mortality following HIV seroconversion. AIDS
2. Lewden C, Salmon D, Morlat P, et al. Causes of death among HIV-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS. Int J Epidemiol
3. Salmon Ceron D, Lewden C, Morlat P, et al. Liver disease as a major cause of death among HIV infected patients: role of hepatitis C and B viruses and alcohol. J Hepatol
4. Koziel MJ, Peters MG. Viral hepatitis in HIV infection. N Engl J Med
5. The Data Collection on Adverse Events of Anti-HIV Drugs Study Group. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med
6. Mocroft A, Soriano V, Rockstroh J, et al. Is there evidence for an increase in the death rate from liver-related disease in patients with HIV? AIDS
7. Sackoff JE, Hanna DB, Pfeiffer MR, et al. Causes of death among persons with AIDS in the era of highly active antiretroviral therapy: New York City. Ann Intern Med
8. Petoumenos K, Law MG. Risk factors and causes of death in the Australian HIV Observational Database. Sex Health
9. Palella FJ Jr., Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV Outpatient Study. J Acquir Immune Defic Syndr
10. Sabin CA, Smith CJ, Youle M, et al. Deaths in the era of HAART: contribution of late presentation, treatment exposure, resistance and abnormal laboratory markers. AIDS
11. Rosenthal E, Pialoux G, Bernard N, et al. Liver-related mortality in human-immunodeficiency-virus-infected patients between 1995 and 2003 in the French GERMIVIC Joint Study Group Network (MORTAVIC 2003 Study). J Viral Hepat
12. The DAD Study Group. Class of antiretroviral drugs and the risk of myocardial infarction. N Engl J Med
13. The Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med
14. Carrat F, Bani Sadr F, Pol S, et al. Pegylated interferon alfa-2b vs standard interferon alfa-2b, plus ribavirin, for chronic hepatitis C in HIV-infected patients-a randomized controlled trial. JAMA
15. Larsen C, Pialoux G, Salmon D, et al. Prévalence des co-infections par les virus des hépatites B et C dans la population VIH+, France, juin 2004. Bull Epidemiol Hebd
16. Hosmer DW, Lemeshow S. Applied Logistic Regression
. New York, NY: John Wiley; 1989.
17. Krentz H, Kliewer G, Gill M. Changing mortality rates and causes of death for HIV-infected individuals living in Southern Alberta, Canada from 1984 to 2003. HIV Med
18. Lau B, Gange SJ, Moore RD. Risk of non-AIDS-related mortality may exceed risk of AIDS-related mortality among individuals enrolling into care with CD4+ counts greater than 200 cells/mm3. J Acquir Immune Defic Syndr
19. Arnold DM, Julian JA, Walker IR. Mortality rates and causes of death among all HIV-positive individuals with hemophilia in Canada over 21 years of follow-up. Blood
20. CépiDc-IFR 69 Centre d'épidémiologie sur les causes médicales de décès. Effectifs et taux de décès par zone géographique (France, région, département ou grande ville), selon l'année, la cause de décès, le sexe et les tranches d'âge décennales. Available at: http://www.cepidc.vesinet.inserm.fr/
. Accessed February 20, 2007.
