Is there an epidemic of HIV infection in the US ESRD program?

Surveys revealed increases in the prevalence of HIV-infected patients in the US end-stage renal disease (ESRD) program in the 1980s and early 1990s, with clustering in young black men 25 to 44 yr old. Since the availability of highly active antiretroviral therapy in 1996, the prognosis of HIV-infected patients has improved, and therapy has been shown to change the course of classic HIV-associated nephropathy. We used the United States Renal Data System database to determine if the incidence and prevalence of HIV-infected patients with renal disease has increased in the ESRD program, by means of principal diagnoses and comorbid AIDS-defining diagnoses. As the number of US patients living with AIDS increased 57% from 214,711 in 1995 to 337,017 in 2000, and the number of incident ESRD patients increased 29.9% from 72,827 to 94,602, the number of incident HIV-infected patients increased only by 3.5%, from 1133 to 1171. Over this time, the percentage of incident ESRD patients with HIV infection fell from 1.56% to 1.24%. Among black men 25 to 44 yr of age, HIV infection as a proportion of incident ESRD cases fell from 8.5% to 6.2% from 1995 to 2000. The incident rate per million of AIDS or HIV infection in black men aged 25 to 44 fell from 107 in 1995 to 78 per million in 2000. The incidence rate for HIV-infected women in the ESRD program rose 14% while it declined 7% in men. Almost 2000 HIV-infected women, or 28.8% of the population, have initiated therapy for ESRD with hemodialysis. The number of prevalent cases increased in absolute numbers 81.3% from 2687 to 4871 (0.90% to 1.16% of the ESRD program). One-year survival rates for HIV-infected incident ESRD patients increased from 53.1% to 67.1% from 1995 to 2000. Although these values may be underestimates because of underreporting due to confidentiality concerns and lack of biopsy confirmation, we conclude that although the prevalence of HIV infection is increasing in the US ESRD population, the increase as a proportion of the program is minimal and is due to better survival after development of renal failure. The incidence of HIV infection in the US ESRD program is stable. Highly active antiretroviral therapy may be responsible for the change in epidemiology of HIV infection in the US ESRD program.