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Mortality Plateaued in 2001 in Large Baltimore Drug Injector Cohort / Mortality Steeply Increased due to Comorbidities
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25th Conference on Retroviruses and Opportunistic Infections (CROI), March 4-7, 2018, Boston
from Jules: look at overall mortality graph and you see mortality IS NOT improved in this group since 1990. Mortality increased until 2000 and has remained the same since WHY? Because AIDS death has declined but deaths due to comorbidities has skyrocketed.
"The ALIVE team stressed that "rising rates of chronic disease mortality demonstrate the critical importance of chronic disease management in the aging population."
Mark Mascolini
A 1988-2015 analysis of almost 4800 people who inject drugs (PWID) in Baltimore determined that all-cause mortality plateaued after 2001, down from a high of about 30 per 1000 person-years [1]. AIDS mortality began falling sharply after the arrival of combination antiretroviral therapy (ART), coincident with a steep rise in mortality due to chronic diseases.
Baltimore has one of the largest and longest ongoing studies of PWID with or without HIV. Follow-up in the ALIVE cohort began in 1988 and continues with twice-yearly exams, lab tests, and questionnaires. ALIVE investigators conducted this study to track changes in mortality through the arrival of ART, changes in drug use, and aging of the study population.
To determine mortality, the research team matched all ALIVE participants with National Death Index records. Three independent physician reviews assigned one of three causes of death: AIDS/infectious disease, chronic disease, and overdose/drugs/violence.
The analysis included 4794 people, 1238 (26%) with HIV. Through 75,327 person-years of follow-up, 2070 cohort members died. The investigators attributed 35% of all deaths to AIDS/infectious disease, 39% to chronic disease, and 26% to overdose/drugs/violence. Among PWID with HIV, they attributed 59% of deaths to AIDS/infectious disease, 22% to chronic disease, and 19% to overdose/drugs/violence.
Median age of the cohort rose from about 35 years in 1988 to 55 in 2015. Over the same span, all-cause mortality peaked at about 30 per 1000 person-years around 1998 (shortly after combination ART arrived), drifted down to about 28 per 1000 person-years around 2001, and stayed around that level through 2015.
AIDS/infectious disease peaked as the cause of death around 1998 at about 12 per 1000 person-years then dropped sharply to about 5 per 1000 person-years in 2015. In contrast, chronic disease explained a consistently rising proportion of deaths from 1998 to 2015 (about 3 to 17 per 1000 person-years). Deaths due to overdose/drug/violence peaked in the late 1990s between 8 and 9 per 1000 person-years, dropped sharply to below 6 per 1000 person-years until 2010, when mortality from this cause began an apparent rebound.
The most frequent chronic disease causes of death in ALIVE were cardiovascular disease (241 deaths, 11.6%), malignancy (206 deaths, 10%), liver disease (123 deaths, 5.9%), and cerebrovascular disease (51 deaths, 2.5%). In the overdose/drugs/violence category, overdose or poisoning explained 67% of deaths.
The ALIVE team stressed that "rising rates of chronic disease mortality demonstrate the critical importance of chronic disease management in the aging population." They suggested that the recent uptick in drug-related deaths reflects growing noninjection and prescription opioid use.
Reference
1. Sun J, Longchamps R, Piggott DA, et al. Shifting mortality trends among persons with HIV and injection drug use over 30 years. 25th Conference on Retroviruses and Opportunistic Infections (CROI). March 4-7, 2018. Boston. Abstract 891.
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