21. Wolf T, Brodt HR, Fichtlscherer S, et al. Changing incidence and prognostic factors of survival in AIDS-related non-Hodgkin's lymphoma in the era of highly active antiretroviral therapy (HAART). Leuk Lymphoma
22. Bonnet F, Balestre E, Thiebaut R, et al. Factors associated with the occurrence of AIDS-related non-Hodgkin lymphoma in the era of highly active antiretroviral therapy: aquitaine cohort, France. Clin Infect Dis
23. CASCADE Collaboration. Changes over calendar time in the risk of specific first AIDS-defining events following HIV seroconversion, adjusting for competing risks. Int J Epidemiol
24. CASCADE Collaboration. Systemic non-Hodgkin lymphoma in individuals with known dates of HIV seroconversion: incidence and predictors. AIDS
25. Clifford GM, Polesel J, Rickenbach M, et al. Cancer risk in the Swiss HIV cohort study: associations with immunodeficiency, smoking, and highly active antiretroviral therapy. J Natl Cancer Inst
26. Engels EA, Pfeiffer RM, Goedert JJ, et al. Trends in cancer risk among people with AIDS in the United States 1980-2002. AIDS
27. Miralles P, Berenguer J, Ribera JM, et al. Prognosis of AIDS-related systemic non-Hodgkin lymphoma treated with chemotherapy and highly active antiretroviral therapy depends exclusively on tumor-related factors. J Acquir Immune Defic Syndr
28. Herida M, Mary-Krause M, Kaphan R, et al. Incidence of non-AIDS-defining cancers before and during the highly active antiretroviral therapy era in a cohort of human immunodeficiency virus-infected patients. J Clin Oncol
29. Bénard A, Tessier J-F, Rambeloarisoa J, et al. HIV infection and tobacco smoking behaviour: prospects for prevention? ANRS CO 3 Aquitaine Cohort, 2002. Int J Tuberc Lung Dis
30. Friis-Møller N, Weber R, Reiss P, et al. Cardiovascular disease risk factors in HIV patients-association with antiretroviral therapy. Results from the DAD study. AIDS
31. Elzi L, Spoerl D, Voggensperger J, et al. A smoking cessation programme in HIV-infected individuals: a pilot study. Antivir Ther
32. Brock MV, Hooker CM, Engels EA, et al. Delayed diagnosis and elevated mortality in an urban population with HIV and lung cancer: implications for patient care. J Acquir Immune Defic Syndr
33. Kirk GD, Merlo C, O' Driscoll P, et al. HIV infection is associated with an increased risk for lung cancer, independent of smoking. Clin Infect Dis
34. Zinkernagel AS, von Wyl V, Ledergerber B, et al. Eligibility for and outcome of hepatitis C treatment of HIV-coinfected individuals in clinical practice: the Swiss HIV cohort study. Antivir Ther
35. Nunes D, Saitz R, Libman H, et al. Barriers to treatment of hepatitis C in HIV/HCV-coinfected adults with alcohol problems. Alcohol Clin Exp Res
36. Payan C, Roudot-Thoraval F, Marcellin P, et al. Changing of hepatitis C virus genotype patterns in France at the beginning of the third millenium: the GEMHEP GenoCII Study. J Viral Hepat
37. Kwong GP, Ghani AC, Rode RA, et al. Comparison of the risks of atherosclerotic events versus death from other causes associated with antiretroviral use. AIDS
38. Lanoy E, Mary-Krause M, Tattevin P, et al. Frequency, determinants and consequences of delayed access to care for HIV infection in France. Antivir Ther
39. Boyd AE, Murad S, O'Shea S, et al. Ethnic differences in stage of presentation of adults newly diagnosed with HIV-1 infection in south London. HIV Med
40. Melchior M, Berkman LF, Kawachi I, et al. Lifelong socioeconomic trajectory and premature mortality (35-65 years) in France: findings from the GAZEL Cohort Study. J Epidemiol Community Health
41. Lewden C, Raffi F, Cuzin L, et al. Factors associated with mortality in human immunodeficiency virus type 1-infected adults initiating protease inhibitor-containing therapy: role of education level and of early transaminase level elevation (APROCO-ANRS EP11 study). J Infect Dis
42. Baker J, Peng G, Rapkin J, et al. HIV-related immune suppression after ART predicts risk of non-opportunistic diseases: results from the FIRST Study. In: Proceedings of the 14th Conference on Retroviruses and Opportunistic Infections
; 2007. Abstract 37.
43. d'Arminio Monforte A, Abrams D, Pradier C, et al. HIV-induced immunodeficiency and risk of fatal AIDS-defining and non-AIDS-defining malignancies: results from the D:A:D Study. In: Proceedings of the 14th Conference on Retroviruses and Opportunistic Infections, Los Angeles, CA, 25-28 February, 2007
. Abstract 84.
