Addressing Disparities in HIV Mortality

Since the introduction of ART in 1996, mortality rates among people with HIV have significantly declined. A new study goes into the trends of cause-specific mortality in those who began ART in Europe and North America, uncovering disparities in the reductions of deaths, particularly from AIDS, across different subgroups. Decreases in the primary causes of death, especially AIDS-related fatalities among people with HIV on ART, were not uniform across all subgroups. Interventions aimed at high-risk populations, managing substance abuse, and treating coexisting health conditions could elevate the life expectancy of people with HIV to levels closer to those of the general population.

The research took data from 189,301 HIV-positive individuals, and 16,832 deaths (8.9%) across 1,519,200 persons to years of observation. AIDS was the leading cause, accounting for 4203 deaths (25.0%), with non-AIDS cancers excluding hepatitis and cardiovascular diseases following. A sharp decline in AIDS-related death proportions from 49% in 1996-1999 to 16% in 2016-2020 was observed, alongside a significant drop in the overall mortality rate from 16.8 per 1000 person-years in the late 1990s to 7.9 in recent years.

“The main strengths of this study are the large sample size, geographical diversity, representativeness of the included people with HIV, and the availability of data on cause-specific mortality, classified according to a common protocol,” investigators wrote. “However, causes of death were classified retrospectively and without complete patient histories, so misclassification is more likely than if the causes had been classified based on full medical history. Autopsy, which is becoming less common over time remains the gold standard for classifying causes of death, and clinical classifications might not correlate well with those from autopsy reports.”

Significant declines were also noted in mortality rates from cardiovascular issues, liver problems, non-AIDS infections, non-AIDS cancers excluding hepatocellular carcinoma, and deaths from suicide or accidents. However, an increase in mortality rates was observed among women who acquired HIV through injecting drug use, with a slight decrease noted among men in this group.

“For some people with HIV, there was information on a number of comorbidities or potential causes of death, which could lead to the death being classified as of unknown cause or unclassifiable,” according to investigators. “In particular, HIV was previously more likely to be mentioned as a cause on a death certificate because the person who died had HIV, even if it was irrelevant to the death. The Coding Causes of Death (CoDe) processes and rules were set up to minimize the impact of this, by accounting for recent CD4 counts and AIDS diagnoses rather than relying solely on death certificate information.”

The study advocates for public health strategies that not only continue to improve ART outcomes but also address the broader social and health-related challenges faced by people living with HIV. Creating interventions to the specific needs of high-risk groups and addressing substance use and comorbidity management could enhance life expectancy between individuals with HIV and the general population, moving towards an era where HIV diagnosis does not dictate a significantly shortened lifespan.

Reference

Trickey A, McGinnis K, Gill M, Abgrall S, Berenguer J, et. al. Longitudinal trends in causes of death among adults with hiv on antiretroviral therapy in Europe and north America from 1996 to 2020: a collaboration of cohort studies. The Lancet. Published January 24, 2024. Accessed February 7, 2024. DOI: https://doi.org/10.1016/S2352-3018(23)00272-2