Since the introduction of combined antiretroviral treatments (cART) in 1996 survival of the HIV-infected population has dramatically improved. As survival improves, causes of death in this population are changing, and patients are increasingly developing end-stage organ diseases.1-3
End-stage renal disease (ESRD) can be managed by renal transplantation (RT) or dialysis (hemodialysis or peritoneal dialysis), which can be a step waiting for a graft or an alternative treatment for patients excluded from transplantation.
The interest in kidney disease in HIV-infected patients has been rising in the most recent years,4,5 but still with a lack of information regarding this issue.
The prevalence of ESRD in HIV-infected patients is unknown. Most studies have focused on chronic kidney disease (CKD) but there is much less information on advanced stages of kidney disease, in particular dialysis.
In the United States, the yearly surveys of HIV prevalence in dialysis units showed an increase in the number of HIV-infected patients receiving dialysis from 1985 (0.3%) to 1992 (1.5%), and remaining stable therafter.6 In 2002, 1.5% and 0.4% of patients receiving dialysis had HIV infection and AIDS, respectively.7 There is little data from Europe. In 1990, the European Dialysis and Transplantation Association (ERA-EDTA) set up a registry of patients under renal replacement therapies (including dialysis and RT). Of 152,658 patients, 190 (0.12%) were HIV infected.8 To our knowledge, no recent prevalence studies have been performed on a European level. The most recent data comes from small local studies performed in France,9,10 Spain11 and the United Kingdom,12 all showing prevalence under 1%.
Given this lack of data, and the encouraging experiences and emerging possibilities for RT in HIV-infected populations.13-15 we aimed to determine the prevalence and characteristics of ESRD patients with HIV infection in Europe.
A cross-sectional multicenter survey of clinics participating in the EuroSIDA study was performed during 2008. The EuroSIDA study is a prospective observational cohort study of 16,599 patients with HIV-1 infection followed in 102 hospitals among 33 European countries plus Israel and Argentina. The details of this study have been published elsewhere.16 A questionnaire was sent to all clinics participating in the EuroSIDA study requesting information on the number of HIV-infected patients and the total number of ESRD patients on dialysis at their clinics. ESRD was defined as irreversible kidney damage (glomerular filtration rate <15 mL/min) treated with either dialysis or RT, and causes of ESRD were classified according to the criteria of the ERA-EDTA.8 RT recipients who experienced a graft rejection were classified according to the Banff 2005 diagnostic criteria for renal allografts.17
We also investigated how many HIV-infected patients diagnosed with ESRD on dialysis were attending the clinic and how many HIV-infected patients had ever received a RT. Finally, we asked for the proportion of HIV positivity among all ESRD patients on dialysis seen within the respective departments of nephrology providing service to the HIV clinic.
A separate questionnaire (available online at www.cphiv.dk) was sent for every HIV-infected patient with either dialysis or RT to obtain the following data: demographic data, etiology of CKD (either clinical or by biopsy), modality of and time on dialysis, data related to HIV infection [duration of HIV infection, risk factors for acquiring HIV infection, prior AIDS events, HIV-1 RNA, CD4+ T-cell count (cells/mm3) and cART regimens], data related to coinfections with viral hepatitis [duration; hepatitis C virus (HCV) RNA and genotype and HBsAg and HBV-DNA if available; clinical situation (asymptomatic cirrhosis and Child-Pugh class); specific antiviral treatments; and virological response], and finally data related to RT (characteristics of donor, immunosuppression regimen, episodes of rejection and graft function).
Variables were expressed as the mean and SD, median and interquartile range (IQR) or as proportions as appropriate. Patients were compared using the χ2 test or Fisher exact test for proportions and the t test or Wilcoxon test for continuous data. The significance level was set at 0.05. All analyses were performed using SAS (Statistical Analysis Software, Cary, NC; Version 9.1).