44. Marin B, Thiébaut R, Rondeau V, et al. Association between CD4 and HIV RNA with non AIDS-related causes of death in the era of combination antiretroviral therapy (cART). In: Proceedings of the: International AIDS Society, ed
. 4th IAS conference on HIV pathogenis, treatment and prevention
; July 22-25, 2007. Abstract WEPEB019.
45. Lewden C, Chêne G, Morlat P, et al. HIV-infected adults with a CD4 cell count greater than 500 cells/mm3
on long term combination antiretroviral therapy reach same mortality rates as the general population. J Acquir Immune Defic Syndr
46. Mary Krause M, Fichou J, Lanoy E, et al. Groupe d'Epidemiologie Clinique de l'ANRS CO4 FHDH. HIV infection after 10 years of combined antiretroviral therapy in the French Hospital Database on HIV infection (ANRS CO4 FHDH). Bull Epidemiol Hebd
47. Deuffic Burban S, Costagliola D. Including pre-AIDS mortality in back-calculation model to estimate HIV prevalence in France, 2000. Eur J Epidemiol
48. Semaille C, Barin F, Cazein F, et al. Monitoring the dynamics of the HIV epidemic using assays for recent infection and serotyping among new HIV diagnoses: experience after 2 years in France. J Infect Dis
49. Lewden C, Jougla E, Alioum A, et al. Number of deaths among HIV-infected adults in France in 2000, three-source capture-recapture estimation. Epidemiol Infect
APPENDIX: MORTALITÉ 2005 (ANRS EN19) GROUP, IN COLLABORATION WITH MORTAVIC
The following are available at: http://etudes.isped.u-bordeaux2.fr/M2005/TELECHARGTS/M2005_GroupeEtude.pdf.
Geneviève Chêne, Dominique Costagliola, Eric Jougla, Thierry May, Philippe Morlat, Dominique Salmon, Patrice Cacoub, Eric Rosenthal, Fabrice Bonnet, Christine Burty, Charlotte Lewden.
Coding, Monitoring Data Management, and Analysis
Muriel François, Jean Boileau, Hélène Zouari, Fabien Tourteau, Vincent Bouteloup.
P. Bursacchi, J. F. Delfraissy (ANRS), C. Semaille (InVS).
Agence Nationale de Recherches sur le Sida et les Hépatites Virales (ANRS; CSS5).
CMIT(Collège des Universitaires de Maladies infectieuses et Tropicales), SFLS (Société Française de Lutte contre le Sida), SNFMI (Société Nationale Française de Médecine Interne), SPILF (Société de Pathologie Infectieuse de Langue Française), ADELF (Association des Epidémiologistes de Langue Française), GERMIVIC (Groupe d'Etude et de Recherche en Médecine Interne et Maladies Infectieuses sur le VIrus de l'hépatite), FPRRH (Fédération des Pôles de Références et Réseaux Hépatites), AFEF (Association Française Etude du Foie), SRLF (Société de Réanimation de langue Française), SPLF (Société de Pneumologie de Langue Française).
