Differences in the causes of death of HIV-positive patients in a cohort study by data sources and coding algorithms

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   Differences in the causes of death of HIV-positive
    patients in a cohort study by data sources and
                   coding algorithms
    Victoria Hernandoa,b, Paz Sobrino-Vegasa,b, M. Carmen Burrielc,
           Juan Berenguerd, Gemma Navarroe, Ignacio Santosf,
         Jesús Reparazg, M. Angeles Martı́nezh, Antonio Antelai,
            Félix Gutiérrezj, Julia del Amoa,b, for CoRIS cohort
                   Objectives: To compare causes of death (CoDs) from two independent sources: National
                   Basic Death File (NBDF) and deaths reported to the Spanish HIV Research cohort [Cohort
                   de adultos con infección por VIH de la Red de Investigación en SIDA CoRIS)] and
                   compare the two coding algorithms: International Classification of Diseases, 10th revision
                   (ICD-10) and revised version of Coding Causes of Death in HIV (revised CoDe).
                   Methods: Between 2004 and 2008, CoDs were obtained from the cohort records (free
                   text, multiple causes) and also from NBDF (ICD-10). CoDs from CoRIS were coded
                   according to ICD-10 and revised CoDe by a panel. Deaths were compared by 13
                   disease groups: HIV/AIDS, liver diseases, malignancies, infections, cardiovascular,
                   blood disorders, pulmonary, central nervous system, drug use, external, suicide, other
                   causes and ill defined.
                   Results: There were 160 deaths. Concordance for the 13 groups was observed in 111
                   (69%) cases for the two sources and in 115 (72%) cases for the two coding algorithms.
                   According to revised CoDe, the commonest CoDs were HIV/AIDS (53%), non-AIDS
                   malignancies (11%) and liver related (9%), these percentages were similar, 57, 10 and
                   8%, respectively, for NBDF (coded as ICD-10). When using ICD-10 to code deaths in
                   CoRIS, wherein HIV infection was known in everyone, the proportion of non-AIDS
                   malignancies was 13%, liver-related accounted for 3%, while HIV/AIDS reached 70%
                   due to liver-related, infections and ill-defined causes being coded as HIV/AIDS.
                   Conclusion: There is substantial variation in CoDs in HIV-infected persons according
                   to sources and algorithms. ICD-10 in patients known to be HIV-positive overestimates
                   HIV/AIDS-related deaths at the expense of underestimating liver-related diseases,
                   infections and ill defined causes. CoDe seems as the best option for cohort studies.
                                                     ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

                                                  AIDS 2012, 26:1829–1834
                      Keywords: AIDS, causes of death, hepatitis, HIV, malignancies, mortality

a
 Red de Investigación en Sida, Centro Nacional de Epidemiologı́a, Instituto de Salud Carlos III, Madrid, bCIBER de Epidemiologı́a y
Salud Pública (CIBERESP), Madrid, cServicio de Vigilancia y Salud Pública, Servicio de Información e Investigación Sanitaria,
Zaragoza, dHospital Universitario Gregorio Marañon, Madrid, eHospital Parc Tauli, Sabadell, fHospital Universitario La Princesa,
Madrid, gHospital de Navarra, Pamplona, hHospital Universitario San Cecı́lio, Granada, iHospital Universitário de Santiago de
Compostela, Santiago de Compostela, and jHospital Universitário de Elche, Elche, Spain.
Correspondence to Victoria Hernando, Red de Investigación en Sida, Centro Nacional de Epidemiologı́a – ISCIII, Avda. Monforte
de Lemos 5, 28029 Madrid, Spain.
Tel: +34 91 8222921; fax: +34 91 3877513; e-mail: vhernando@isciii.es
Received: 24 October 2011; revised: 4 January 2012; accepted: 16 February 2012.

