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Changing Causes of Illness and Death among HIV Positive Individuals in the HAART Era

By Liz Highleyman

As reported in the October 1, 2007 issue of AIDS, researchers conducted a study to assess trends in “perimortal” conditions -- defined as pathological conditions contributing to death or present at death, but not necessarily the reported cause of death -- during 3 periods:

·         Pre-HAART (1992-1995);

·         Early HAART (1996-1999);

·         Contemporary HAART (2000-2003).

They looked at annual mortality rates and use of antiretroviral therapy among more than 36,000 participants in the Adult/Adolescent Spectrum of HIV Disease (ASD) cohort. Looking at patients who died between 1992 and 2003, the investigators determined proportionate mortality for selected perimortal conditions, annual mortality rates, and prevalence of antiretroviral therapy use, standardized by sex, race/ethnicity, age at death, HIV transmission category, and lowest-ever (nadir) CD4 cell count. Multivariate generalized linear regression was used to estimate trends over time.

Results

·         Of 13,895 total deaths during the study period, 9225 with recorded perimortal causes were analyzed:

o        58.6% occurred during 1992-1995;

o        29.5% occurred during 1996-1999;

o        11.9% occurred during 2000-2003.

·         Mortality rates decreased from 487.5 to 100.6 per 1000 person-years between 1995 and 2002.

·         The rate of decline in mortality slowed in recent years (i.e., the death rate continued to fall, but did not fall as fast).

·         Over the study period, individuals who died were less likely to be gay white men, more likely to be women or black, more likely to be age 55 or older, and more often never had a pre-treatment CD4 count below 100 cells/mm³.

·         The proportion of deaths due to AIDS-defining infectious diseases (e.g., Pneumocystis pneumonia, non-tuberculosis mycobacterial infections, cytomegalovirus) decreased significantly during the study period.

·         In parallel, the proportion of deaths due to non-infectious diseases -- such as liver disease, high blood pressure, and excessive alcohol use -- increased significantly.

·         About 75% of cohort participants were prescribed antiretroviral therapy annually (increasing from about 60% to about 80% between 1995 and 1997).

Conclusion

Based on these findings, the authors concluded, “Among HIV-infected patients, the majority of whom were prescribed antiretroviral therapy, the increasing trend in common non-infectious perimortal conditions support screening and treatment for these conditions in order to sustain the trend in declining mortality rates.”

In a related study published in the October 2007 American Journal of Public Health, researchers assessed differences in mortality between black and white people with HIV/AIDS before and after the introduction of HAART.

They found that national black-white disparities in rates of death widened significantly after the introduction of HAART, especially among women and elderly individuals. However, neither socioeconomic status nor race/ethnicity were significant predictors after controlling for pre-HAART mortality. Socioeconomic status, race, and pre-HAART mortality were all significant independent predictors of mortality among black men. Based on these findings, the researchers concluded that racial disparities “were not inevitable” and tended to reflect pre-HAART levels.

Epidemic Intelligence Service, Office of Workforce and Career Development; Division of HIV/AIDS Prevention; Global AIDS Program, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA; Public Health, Seattle and King County, Seattle, WA.