List of Participants
The following are available at: http://etudes.isped.u-bordeaux2.fr/M2005/TELECHARGTS/M2005_ListeParticipants.pdf
Abbeville S. Redecker/Agen Y. Imbert P. Rispal/Aix En Provence T. Allègre J. Riou M. Marquant/P. Undreiner/Ajaccio J. Abino/Albi P. Barel/Greziller/Alencon Gosse/Ales A. Lagier D. Bastide/Amiens J. L. Schmit N. Decaux/Angers J. Chennebault P. Fialaire P. Abgueguen J. Loison/Annecy J. Gaillat/Annonay E. Legrand/Antibes Juan Les Pins J. Dor D. Quinsat L. Lerousseau Chavaillon E. Toquet-Maillet/Argenteuil L. Sutton P. Genet/Arles J. Salord/Arpajon G. Raison/Arras D. Dubois/Y. Lierman J. Bervar/Auch B. Castan/Aulnay Sous Bois D. Malbec J. Delassus/Auxerre R. Bakir/Avignon G. Lepeu G. Pichancourt A. Théodourou-Touchais/Olivier A. De La Blanchardière/Bar Le Duc P. Evon/Y. Aubry/Basse Terre B. Giffo/Bayonne F. Bonnal S. Labarrère/Bazas M. Amanieu/Beauvais D. Valet/Belfort J. P. Faller P. Eglinger F. Duchene/Besancon P. Humbert/J. Dupond/J. Estavoyer B. Hoen C. Roche C. Chirouze J. Faucher/Béziers E. Oziol A. Saad M. Cabrol/Blaye P. Gateau S. Seiberras/Blois C. Vidal/A. Mazari/Bobigny M. Bentata P. Honore/O. Bouchaud/Bois Guillaume C. Bessin/Bondy V. Jeantils S. Tassi/O. Fain/Bordeaux M. Dupon/P. Morlat J. Beylot D. Lacoste M. Bonarek N. Bernard F. Bonnet/J. M. Ragnaud/M. Longy-Boursier P. Mercié/C. Séries/Bordeaux Armées B. Portal F. Terrier/Boulogne E. Rouveix C. Olivier/J. Vaillant/Boulogne Billancourt S. Moulias/T. Hanslik/Bourg En Bresse P. Granier/T. Colucci/Bourges M. Mornet/L. Aaron Y. Guimard J. Agbodjan J. Julien/Bourgoin Jallieu M. Fabre/Brest M. Garre/Gouerou O. Savary J. Nousbaum/Brest Armées H. Granier/Briançon P. Brousse/Caen R. Verdon P. Féret/Guivarch/ Cahors S. Sire/Cannes P. Simonet S. Tempesta B. Vialatte/Castres L. Prudhomme/Cayenne F. Djossou S. Bichat M. Nacher P. Couppié/Chalon Sur Saône Dellinger/Chalons En Champagne J. Picard/Sabbagh/Chambery O. Rogeaux/Charleville Mézières C. Penalba/Chartres C. Aubert/Chaumont C. Alba/ Clamart P. Galanaud F. Boué/G. Defuentes/Clermont De L'oise J. Pik/Clermont-Ferrand H. Laurichesse J. Beytout L. Cormerais/Clichy B. Fantin A. Uludag/J. Mantz J. Cohen/Colmar F. Kohser/N. Plaisance G. Blaison M. Martinot/Colombes C. Minozzi C. Ferreira F. Zeng/Compiègne Y. Domart D. Merrien D. Zylberait/Corbeil-Essonnes A. Devidas I. Turpauld P. Chevojon/Coulommiers M. Bardet/Coutances P. Jacquemard/Créteil A. Sobel C. Jung C. Dumont/M. Chousterman/B. Housset L. Bassinet/F. Schortgen/Dax P. Loste/Désertine O. Antoniotti E. Nehme/Digne Les Bains P. Granet Brunello/Dijon H. Portier M. Grappin M. Buisson M. Duong C. Braconnier A. Waldner-Combernoux/Dinan J. Laine/Dole A. Brousse/Douai G. Cardon/F. Visticot/Draguignan M. Vella/ Dunkerque F. Bonnevie/Vanrenterghem/Eaubonne T. Soupison/N. Gruat/J. Roche Sicot J. Saraux A. Leprêtre L. El Hajj/Ecrouves