DOI:10.1097/QAD.0b013e328352ada4

              ISSN 0269-9370 Q 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins                                              1829
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1830     AIDS    2012, Vol 26 No 14

         Introduction                                                 text variables. For the purpose of this study, we coded
                                                                      CoDs according to two coding systems:
         Accurate information on causes of death (CoDs) is hard to
         obtain and is subject to selection and information biases.   (1) ICD-10 – we assigned a code to each death with the
         Most countries have national death registries that compile       assistance of an ICD-10 coding expert familiar with
         information from death certificates and code CoD by              coding rules.
         international classification rules. In Spain, the National   (2) Revised CoDe – we assigned a code to each death
         Statistics Institute collects data on CoD according to the       following CoDe protocol assisted by ART-CC.
         International Classification of Diseases, 10th revision
         (ICD-10). ICD-10 provides a set of rules to extract the
         maximum information from the death certificate, usually      National Statistics Institute: National Basic
         based on a single CoD [1]. ICD-10 was implemented in         Death File
         1999 and introduced specific codes for HIV/AIDS which        The NBDF provides information on the date and CoDs
         were not present in ICD-9 [2]. Cohort studies of HIV-        of all persons dying in Spain coded by the underlying
         positive patients have not traditionally used the ICD-10.    CoDs in accordance with the ICD-10. The data are
         Other algorithms, such as the Coding Causes of Death in      obtained from civil registries and from the National
         HIV (CoDe) protocol are used instead [3,4]. CoDe was         Statistics Institute itself through the Statistical Bulletin on
         developed in 2004 by the Copenhagen HIV Programme            Deaths which is compiled from death certificates.
         (CHIP) (http://www.cphiv.dk) and collects extensive
         information on CoD which is examined in a centralized        Period of analysis
         review process. CoDe is used by the Data Collection on       Data from the two sources were cross-matched in the first
         Adverse events of Anti-HIV Drugs (D:A:D) and                 quarter of 2010 for individuals who had died between
         EuroSIDA, among others [5–7]. Unfortunately, as it is        January 2004, when CoRIS was created, and December
         not always possible to collect detailed information, a       2008, date of the last available update of the NBDF.
         simplified version of CoDe selection rules has been used
         by the Antiretroviral Therapy Cohort Collaboration           Data analysis
         (ART-CC) in what we call the ‘revised CoDe’ (http://         Thirteen clinical categories were created for the CoD in
         www.art-cohort-collaboration.org).                           HIV-positive persons. These are described in Table 1,
                                                                      which also shows the individual ICD-10 and revised
         CoRIS, the Cohort of the Spanish Network of                  CoDe codes included in each category.
         Excellence on HIV/AIDS Research, collects information
         on multiple CoDs from reporting physicians. In 2008, we      The CoD from each source – those reported to CoRIS
         obtained CoDs for deceased cohort members from the           and those included in the NBDF, and from each
         National Statistics Institute, which provides single CoD     algorithms – ICD-10 rules and revised CoDe, for
         coded with ICD-10. We hypothesize that CoD identified        CoD reported to CoRIS– were compared according
         from each of source will vary substantially due either to    categories of diseases.
         sources and/or the coding rules. Our objectives are to
         compare the CoD obtained from two independent
         data sources using ICD-10: the National Basic Death          Results
         File (NBDF) and reports to CoRIS provided directly by
         the physicians between 2004 and 2008. We also compare        Overall, 4687 patients, 11 491.28 person-years follow-up
         deaths reported in CoRIS using two different coding          and 160 deaths were observed from January 2004 to
         algorithms: the ICD-10 and the revised CoDe.                 December 2008, yielding a crude mortality rate of 1.39
                                                                      per 100 person-years [95% confidence interval (CI)
                                                                      1.19–1.62]. Of these 160 deaths, 87% (n ¼ 139) were
         Methods                                                      men, median age was 44 years [interquartile range (IQR)
                                                                      37–51], 36% (n ¼ 57) were injecting drug users, 38%
         Sources of information                                       (n ¼ 60) heterosexuals, 18% (n ¼ 29) MSM and 9%
         CoRIS                                                        (n ¼ 14) had others or unknown categories. The median
         CoRIS is an open multicentre cohort of HIV-positive          CD4 cell count within 6 months of death for the 55%
         patients naive to antiretroviral therapy from 32 centres     patients with data available was 117 cells/ml (IQR 39–
         from 12 of the 17 autonomous regions of Spain. The           259) and 67% received antiretroviral treatment.
         project was approved by the Institutional Ethics Review
         Boards and each participant is required to sign an           Comparing cause of death in National Basic
         informed consent form [8]. The variables collected           Death File and CoRIS using International
         include socio-demographic, epidemiological, clinical,        Classification of Diseases, 10th revision
         treatment and mortality data; vital status, date of death    Comparing the CoD for the 13 categories from each
         and underlying CoD, as well as contributing causes as free   source yielded concordance in 111 (69%) cases (k ¼ 0.48;

       Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Coding causes of death in cohort studies Hernando et al.                    1831

Table 1. International Classification of Diseases, 10th revision and revised Coding Causes of Death in HIV codes included in each disease group
category.

