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Most AIDS Deaths Involve Women, Blacks, and Younger People in UK Cohort
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15th European AIDS Conference, October 21-24, 2015, Barcelona
Mark Mascolini
Women, black Africans, and younger adults accounted for the bulk of AIDS deaths in a 2000-2012 analysis of the UK CHIC cohort [1]. Two thirds of people who died of AIDS got diagnosed at a CD4 count below 200. But AIDS mortality dwindled across the study period.
Although non-AIDS deaths from cancer, cardiovascular disease, and liver disease account for a growing proportion of deaths in HIV populations, noted the UK CHIC team that conducted this study, AIDS remains a major killer of people with HIV. They analyzed data from their cohort to describe characteristics of cohort members who died of AIDS during a period of potent antiretroviral therapy, 2000 through 2012.
The researchers linked routinely collected UK CHIC data to mortality records then assigned a 3-clinician committee to determine a single primary cause of death. Researchers classified causes of death as AIDS infection, AIDS malignancy, multiple or unknown AIDS illnesses, or non-AIDS causes.
From 2000 through 2012, the researchers counted 3116 deaths representing 6.6% of the UK CHIC cohort. Age averaged 44 years at death, 78% who died were men, 61% white, 26% black, 45% men who have sex with men (MSM), and 32% people infected with HIV during heterosexual sex. The researchers assigned primary causes of death in 2281 cases, listing AIDS as the primary cause in 753 cases (33%).
AIDS explained about 40% of deaths in 2000-2003, about 35% in 2004-2007, and about 30% in 2008-2012, a significant decline (P < 0.001). Among all UK CHIC women, about 40% died of AIDS, compared with about 30% of men (P < 0.001). AIDS explained about 40% of deaths in people younger than 41, compared with slightly more than 30% in 41-to-50-year olds and even lower proportions in people over 50 (P < 0.001). AIDS caused about half of deaths among black Africans, compared with about 30% in other blacks and about 25% in whites (P < 0.001). AIDS accounted for slightly more than 40% of deaths among people infected heterosexually compared with about 25% among MSM.
Among people died of AIDS, median CD4 count at HIV diagnosis did not change across the study period, standing at 124 in 2000-2003, at 108 in 2004-2007, and at 129 in 2008-2012. About two thirds of people who died came to care with a CD4 count at or below 200 or an AIDS illness within 1 month of HIV diagnosis--65% in 2000-2003, 73% in 2004-2007, and 67% in 2008-2012. People who died of AIDS generally survived 4 years or more after HIV diagnosis, with medians of 4.7 years in 2000-2003, 3.9 years in 2004-2007, and 6.1 years in 2008-2012. Fewer than one third of UK CHIC members who died had been diagnosed with HIV within 1 year of death in any of the 3 study period.
Highest median CD4 count among people who died of AIDS rose from 188 in 2000-2003, to 237 in 2004-2007, and to 345 in 2008-2012. Proportions of people who started combination antiretroviral therapy (cART) before they died were 71.7% in 2000-2003, 70.2% in 2004-2007, and 77% in 2008-2012. Median cART duration at death over those 3 periods was 3.4 years, 2.0 years, and 3.5 years.
Proportion of cART time with a viral load below 200 copies jumped from 5.2% in 2000-2003, to 18.1% in 2004-2007, and to 29.8% in 2008-2012. It is notable, though, that people who died of AIDS spent more than two thirds of their time on cART with a viral load above 200 copies throughout the study period. Only about one third of people who died of AIDS had a viral load below 50 copies at death across the 3 study periods. Median CD4 count at death rose across the 3 study periods but always remained low, at 52, 68, and 79 cells.
Summing up, the UK CHIC researchers stressed that people who died of AIDS usually entered care with a CD4 count below 200, and although most started cART, they did so at low CD4 counts, did not makes substantial CD4 gains, and usually did not reach an undetectable viral load.
The investigators believe their findings "reinforce the importance of timely HIV diagnosis, prompt initiation of cART and good adherence in preventing deaths from AIDS-defining illness in the cART era." They urged colleagues to "redouble their efforts to target the subgroups at particular ongoing risk of death from AIDS-defining illness, in order to engage and keep them in healthcare and on long-term virologically suppressive cART."
Reference
1. Jose S, Pett S, Arenas-Pinto A, et al. Ongoing contribution of AIDS deaths in the HAART era. 15th European AIDS Conference, October 21-24, 2015, Barcelona. Abstract PE12/7.
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