Frossard/ Elbeuf M. Brung Lefebvre/Epinal I. Béguinot H. Schuhmacher/Etampes J. Hirsch/Evreux/G. Reumont/Saad/Eysses Galan/Foix Estebe/Fort De France A. Cabié S. Abel/D. Quist/Frejus E. Counillon R. Armero P. Del Giudice/Frelinghien V. Gamblin/Fresnes I. Bouchard/Garches P. De Truchis H. Berthe/Grenoble P. Leclercq C. Brambilla E. Gineste F. Sarrot-Reynauld/Jenny/Ingwiller J. Class/Ivry Sur Seine A. Raynaud-Simon/Kourou F. Alvarez/La Roche Sur Yon P. Perre O. Aubry I. Suaud/La Rochelle I. Courbes B. Batejat/La Teste De Buch A. Dupont/Lagny Sur Marne P. Lagarde F. David-Ouaknine/Landerneau E. Le Moigne/Langon B. Caumont/Laon M. Robin/Laval J. Hoel/Le Chesnay J. Doll P. Colardelle S. Roussin-Bretagne/A. Greder Belan/J. Bedos F. Bruneel/Le Grand Luce F. Thibous Lemeunier/Le Kremlin Bicêtre J. Delfraissy C. Goujard M. Rannou/Le Port P. Wind/Le Puy En Velay B. Monange/Lens C. Lamblin K. Cochonat/M. Balquet/Levallois Perret D. Champetier De Ribes G. Force/Libourne J. Ceccaldi/J. Marcos/Lille Y. Hammou/X. Codaccioni/Limoges P. Weinbreck C. Genet/M. Debette-Gratien/Lisieux L. Geffray/Longjumeau Y. Le Mercier/Longuenesse Follet/Lons Le Saunier B. Duvert/Lacroix/Loudun A. Arnaud/Lure Y. Selles/F. Levasseur/Lyon J. Touraine F. Jeanblanc/C. Trepo N. Benmakhlouf B. Lebouche/D. Peyramond A. Boibieux C. Chidiac C. Delorme/E. Carbonnel/V. Baty/Macon J. Kisterman X. Roubert/Mantes La Jolie F. Granier F. Trémolières C. Billy V. Perronne/Marmande J. Testaud/Marseille J. Gastaut M. Drogoul G. Fabre/A. Stein H. Gallais I. Ravaux/J. Moreau E. Vandergheynst/M. Bourlière/J. Ruiz/P. Philibert/T. Gamby/N. Petit/Marseille Armées F. Simon/Maubeuge Fontaneau/Mende P. Meissonnier/Menton J. Bayada/Metz B. Christian A. Armand/Metz Armées M. Galzin/Millau D. Dumas/Mont De Marsan S. De Witte/Montbéliard J. Jobard/Montélimar A. Poncet/B. Caillet/Montpellier J. Reynes C. Merle De Boever M. Siffert A. Bourgeois A. Villadoro C. Tramoni/V. Faucherre/D. Larrey/O. Jonquet Landreau/Montreuil M. Andre C. Winter/Morlaix C. Roge/Mulhouse G. Beck-Wirth B. Drenou M. Benomar/Nanterre M. Ruel K. Chemlal/Nantes F. Raffi P. Morineau-Le Houssine C. Guerbois Le Bavec/F. Lemesre/Narbonne B. Masson/Nemours F. Loison M. Razafimahery/Nevers J. Lebas De Lacour/Nice P. Dellamonica V. Mondain-Miton E. Cua N. Oran L. Valério/E. Rosenthal J. Fuzibet/A. Tran/P. Brocker/P. Barrelier/Nimes D. Vincent J. Mauboussin C. Barbuat I. Rouanet/N. Jourdan/A. Sotto F. Del Bucchia J. Jourdan/Niort M. Lapine/Nouméa P. Capdevielle/F. Lacassin-Beller F. Droetto/Noyon G. Diab F. Grihon/Orléans P. Arsac/L. Hocqueloux/Orsay M. Levasseur/Paimpol M. Fourdilis/Papeete P. Jarno/Paris J. Derouineau/P. Morel F. Timsit/A. Compagnucci/E. Oksenhendler L. Gérard J. Delgado/D. Sereni C. Lascoux-Combe/J. Viard B. Dupont A. Maignan/J. Bergmann P. Sellier J. Magnier/G. Pialoux V. Godard A. Goetschel