Disease groups                          ICD-10 code                                                  CoDe code

HIV/AIDS-associated diseases            A02, A073, A15–A19, A30, A31, A812,                          01 (AIDS)
                                          B00, B20–B24, B25, B371, B383–B389,
                                          B393–B399, B451–B459, B582, B588–B589,
                                          C46, C53, C83, C857, C859, R75
Liver disease                           B15–B19, K65, K70–K77, K922                                  03   (chronic viral hepatitis),
                                                                                                     14   (liver failure)
Tumours                                 C00–C52, C54–C82, C84–D48                                    04   (malignancy)
Infectious diseases                     A00–A019, A03–A072, A078–A09, A20–A28,                       02   (infection)
                                          A32–A563, A568–A811, A813–A99, B01–B09,
                                          B25–B370, B372–B382, B39–B392, B40–B450,
                                          B46–B581, B583, B99, G00–G02, J12–J18
Cardiovascular disease                  I00–I45, I47–I99                                             08 (ischaemic heart disease), 09 (stroke),
                                                                                                       24 (heart or vascular disease)
Diseases of the blood                   D50–D89                                                      20 (haematological disease)
Pulmonary diseases                      J40–J99                                                      11 (primary pulmonary hypertension),
                                                                                                       12 (lung embolus), 13 (chronic
                                                                                                       obstructive lung disease),
                                                                                                     25 (respiratory disease)
Central nervous system diseases         G048-G99                                                     23 (CNS disease)
Drug abuse                              F192, X40–X44, T36–T50, Y10–Y15                              19 (substance abuse)
External causes                         X00–X30, X45–X49, X50–X59, X85–X90, V01–Y98                  16 (accident or violent death)
Suicide                                 X60–X84                                                      17 (suicide)
Other diseases                          Any other code                                               Any other code
Ill defined and unknown causes          R092, R95, R960–R961, R98, R99                               91 (unclassifiable cause),
                                                                                                     92 (unknown)

CoDe, Coding Causes of Death in HIV; CNS, central nervous system; ICD-10, International Classification of Diseases, 10th revision.

CI 95% 0.36–0.59). However, only 29 of the 82 HIV/                        known to be HIV infected. When the CoD is pneumonia
AIDS-associated deaths (35%) were classified with exactly                 in an HIV-positive person, the assigned ICD-10 code is
the same ICD-10 code in each source, so concordance for                   B20, B20.9 or B24 (HIV/AIDS related), whereas revised
individual codes was very low, although moderate for the                  CoDe considers CD4 cell counts prior to death: if CD4
13 categories. Of the 49 (31%) discordant CoD, 19 (39%)                   cell count is below 100 cells/ml, it gets coded as 01
had a completely different CoD, but 14 (29%) would have                   (AIDS), but if it is unknown or above 100 cells/ml, it gets
been concordant if the information about HIV-positive                     coded as 02 (infection).
status had been recorded in the Bulletin on Death. For
example, if CoD is cirrhosis and HIV status is unknown,                   Distribution of the cause of death using different
according to ICD-10, it gets coded as K74.6 (other and                    data sources and coding algorithms
unspecified cirrhosis of liver), but if HIV status is positive,           ‘HIV/AIDS-associated causes’ was the most frequent
it gets coded as B23.8 (HIV disease resulting in other                    CoD irrespective of the source and coding algorithm,
specified conditions).                                                    accounting for 91 (57%) of the causes in the NBDF, 112
                                                                          (70%) in CoRIS_ICD-10 and 85 (53%) in CoRIS_
Comparing cause of death in CoRIS using                                   CoDe. The second most common category was ‘non-
International Classification of Diseases, 10th                            AIDS-defining tumours’: 16 (10%) in the NBDF, 21
revision and revised Coding Causes of Death in                            (13%) in CoRIS_ICD-10 and 18 (11%) in CoRIS_
HIV                                                                       CoDe. ‘Liver diseases’ was the third most common cause
We compared the CoD according to ICD-10 rules and                         in CoRIS_CoDe, accounting for 15 (9%) cases, as well as
the revised CoDe algorithm and found concordance in                       in the NBDF, accounting for 12 (8%) cases. In contrast,
115 (72%) cases for the 13 categories (k ¼ 0.54; CI 95%                   ‘liver diseases’ accounted for only five (3%) cases in
0.43–0.64). Of the 45 discordant causes, 33 (73%) were                    CoRIS_ICD-10 (Fig. 1).
classified as ‘HIV/AIDS associated causes’ by ICD-10,
whereas 15 of these 33 (45%) are coded as poorly defined
by revised CoDe, 10 (30%) are classified as liver-related
and eight (24%) as infectious diseases. This is due to an                 Discussion
ICD-10 coding rule that converts into B24 codes (HIV
disease) all CoD which are unknown or ill defined in                      There are substantial differences in the CoD of HIV-
anyone who is known to be HIV infected. ICD-10 also                       positive people according to data sources and classifi-
converts into B23.8 codes (HIV disease) deaths from                       cation algorithms. HIV/AIDS-associated deaths were the
cirrhosis of viral cause or of unknown cause in people                    most frequent in our cohort for the 2004–2008 period,