Survey of Clinics Participating
Forty-one EuroSIDA clinics including 62,306 patients participated in the study. Using the same geographical regions as in the EuroSIDA study,18 the participating clinics were from Eastern Europe (31.7%), Central Europe (36.6%), Northern Europe (17.1%), Southern Europe (12.2%), and Argentina (2.4%). Sixteen clinics provided data for prevalence monitoring. ESRD among HIV-infected patients occurred in 0.46% (95% CI: 0.38% to 0.54%) with some regional differences: Northern Europe had the highest prevalence [0.80% (0.46 to 1.11)] followed by Southern [0.65% (0.44 to 0.85)] and Central Europe [0.45% (0.34 to 0.56)]. In contrast, Eastern Europe showed the lowest prevalence [0.13% (0.03 to 0.22)]. Twenty-three (59%) and 14 (35.9%) clinics reported HIV-infected patients on dialysis and RT, respectively. Patient and disease characteristics are shown in Table 1.
Information about HIV infection in dialysis and RT patients is shown in Table 2. The majority of patients were young males of black ethnic origin. Sexual transmission was the most frequent risk factor for acquiring HIV infection. Thirty-nine patients (32.8%) had 68 previous AIDS diagnoses (58 in dialysis patients and 10 in RT recipients); 24 (61.5%) of whom had experienced 1; and 15 (38.5%) had more than 1 previous AIDS diagnosis. The most frequent diagnoses were tuberculosis (n = 11) and oesophageal candidiasis (n = 10), followed by cytomegalovirus infection (n = 9), Pneumocystis jirovecii pneumonia (n = 8), and Kaposi sarcoma (n = 8). Most patients had a good virological and immunological status. The majority of the patients had taken or were currently receiving antiretroviral drugs, and the most frequent regimens were protease inhibitor-based and nonnucleoside reverse transcriptase inhibitor-based regimens. When comparing the patients characteristics stratifying according to whether they were on dialysis or had received a RT, few differences were found as follows: RT recipients were younger, had fewer prior AIDS events, higher CD4+ T-cell counts, and viral load was undetectable in all cases.
Hepatitis Virus Coinfections
Information on coinfection with viral hepatitis was obtained for 119 patients: 23 patients had HCV coinfection (positive HCV antibodies), 13 had HBV coinfection (positive HBsAg), and 2 had both HCV and HBV. We found few differences when comparing coinfected with HIV-monoinfected patients. HCV-coinfected patients had acquired HIV infection more often by parenteral transmission and had a longer history of HIV diagnosis. HBV-coinfected and HIV-monoinfected patients acquired HIV by sexual transmission. We did not find differences between coinfected and monoinfected patients concerning virological and immunological parameters, antiretroviral regimens, and access to RT waiting list.
Additional information was obtained for the 25 HCV-coinfected patients, 21 (21.9%) on dialysis, and 4 (15.4%) with RT. The genotype was reported for 17 patients.
Genotype 1 and 4 were the most frequent genotypes (47.1% and 29.4%, respectively). Information on HCV RNA was reported for 17 patients with a median HCV RNA count of 5.9 log copies per milliliter (IQR: 4.9-6.4 log copies/mL). Five (29.4%) patients had cleared HCV RNA. Of 22 patients with clinical information on HCV infection, 19 were described as asymptomatic. Three patients were cirrhotic (the Child-Pugh score was A in 2 and B in 1 of these patients). Of 24 patients with information on treatment for HCV, 3 had received treatment (12.5%), and in one of these, a sustained virologic response was achieved.
Similarly, information about 15 HBV-coinfected patients was obtained; 13 of 93 on dialysis (14.0%) and 2 of 26 (7.7%) with transplantation (P = 0.52). Clinical information was provided in 11 patients, 10 of whom were described as asymptomatic and 1 as cirrhotic (Child-Pugh score of A). Information on treatment for HBV was reported for 11 of the coinfected patients, 4 of whom started treatment. Outcome was reported for 3 patients, of whom, 2 were reported to be aviremic.