M. Lebrette/L. Weiss D. Tisné-Dessus/C. Leport J. Ecobichon U. Colasante/L. Guillevin D. Salmon-Ceron M. Piétri A. Brunet B. Silbermann P. Blanche/H. Schoen M. Valantin P. Hausfater V. Martinez/S. Herson A. Simon C. Brancon/P. M. Girard A. Béglé G. Raguin C. Lupin/J. M. Molina D. Ponscarme V. Garrait P. Cabotin M. Janier E. Spindler/P. Yéni J Gerbe/J. Cabane/J. Ziza J. Aerts/J. Carlet J. Gilquin I. Auperin B. Misset A. Crof/J. Piette P. Cacoub/G. Turpin/B. Varet/N. Dupin/C. Le Jeunne E. Aslangul/S. Pol/T. Poynard P. Lebray/N. Carbonell/P. Benlian/M. Goujon/J. Dhainaut J. Charpentier/J. Andrieu/M. Brunel/N. Landgraf/M. Bary/Pau Pouyanne/Périgueux J. Méraud/C. Rivière/Perpignan H. Aumaître M. Saada/H. Cros/Pessac J. L. Pellegrin R. Adjeoda/Pierre Benite I. Durieu H. Rousset D. Vital-Durand/Pointe A. Pitre I. Lamaury M. Sow/Poissy D. Hillion H. Masson/Poitiers B. Becq-Giraudon G. Le Moal/C. Silvain/Pontoise O. Danne L. Blum/Quimper J. Larzul P. Perfezou/Reims C. Rouger/J. Novella/Rennes C. Michelet P. Tattevin C. Arvieux F. Souala M. Delmont-Hanry D. Guyader/V. Gandemer/C. Camus/Taverson/Roanne M. Lutz/Rochefort M. Climas/Roubaix J. Wemeau/Rouen I. Gueit P. Suel/F. Caron/Saint Denis D. Mechali M. Khuong-Josses/Saint Die Des Vosges Y. Etienne/Saint Etienne F. Lucht A. Fresard V. Ronat/Vergnon/Garcier/Saint Girons J. Deluca/Saint Laurent Du Maroni A. Randrianjohany/Saint Omer H. Monnot/Saint Pierre De La Réunion P. Poubeau H. Andre/Saint-Brieuc C. Beuscart/M. Aubry/Saint-Denis E. Hurbin/Saint-Mandé T. Debord C. Rapp/Saint-Martin F. Bissuel V. Walter/Saint-Martin-De-Ré J. Ferret/ Saint-Michel M. Bonnefoy A. Riche/Saint-Nazaire J. Marot C. Michau/Saintes E. Bonnin/T. Pasdeloup/Salouel G. Chaby/Sarrebourg E. Grilliat/Saverne E. Wurtz/F. Loth/Sete B. Kitschke/Soissons D. Line/St Denis De La Réunion C. Gaud C. Sautron/St Etienne P. Cathebras/St Germain En Laye Y. Welker/St Nazaire D. Sandron/Strasbourg J. M. Lang P. Fischer/J. Pasquali H. Lalanne/C. Chartier/C. Berlin/E. Andres/D. Christmann Y. Hansmann/P. Fraisse/Suresnes O. Bletry D. Zucman C. Majerholc/M. Stern L. Couderc/Tarbes J. Petitou/Thionville F. Truchetet J. Pouaha/Thonon Les Bains P. Romand/Toulon A. Lafeuillade V. Lambry/Toulon Naval P. Bernard/Toulouse D. Adoue M. Duffaut/B. Marchou D. Garipuy L. Cuzin/M. Uzan/J. Vinel S. Metivier/A. Didier R. Rouquet/Tourcoing Y. Mouton Y. Yazdanpanah F. Marysse/B. Guery K Faure/Tours J. M. Besnier P. Le Bret P. Nau H. Sigogneau/Troyes J. Bressieux E. Libbrecht L. Rezzouk/Tulle A. Collignon/Valence B. Ponceau/Valenciennes X. Kyndt/A. Vermersch-Langlin/Vandoeuvre Les Nancy T. May C. Burty/P. Lederlin/Vannes Y. Poinsignon/Verdun C. Creusat/Vernon C. Richard/Vesoul C. Merle/Vierzon A. Essayan/Villejuif D. Vittecoq C. Bolliot/Villenauxe-La-Grande Quignard/Villeneuve St Georges O. Patey S. Dellion/Villeneuve/Lot I. Chossat. Cited Here...