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Swiss Suicide Risk Still High With HIV, But HAART Made a Difference
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5th IAS Conference on HIV Pathogenesis, Treatment and Prevention, July 19-22, 2009, Cape Town
Mark Mascolini
People enrolled in the Swiss HIV Cohort Study (SHCS) had more than a 10 times higher risk of suicide than the general population before the dawn of highly active antiretroviral therapy (HAART) in 1996 [1]. That high standardized suicide ratio (SSR) dropped steeply after HAART arrived, but Swiss people with HIV still kill themselves proportionately more often than people with cancer or multiple sclerosis. A link between injecting drug use and suicide probably partly explains the higher suicide risk with HIV than with other grave diseases.
SHCS investigators compared suicide rates and predictors in HIV-infected cohort members and the general-population Swiss National Cohort. They calculated SSRs by comparing observed numbers of suicides among HIV-infected people with expected numbers for people of the same age and gender in the general population during the same period. The HIV group was split into the pre-HAART era (1998-1995) and the HAART era (1996-2008). The Swiss National Cohort links data from the 1990 and 2000 censuses with routinely collected mortality data.
Of 15,275 SHCS cohort members analyzed, 150 committed suicide, including 92 in the pre-HAART era and 58 in the HAART era. Among SHCS members who killed themselves, the proportion of females rose from 12% pre-HAART to 24% with HAART, while proportions treated by a psychiatrist rose from 11% to 19%. Other variables analyzed did not vary greatly from pre-HAART days to the HAART era: median age 31 and 34, median CD4 count 307 and 376, proportion of injecting drug users 46% and 38%, proportion with Swiss nationality 85% and 90%.
SSRs fell sharply for both men and women when strong HAART combinations came into use:
· Men: pre-HAART SSR 13.7 (95% confidence interval [CI] 11.0 to 17.0)
· Men: HAART SSR: 3.5 (95% CI 2.5 to 4.8)
· Women: pre-HAART SSR: 11.6 (95% CI 6.4 to 20.9)
· Women: HAART SSR: 5.7 (95% CI 3.2 to 10.3)
These declines relative to the general population are all the more impressive when considering that overall suicide rates dropped in Switzerland during the study period.
Survivors of 133 suicide victims (89%) completed follow-up questionnaires. Eighty-two of these 133 (62%) had a mental illness diagnosis, usually depression, and 58 people (71% of 82) received some form of treatment for their mental health problem. Forty people (30% of 133) had a history of alcohol abuse, and 40 had attempted suicide earlier. Worsening HIV infection was blamed for 57 suicides (43%). If that explanation is correct, it would partly explain why suicide rates declined when HAART arrived.
Multivariate analysis identified female gender as a protective factor in suicide risk in pre-HAART years (adjusted odds ratio [AOR] 0.4, 95% confidence interval [CI] 0.2 to 0.7) but not after HAART arrived (AOR 0.8, 95% CI 0.4 to 1.4). Every additional 10 years of age independently raised the suicide risk 20% in pre-HAART years (AOR 1.2, 95% 0.9 to 1.5), and that trend grew to 30% and became statistically significant with HAART (AOR 1.3, 95% CI 1.0 to 1.7).
This analysis also found a trend toward a heightened suicide risk among injecting drug users in pre-HAART days (AOR 1.2, 95% CI 0.8 to 1.9), and that trend became stronger after the arrival of HAART (AOR 1.5, 95% CI 0.9 to 2.8). Psychiatric treatment independently predicted suicide before HAART (AOR 2.7, 95% CI 1.4 to 5.3) and with HAART (AOR 3.2, 95% CI 1.6 to 6.3). CDC class C infection independently predicted suicide in the earlier era (AOR 1.9, 95% CI 1.1 to 3.2) but not in the HAART era (AOR 1.6, 95% CI 0.8 to 3.2). The last correlation adds to the evidence indicating that better HIV control with HAART helped lower suicide rates.
The SHCS investigators stressed that the risk of suicide with HIV relative to the general population still runs higher than relative risks reported for other hard-to-treat diseases such as cancer and multiple sclerosis. They concluded that "patients with HIV and other life-threatening illnesses are an important target for suicide prevention."
Reference
1. Keiser O, Spoerri A, Brinkho M, et al. Trends over time and risk factors for suicide in HIV-infected individuals and the general Swiss population, 1988-2008. 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention. July 19-22, 2009. Cape Town. Abstract MOPEB026.
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