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1832     AIDS    2012, Vol 26 No 14

                                                      80

                                                      70

                                                      60                                                                               NBDF
                                                                                                                                       CoRIS_ICD10

                                        Percentage
                                                      50
                                                                                                                                       CoRIS_CoDe
                                                      40

                                                      30

                                                      20

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                           IV
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         Fig. 1. Distribution of the 160 deaths in the CoRIS cohort by disease group category as classified by the National Basic Death
         Files (NBDF) and by two coding systems: CoRIS International Classification of Diseases, 10th revision (CoRIS_ICD-10) and
         CoRIS Coding Causes of Death in HIV (CoRIS_CoDe).

         followed by non-AIDS-defining tumours, for both data                                                      1000 person-years of follow-up in 1997 to 4.4 per 1000
         sources and both classification algorithms. The third most                                                person-years in 2002 [10]. The ART-CC found that 50%
         common CoD was liver disease according to the NBDF                                                        of deaths from 1996 to 2006 were associated with AIDS,
         and revised CoDe in CoRIS but was not when cohort                                                         followed by non-AIDS malignancies (12%) and non-
         data was coded using ICD-10. Applying ICD-10 to                                                           AIDS infections (8%). Overall, a decline in HIV/AIDS-
         cohort data overestimates HIV/AIDS-associated deaths                                                      associated mortality was observed with increased duration
         largely at the expense of labelling as HIV/AIDS-                                                          of antiretroviral therapy [6].
         associated ill defined causes and liver diseases because
         deaths from cirrhosis of viral cause or of unknown cause                                                  In this study, data from the NBDF, which were coded by
         in people known to be HIV infected are assigned to HIV/                                                   ICD-10, seem to be more concordant with those from
         AIDS-related causes. This explains why in CoRIS_ICD-                                                      CoRIS_CoDe than with CoRIS_ICD-10. This is
         10 liver-related causes are in fourth position, why there                                                 because the largest source of misclassification bias we
         are virtually no deaths attributed to infectious diseases,                                                found was derived from the rule that deaths in persons
         none is labelled as ill defined, and HIV/AIDS-associated                                                  known to be HIV-positive should be coded as HIV/
         causes account for 70% of all deaths. In fact, Garcia-                                                    AIDS-related deaths. As information on HIV status is
         Fulgueiras et al. [9], in a study of hepatitis B and C                                                    more likely to be missing from death certificates than in
         mortality in Spain, included an estimation of the                                                         CoRIS, a cohort of people with confirmed HIV
         attributable fraction of mortality due to hepatitis virus                                                 infection, lack of information seems to result in a picture
         among cases coded as AIDS.                                                                                which is closer to reality. These results call for caution
                                                                                                                   when comparing different studies, as this rule is often not
         Applying CoDe to CoRIS shows that just over half of the                                                   taken into account.
         deaths are due to AIDS, which seems to be more in line
         with recent data from similar settings which show a                                                       One of the main limitations of NBDF – given that it
         reduction in HIV/AIDS-associated deaths compared                                                          depends on death certificates – is the poor quality of the
         with previous years [5,6,10,11]. In the Swiss HIV Cohort                                                  latter. The importance of correct completion of death
         Study, HIV/AIDS-associated deaths decreased to 15% of                                                     certificates has been well described, together with the
         all CoD between 2005 and 2009; 85% of deaths were due                                                     common errors that can be minimized with adequate
         to non-AIDS-defining conditions, and non-AIDS-                                                            training [12,13]. Also, when deaths occur outside the
         defining malignancies were the most important CoD.                                                        hospital or the doctor certifying the death does not know
         In our cohort, non-AIDS-defining malignancies were the                                                    the deceased, death certificates may miss important
         second CoD [11]. Likewise, data from EuroSIDA show a                                                      information [12,14] and HIV infection may be missing
         decrease in the incidence rate of AIDS from 118.3 per                                                     because of the stigma associated. However, for some

       Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Coding causes of death in cohort studies Hernando et al.         1833

conditions such as suicide, which trigger legal notifica-         y Marı́a Ángeles Muñoz. Fieldwork, data management
tion, the proportion of deaths was exactly the same with          and analysis: Ana Maria Caro Murillo, Paz Sobrino Vegas,
all three strategies.                                             Santiago Pérez-Cachafeiro, Victoria Hernando Sebastián,
                                                                  Belén Alejos Ferreras, Débora Álvarez del Arco, Susana
The main limitation of this study is the low number of            Monge Corella, Inma Jarrı́n Vera. Committee for coding
deaths, which may have introduced random error in some            cause of death: Victoria Hernando Sebastián, Paz Sobrino
of our estimates and comparisons. However, this does not          Vegas, Carmen Burriel, Roberto Muga, Félix Gutiérrez,
apply to systematic error and the relatively small number         Santiago Moreno, Julia del Amo. BioBanco: M Ángeles
of deaths permitted a more comprehensive exploration of           Muñoz-Fernández, Isabel Garcı́a-Merino, Coral Gómez
the misclassification bias which would have been                  Rico, Jorge Gallego de la Fuente y Almudena Garcı́a
unmanageable with larger numbers. Although both                   Torre. Participating centres: Hospital General Universi-
coding algorithms establish clear rules, we must take             tario de Alicante (Alicante): Joaquı́n Portilla Sogorb,
into account that different reviewers can give different          Esperanza Merino de Lucas, Sergio Reus Bañuls, Vicente
codes for a given death. Therefore, it is important to            Boix Martı́nez, Livia Giner Oncina, Carmen Gadea
establish a centralized review system in order to check and       Pastor, Irene Portilla Tamarit, Patricia Arcaina Toledo.
correct these discrepancies.                                      Hospital Universitario de Canarias (Santa Cruz de
                                                                  Tenerife): Juan Luis Gómez Sirvent, Patricia Rodrı́guez
We can conclude that the revised CoDe classification is           Fortúnez, Marı́a Remedios Alemán Valls, Marı́a del Mar
the best way to classify CoD in a cohort study of HIV-            Alonso Socas, Ana Marı́a López Lirola, Marı́a Inmaculada
positive patients. Linkage with external registries such as       Hernández Hernández, Felicitas Dı́az-Flores. Hospital
the national death index to obtain CoD in people lost to          Carlos III (Madrid): Vicente Soriano, Pablo Labarga,
follow-up or with an unknown cause may introduce bias             Pablo Barreiro, Carol Castañares, Pablo Rivas, Andrés
given that the ICD-10 overestimates HIV/AIDS-related              Ruiz, Francisco Blanco, Pilar Garcı́a, Mercedes de Diego.
deaths.                                                           Hospital Universitario Central de Asturias (Oviedo):
                                                                  Victor Asensi, Eulalia Valle, José Antonio Cartón.
                                                                  Hospital Clinic (Barcelona): José M. Miró, Marı́a
Acknowledgements                                                  López-Dieguez, Christian Manzardo, Laura Zamora,
                                                                  Iñaki Pérez, M Teresa Garcı́a, Carmen Ligero, José Luis
V.H.S. and J.d.A. conceived the study and wrote the first         Blanco, Felipe Garcı́a-Alcaide, Esteban Martı́nez, Josep
draft of the manuscript. All authors contributed to the           Mallolas, José M. Gatell. Hospital Doce de Octubre
final draft. V.H.S. and M.C.B. checked and coded data for         (Madrid): Rafael Rubio, Federico Pulido, Silvana
