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Death Rate Has Not Dropped in Certain Disadvantaged HIV+ US Groups
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XVIII International AIDS Conference, July 18-23, 2010, Vienna
Mark Mascolini
Stronger and safer antiretroviral combinations available in recent years and free access to treatment have not reduced all-cause mortality in five disadvantaged groups studied in the HIV clinic of San Francisco General Hospital [1]. AIDS, non-AIDS cancers, substance abuse, and violence accounted for most deaths in these populations.
This study involved 1651 people with a lowest-ever (nadir) CD4 count below 350 who had two or more primary care visits at the HIV clinic between January 1998 and August 2009. Everyone was eligible for antiretroviral therapy, which is free in the clinic, and everyone fell into one of five disadvantaged groups: (1) injection drug users (IDUs), (2) people with alcohol dependence, (3) people with a mental health diagnosis, (4) nonwhites, and (5) women or transgendered people.
One quarter of the study group became infected by injecting drugs, one quarter through heterosexual sex, and the rest through gay sex. The study group averaged 49 years in age, 87% were men, 47% were white, 40% had a mental health diagnosis, and 29% had hepatitis C virus infection.
All-cause mortality (confirmed in Social Security records) stood at 10% from 2000 to 2004 (2.6% per person-year) and inched up to 11% from 2005 to 2009 (2.7% per person-year). In contrast, all-cause mortality in the European/North American ART Cohort Collaboration stands around 5% for this study period. Of the 172 deaths recorded, AIDS caused 71 (41%), non-AIDS causes 42 (24%), and undetermined causes 59 (34%). The leading non-AIDS causes of death were suicide, overdose, or trauma in 18, followed by lung cancer in 7, liver disease including hepatocellular carcinoma in 6, other non-AIDS cancers in 5, and cardiovascular disease in 3.
All five disadvantaged groups had higher mortality in 2005-2005 than in 2000-2004. In an analysis adjusted for age, initial CD4 count, initial viral load, HCV coinfection, and earlier antiretroviral use, the hazard ratio (HR) for higher death risk in the later period approached statistical significance for alcohol abusers (HR 6.62, 95% confidence interval [CI] 0.83 to 52.9, P = 0.07) and reached statistical significance for IDUs (HR 4.15, 95% CI 1.41 to 12.2, P = 0.009).
Among the 64 IDUs who died, AIDS accounted for 25 deaths (41%), non-AIDS causes for 17 (28%), and unknown causes for 19 (31%). About half of those with an unknown cause of death had a CD4 count above 200 at death. Among all 172 people who died, 99 (58%) never had a recorded undetectable viral load, a result suggesting these people never received adequate treatment (or any treatment) or that they adhered poorly to their regimen. In contrast, only 31% of 1479 survivors never had a recorded undetectable viral load.
Presenting the results for the San Francisco group, David Dowdy concluded that lack of adherence and/or failure to keep clinic visits explained much of the mortality. The researchers did not have adherence data on this group. A San Francisco study published in 2004 found that one third of HIV-infected homeless people discontinued antiretroviral therapy during 12 months of follow-up [2]. But among those who continued treatment, adherence was as good as in other clinical populations.
References
1. Dowdy D, Geng E, Christopoulos E, et al. Mortality trends among socially-disadvantaged ART-eligible patients. XVIII International AIDS Conference. July 18-23, 2010. Vienna. Abstract TUAC0105.
2. Moss AR, Hahn JA, Perry S, Charlebois ED, Guzman D, Clark RA, Bangsberg DR. Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study. Clin Infect Dis. 2004;39:1190-1198.
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