Etiology and Characteristics of CKD
Information about CKD in both dialysis and RT patients is shown in Table 3. The etiology of CKD was known for 113 patients, HIV-associated nephropathy (HIVAN) and other types of glomerulonephritis being the most frequent. The diagnosis was proven by biopsy in 65 patients (61.9%) and was significantly more likely to be proven by biopsy in transplanted patients (P = 0.031). HIVAN was more frequent in black patients (33 of 51, 64.7%) as compared with white patients (8 of 37, 21.6%) (P = 0.0003). There were no differences in etiology between hepatitis coinfected and HIV-monoinfected patients. Hemodialysis was used in 109 patients (93.2%) and peritoneal dialysis in 20 patients (17.9%). Among 99 hemodialysis patients, 77 had an arteriovenous fistula (77.8%), 13 a catheter (13.1%), and 9 (9.1%) both, with no differences between transplanted and dialysed patients. Seventy patients were receiving erythropoietin for the treatment of CKD-related anemia (75.3%, 93 responses).
ESRD Patients on the Renal Transplant Waiting List
Thirty patients with ESRD on dialysis were reported to be on the renal transplant waiting list (34.1%, n = 88 responders), and the median duration of being on the list was 1.1 (interquartile range [QR] 0.2-2.1) years. 58 of 88 dialysis patients (65.9%) were excluded from the waiting list at the time of the survey. There were 67 reasons reported for exclusion from the waiting list, which are shown in Figure 1. Criteria related to a poor control of HIV infection (low CD4+ T-cell count or detectable viral load) was reported in 13 cases (22.4%) and underlying cardiovascular problems or diabetes was reported in 12 cases (20.6%). In 2 cases (4%), it was reported that transplantation was contraindicated in HIV-infected patients. No reason or unknown was specified for 9 and 5 patients, respectively.
Among transplanted patients, the median calendar year of initiating renal replacement therapy was 2002 (IQR: 2000-2004), and the median year of inclusion on the RT waiting list was 2004 (IQR: 2003-2006). The donor was cadaveric in 21 patients (95.5%) and a live donor in one. The initial immunosuppressive regimen was reported for 22 patients and consisted of 1 (n = 1, 4.3%), 2 (n = 12, 52.2%), or 3 drugs (n = 10, 43.5%). The current immunosuppressive regimen was reported for 17 patients and consisted of 1 (n = 2, 11.8%), 2 (n = 6, 35.3%), or 3 drugs (n = 9, 52.9%). The most frequent immunosuppressive regimens used in combination with antiretrovirals in the posttransplant period included the combination of a calcineurin inhibitor (tacrolimus), corticosteroids, and mycophenolate mofetil.
Episodes of graft rejection were reported in 8 patients (30%), and the characteristics and description of rejection are shown in Table 4. All transplants were performed from cadaveric donors. Despite treatment for rejection (with steroids in 7 cases), 5 patients lost their grafts and were again under dialysis at the time of the survey.
Vital status was reported for 25 patients, and all were reported to be alive at the time of last follow-up. Information on survival could be calculated for 12 patients with a median survival of 2.4 (IQR: 1.1-3.0) years.