all patients. V.H.S. and P.S.-V. extracted the data from          Fiorante, Jara Llenas, Violeta Rodrı́guez, Mariano
CoRIS and did the analyses. F.G., J.B., G.N., I.S., J.R.,         Matarranz. Hospital Donostia (San Sebastián): José
M.A.M. and A.A. contributed to data interpretation.               Antonio Iribarren, Julio Arrizabalaga, Marı́a José
                                                                  Aramburu, Xabier Camino, Francisco Rodrı́guez-
Conflicts of interest                                             Arrondo, Miguel Ángel von Wichmann, Lidia Pascual
This study would not have been possible without the               Tomé, Miguel Ángel Goenaga, M Jesús Bustinduy,
collaboration of all the patients, medical and nursing staff      Harkaitz Azkune Galparsoro. Hospital General Univer-
and data managers who have taken part in the project.             sitario de Elche (Elche): Félix Gutiérrez, Mar Masiá,
The RIS Cohort (CoRIS) is funded by the Instituto de              José Manuel Ramos, Sergio Padilla, Andrés Navarro,
Salud Carlos III through the Red Temática de Investiga-          Fernando Montolio, Yolanda Peral, Catalina Robledano
ción Cooperativa en Sida (RIS C03/173).                          Garcı́a. Hospital Germans Trı́as i Pujol (Badalona):
                                                                  Bonaventura Clotet, Cristina Tural, Lidia Ruiz, Cristina
The ART-Cohort Collaboration (ART-CC), which                      Miranda, Roberto Muga, Jordi Tor, Arantza Sanvisens.
provided a simplified version of the CoDe protocol used           Hospital General Universitario Gregorio Marañón
in this study, is funded by the UK Medical Research               (Madrid): Juan Berenguer, Juan Carlos López Bernaldo
Council, grant number G0700820.                                   de Quirós, Pilar Miralles, Jaime Cosı́n Ochaı́ta, Matilde
                                                                  Sánchez Conde, Isabel Gutiérrez Cuellar, Margarita
This work has been partially funded by grant from FIS             Ramı́rez Schacke, Belén Padilla Ortega, Paloma Gijón
(Spanish Networks for Research on AIDS and Public                 Vidaurreta. Hospital Universitari de Tarragona Joan
Health), 04/0900 and RIS (Spanish HIV Research                    XXIII, IISPV, Universitat Rovira i Virgili (Tarragona):
Network for excellence), RD06/006. We are grateful for            Francesc Vidal, Joaquı́n Peraire, Consuelo Viladés, Sergio
funds provided by CIBERESP (Ciber de Epidemiologia y              Veloso, Montserrat Vargas, Miguel López-Dupla,
Salud Pública).                                                  Montserrat Olona, Joan-Josep Sirvent, Alba Aguilar,
                                                                  Antoni Soriano. Hospital Universitario La Fe (Valencia):
Centres and investigators involved in CoRIS: Executive            José López Aldeguer, Marino Blanes Juliá, José Lacruz
committee: Juan Berenguer, Julia del Amo, Federico                Rodrigo, Miguel Salavert, Marta Montero, Eva Calabuig,
Garcı́a, Félix Gutiérrez, Pablo Labarga, Santiago Moreno        Sandra Cuéllar. Hospital Universitário La Paz (Madrid):

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1834     AIDS    2012, Vol 26 No 14

         Juan González Garcı́a, Ignacio Bernardino de la Serna,         This work has been presented as Oral Communication
         José Marı́a Peña Sánchez de Rivera, Marta Mora Rillo,        at the 13th European AIDS Conference, 12 – 15
         José Ramón Arribas López, Marı́a Luisa Montes                October 2011, Belgrade, Serbia.
         Ramı́rez, José Francisco Pascual Pareja, Blanca Arribas,
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