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PLoS One. 2014 Mar 25;9(3):e92606. doi: 10.1371/journal.pone.0092606. eCollection 2014.

The VACS index accurately predicts mortality and treatment response among multi-drug resistant HIV infected patients participating in the options in management with antiretrovirals (OPTIMA) study.

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James J. Peters VA Medical Center, Bronx, New York, United States of America; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America.
Section of General Internal Medicine, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America; Yale University Schools of Medicine and Public Health, New Haven, Connecticut, United States of America.
VA Cooperative Studies Program Coordinating Center, VA Connecticut Healthcare System, West Haven, Connecticut, United States of America.
VA Palo Alto Healthcare System, Palo Alto, California, United States of America; Department of Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America.
Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom.
University of Ottawa at the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.



The VACS Index is highly predictive of all-cause mortality among HIV infected individuals within the first few years of combination antiretroviral therapy (cART). However, its accuracy among highly treatment experienced individuals and its responsiveness to treatment interventions have yet to be evaluated. We compared the accuracy and responsiveness of the VACS Index with a Restricted Index of age and traditional HIV biomarkers among patients enrolled in the OPTIMA study.


Using data from 324/339 (96%) patients in OPTIMA, we evaluated associations between indices and mortality using Kaplan-Meier estimates, proportional hazards models, Harrel's C-statistic and net reclassification improvement (NRI). We also determined the association between study interventions and risk scores over time, and change in score and mortality.


Both the Restricted Index (c = 0.70) and VACS Index (c = 0.74) predicted mortality from baseline, but discrimination was improved with the VACS Index (NRI = 23%). Change in score from baseline to 48 weeks was more strongly associated with survival for the VACS Index than the Restricted Index with respective hazard ratios of 0.26 (95% CI 0.14-0.49) and 0.39(95% CI 0.22-0.70) among the 25% most improved scores, and 2.08 (95% CI 1.27-3.38) and 1.51 (95%CI 0.90-2.53) for the 25% least improved scores.


The VACS Index predicts all-cause mortality more accurately among multi-drug resistant, treatment experienced individuals and is more responsive to changes in risk associated with treatment intervention than an index restricted to age and HIV biomarkers. The VACS Index holds promise as an intermediate outcome for intervention research.

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