This is the first multinational cross-sectional study among ESRD patients with HIV infection in Europe. The overall prevalence of ESRD in HIV-infected patients was low with some differences between European regions. The geographic differences in prevalence rates could be in part related to the availability of dialysis/RT for HIV-infected individuals, it could reflect underlying differences in the risk factors for developing ESRD, or it could be a consequence of differences in survival and access to HIV-related care, and competing risks for HIV associated mortality and morbidity.19
Most patients were young males of black ethnic origin. The proportion of non-white ethnicities varies substantially between individual countries. In the United States, almost all patients are African American20; in Europe, white race is more common with substantial variability between the countries: French9,10 and Spanish21 studies reported 60%-65%, and 6% of black patients, respectively. The most frequent aetiologies of CKD found in our study were HIVAN and other glomerulonephritis, consistent with the racial distribution found in our study. European and Asian case series of patients with HIV infection and renal disease show that patients of European descent typically have glomerulonephritis, whereas patients of African descent in the same centers usually have HIVAN. Spanish series found a prevalence of HIVAN that ranged from 0% to 6%,11,21 and this proportion rises up to 39%-40% in French series where again a high percentage of African and Caribbean patients is found.9,10 Recent studies have demonstrated that the MYH9 gene polymorphisms is associated with nondiabetic etiologies of ESRD in African Americans. In the case of HIVAN, HIV infection seems to be a common initiator of renal disease in African Americans and serves as an example of one environmental exposure that can initiate MYH9-associated HIVAN.22
Most patients had well-controlled HIV infection under different cART regimens and one third of them had prior AIDS events, the most frequent were tuberculosis and oesophageal candidiasis, which are not exclusion criteria for RT.23-25 Few differences were found when comparing dialysis patients with RT recipients. RT recipients were younger with less AIDS events and with better HIV control.
Hepatitis C coinfection was found in a relatively low percentage in comparison with other series, probably, because the most common route of HIV transmission was sexual. French series with a high percentage of sexual HIV transmission have reported coinfection rates of 25%-27%.9,10 In contrast, in Spanish and American series with a high percentage of former injection drug users the rate of coinfected patients is 60%-68%.11,20,21 Almost all coinfected patients were asymptomatic. Treating viral hepatitis involves important challenges. It is recommended to eradicate HCV infection in dialysis patients awaiting RT and those with significant chronic liver disease. Interferon monotherapy is the standard treatment for HCV infection in this setting but has many drawbacks such as poor tolerance and marginal responses. The addition of ribavirin is generally contraindicated in these patients due to a risk of hemolytic anemia. The options for antiviral therapy in the posttransplant period are even more limited; Interferon is contraindicated once the patient is transplanted because of the risk of developing acute rejection and/or acute interstitial nephropathy.26 Probably for those reasons, only 3 patients had previously received specific antiviral treatment.
The most frequently used type of dialysis in HIV-infected patients was hemodialysis via arteriovenous fistula. The prognosis of patients with fistula is more favourable in comparison with catheter because there is less risk of catheter-related infection and mortality.27 Hemodialysis was also the most frequent modality of dialysis in the general European dialysis population in 2007.28 The median time on dialysis (3.3 and 2.0 years in hemodialysis and peritoneal dialysis, respectively) was also similar to previously reported studies.9,11
There is little information regarding HIV-infected patients on the RT waiting list. In our study, only 34% of the patients were on the RT waiting list, and the remaining 66% were excluded for different reasons. The largest study performed in this setting between January 2000 and October 2007, retrospectively, reviewed 309 potentially eligible HIV patients; only 20% of HIV patients were listed or transplanted compared with 73% of HIV-negative patients evaluated over the same period. The most common reasons of failure to proceed for full evaluation were CD4+ T-cell count and viral load data not provided at initial evaluation (35%), CD4+ T-cell count and viral load not meeting the eligibility criteria (21%), and other factors including black race and history of illicit drug use.29 In our study, HIV infection was listed as a contraindication for transplantation for 2 patients from 1 specific clinic. This may also have been the case for several other clinics, which did not respond to this question. In Spain, a cross-sectional multicenter study found that 39% of HIV-infected patients met criteria for inclusion on the RT waiting list, but only 12% were included at the time of the survey.11 In 1998, 90% of the 148 US transplant centers participating in a multicenter survey responded that they would not transplant kidneys to HIV-infected patients on dialysis, even if their infection was asymptomatic.30 In the last decade, this view has dramatically changed, and most transplant groups from Europe (Spain,23 United Kingdom,24 and Italy31) and North America25 have been working toward harmonizing criteria for solid organ transplantation in HIV-infected patients, using similar HIV-associated criteria for RT. It is important to point out that currently, a previous opportunistic infection is not a strict exclusion criterion by itself. A CD4+ T-cell count above 200 cells per cubic millimeter and an undetectable viral load in plasma are required criteria in all these guidelines.
Reported rejection of RT in patients with HIV ranges from 13% to 67%,32 consistent with the 30% observed in this study. The prevalence of acute kidney rejection in HIV-infected RT recipients is higher that in non-HIV RT recipients (10%-15%).33 The aetiology of such high rejection rates is unclear, although dysregulation of the immune system or insufficient immunosuppression (due to pharmacological interactions between antiretroviral and immunosuppressive drugs) are 2 possible causes. Information on survival could only be calculated for 12 patients with a median survival of 2.4 years. The ERA-EDTA Annual Report estimated a 2-year survival probability for the general European renal transplant population (cohort 2001-2005) of 95.6% (95% CI: 95.3-96.0).28
The present study has some limitations. First, the Eurosida network has some limitations; the main objective is to assess the impact of ART on the outcome of the population of HIV-infected patients living in Europe, and the clinics are centres of excellence probably not representative of the general ESRD/HIV population. Further, not all clinics in the EuroSIDA network provided data and we cannot rule out the possibility of differences between those that did or did not participate in terms of the patients with either ESRD or HIV, and we cannot be sure that the prevalence of ESRD is similar in those centres not participating in EuroSIDA or in this particular survey. The data are not complete, with only 41 centres responding to the survey, and incomplete data for some of the variables of interest. If centres with no HIV-infected patients with ESRD have failed to answer to survey, prevalence data will be overestimated. In addition, we requested information on the numbers of patients under current follow-up, and information on renal transplant since the introduction of highly active antiretroviral therapy. It is possible that some patients with renal transplant have died and were not included in this study, which will result in overestimation of survival and underestimation of prevalence of RT in this population. Third, this study is cross sectional in design and, therefore, our results should be interpreted with caution.
To conclude, this is the first epidemiological information of ESRD among HIV-infected patients in Europe in the highly active antiretroviral therapy era. More studies are needed to improve knowledge in prevalence and survival rates in HIV-infected patients with ESRD in European countries.
We are indebted to the study participants and to all staff in the nephrology units in the centres for assisting with the extraction of detailed information on dialysis and transplantation.
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APPPENDIX I: THE EUROSIDA STUDY GROUP
The Multicentre Study Group of EuroSIDA (National Coordinators in Parenthesis)
Argentina: (M. Losso), C Elias, Hospital J. M. Ramos Mejia, Buenos Aires. Austria: (N. Vetter), Pulmologisches Zentrum der Stadt Wien, Vienna; R. Zangerle, Medical University Innsbruck, Innsbruck. Belarus: (I Karpov), A. Vassilenko, Belarus State Medical University, Minsk, V. M. Mitsura, Gomel State Medical University, Gomel; O. Suetnov, Regional AIDS Centre, Svetlogorsk. Belgium: (N. Clumeck), S De Wit, M. Delforge, Saint-Pierre Hospital, Brussels; R. Colebunders, Institute of Tropical Medicine, Antwerp; L. Vandekerckhove, University Ziekenhuis Gent, Gent. Bosnia-Herzegovina: (V. Hadziosmanovic), Klinicki Centar Univerziteta Sarajevo, Sarajevo. Bulgaria: (K. Kostov), Infectious Diseases Hospital, Sofia. Croatia: (J. Begovac), University Hospital of Infectious Diseases, Zagreb. Czech Republic: (L. Machala), H. Rozsypal, Faculty Hospital Bulovka, Prague; D. Sedlacek, Charles University Hospital, Plzen. Denmark: (J. Nielsen), G. Kronborg, T. Benfield, M. Larsen, Hvidovre Hospital, Copenhagen; J. Gerstoft, T. Katzenstein, A-B E. Hansen, P. Skinhøj, Rigshospitalet, Copenhagen; C. Pedersen, O. D Larsen, Odense University Hospital, Odense; L. Oestergaard, Skejby Hospital, Aarhus. Estonia: (K. Zilmer), West-Tallinn Central Hospital, Tallinn; Jelena Smidt, Nakkusosakond Siseklinik, Kohtla-Järve. Finland: (M. Ristola), Helsinki University Central Hospital, Helsinki. France: (C. Katlama), Hôpital de la Pitié-Salpétière, Paris; J-P. Viard, Hôpital Necker-Enfants Malades, Paris; P-M. Girard, Hospital Saint-Antoine, Paris; J. M. Livrozet, Hôpital Edouard Herriot, Lyon; P. Vanhems, University Claude Bernard, Lyon; C. Pradier, Hôpital de l'Archet, Nice; F. Dabis, D. Neau, Unité INSERM, Bordeaux. Germany: (J. Rockstroh), Universitäts Klinik Bonn; R. Schmidt, Medizinische Hochschule Hannover; J. van Lunzen, O. Degen, University Medical Center Hamburg-Eppendorf, Infectious Diseases Unit, Hamburg; H. J. Stellbrink, IPM Study Center, Hamburg; S. Staszewski, J. W. Goethe University Hospital, Frankfurt; J. Bogner, Medizinische Poliklinik, Munich; G. Fätkenheuer, Universität Köln, Cologne. Greece: (J. Kosmidis), P. Gargalianos, G. Xylomenos, J. Perdios, Athens General Hospital; G. Panos, A. Filandras, E. Karabatsaki, 1st IKA Hospital; H. Sambatakou, Ippokration Genereal Hospital, Athens. Hungary: (D. Banhegyi), Szent Lásló Hospital, Budapest. Ireland: (F. Mulcahy), St. James's Hospital, Dublin. Israel: (I. Yust), D. Turner, M. Burke, Ichilov Hospital, Tel Aviv; S. Pollack, G. Hassoun, Rambam Medical Center, Haifa; S. Maayan, Hadassah University Hospital, Jerusalem. Italy: (A. Chiesi), Istituto Superiore di Sanità, Rome; R. Esposito, I. Mazeu, C. Mussini, Università Modena, Modena; C. Arici, Ospedale Riuniti, Bergamo; R. Pristera, Ospedale Generale Regionale, Bolzano; F. Mazzotta, A. Gabbuti, Ospedale S. Maria Annunziata, Firenze; V. Vullo, M. Lichtner, University di Roma la Sapienza, Rome; A. Chirianni, E. Montesarchio, M. Gargiulo, Presidio Ospedaliero A. D. Cotugno, Monaldi Hospital, Napoli; G. Antonucci, F. Iacomi, P. Narciso, C. Vlassi, M. Zaccarelli, Istituto Nazionale Malattie Infettive Lazzaro Spallanzani, Rome; A. Lazzarin, R. Finazzi, Ospedale San Raffaele, Milan; M. Galli, A. Ridolfo, Osp. L. Sacco, Milan; A d'Arminio Monforte, Istituto Di Clinica Malattie Infettive e Tropicale, Milan. Latvia: (B. Rozentale), I. Zeltina, Infectology Centre of Latvia, Riga. Lithuania: (S. Chaplinskas), Lithuanian AIDS Centre, Vilnius. Luxembourg: (R. Hemmer), T. Staub, Centre Hospitalier, Luxembourg. Netherlands: (P. Reiss), Academisch Medisch Centrum bij de Universiteit van Amsterdam, Amsterdam. Norway: (J. Bruun), A. Maeland, V. Ormaasen, Ullevål Hospital, Oslo. Poland: (B. Knysz) J. Gasiorowski, Medical University, Wroclaw; A. Horban, E. Bakowska, Centrum Diagnostyki i Terapii AIDS, Warsaw; A. Grzeszczuk, R. Flisiak, Medical University, Bialystok; A. Boron-Kaczmarska, M. Pynka, M. Parczewski, Medical Univesity, Szczecin; M. Beniowski, E. Mularska, Osrodek Diagnostyki i Terapii AIDS, Chorzow; H. Trocha, Medical University, Gdansk; E. Jablonowska, E. Malolepsza, K. Wojcik, Wojewodzki Szpital Specjalistyczny, Lodz. Portugal: (F. Antunes), E. Valadas, Hospital Santa Maria, Lisbon; K. Mansinho, Hospital de Egas Moniz, Lisbon; F. Maltez, Hospital Curry Cabral, Lisbon. Romania: (D Duiculescu), Spitalul de Boli Infectioase si Tropicale: Dr Victor Babes, Bucarest. Russia: (A. Rakhmanova), Medical Academy Botkin Hospital, St Petersburg; E. Vinogradova, St Petersburg AIDS Centre, St Peterburg; S. Buzunova, Novgorod Centre for AIDS, Novgorod. Serbia: (D. Jevtovic), The Institute for Infectious and Tropical Diseases, Belgrade. Slovakia: (M. Mokráš), D. Staneková, Dérer Hospital, Bratislava. Slovenia: (J. Tomazic), University Clinical Centre Ljubljana, Ljubljana. Spain: (J. González-Lahoz), V. Soriano, P. Labarga, J. Medrano, Hospital Carlos III, Madrid; S. Moreno, Hospital Ramon y Cajal, Madrid; B. Clotet, A. Jou, R. Paredes, C. Tural, J. Puig, I. Bravo, Hospital Germans Trias i Pujol, Badalona; J. M. Miró, J. C. Trullas, A. Moreno, F. Cofan, C. Cervera, L. Zamora and J. M. Gatell, Hospital Clinic i Provincial, Barcelona; P. Domingo, M. Gutierrez, G. Mateo, M. A. Sambeat, Hospital Sant Pau, Barcelona. Sweden: (A. Karlsson), Venhaelsan-Sodersjukhuset, Stockholm; L. Flamholc, Malmö University Hospital, Malmö. Switzerland: (B. Ledergerber), R. Weber, University Hospital, Zürich; P. Francioli, M. Cavassini, Centre Hospitalier Universitaire Vaudois, Lausanne; B. Hirschel, E. Boffi, Hospital Cantonal Universitaire de Geneve, Geneve; H. Furrer, Inselspital Bern, Bern; M. Battegay, L. Elzi, University Hospital Basel. Ukraine: (E. Kravchenko), N. Chentsova, Kiev Centre for AIDS, Kiev; G. Kutsyna, Luhansk State Medical University; Luhansk; S. Servitskiy, Odessa Region AIDS Center, Odessa; S. Antoniak, Kiev; M. Krasnov, Kharkov State Medical University, Kharkov. United Kingdom: (S. Barton), St. Stephen's Clinic, Chelsea and Westminster Hospital, London; A. M. Johnson, D Mercey, Royal Free and University College London Medical School, London (University College Campus); A. Phillips, M. A. Johnson, A. Mocroft, Royal Free and University College Medical School, London (Royal Free Campus); M. Murphy, Medical College of Saint Bartholomew's Hospital, London; J. Weber, G. Scullard, Imperial College School of Medicine at St. Mary's, London; M. Fisher, Royal Sussex County Hospital, Brighton; C. Leen, Western General Hospital, Edinburgh.
Virology group: B. Clotet, R. Paredes (Central Coordinators) plus ad hoc virologists from participating sites in the EuroSIDA Study.
Steering Committee: F. Antunes, B. Clotet, D. Duiculescu, J. Gatell, B. Gazzard, A. Horban, A. Karlsson, C. Katlama, B. Ledergerber (Chair), A. D'Arminio Montforte, A. Phillips, A. Rakhmanova, P. Reiss (Vice-Chair), J. Rockstroh.
Coordinating Centre Staff: J. Lundgren (project leader), O. Kirk, A. Mocroft, N. Friis-Møller, A. Cozzi-Lepri, W. Bannister, M. Ellefson, A. Borch, D. Podlekareva, J. Kjær, L. Peters, J. Reekie, J. Kowalska.