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Overdose Deaths Cut 10 Years Off HIV Life Expectancy: British Columbia
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AIDS 2020: 23rd International AIDS Conference Virtual, July 6-10, 2020
Mark Mascolini
A multiyear rash of drug overdose deaths took up to 10 years off life expectancy with HIV in a British Columbia analysis [1]. The “overdose epidemic” dramatically reduced survival gains that came with triple combination antiretroviral therapy (ART) in this population.
University of British Columbia (UBC) researchers who conducted this study pointed out that substance use disproportionately affects people with HIV. And HIV infection can heighten risk of dying from an overdose, for example, because HIV worsens respiratory depression. In addition, competing needs may keep people with HIV from taking advantage of substance use treatment. Highly prevalent substance use in HIV and non-HIV populations in British Columbia drives an upswing in overdose mortality that began around 2014 and became recognized as a public health emergency in 2016.
Because of this concerning scenario, UBC researchers conducted this study with two main goals: (1) to estimate potential gains in life expectancy if overdose mortality were eliminated, and (2) to identify risk factors for overdose mortality in a real-world setting. They gathered data from the BC HIV/AIDS Drug Treatment Program clinical registry. People in the registry were eligible for this analysis if they started triple ART in the Drug Treatment Program between April 1, 1996 and December 30, 2017. Participants had to be at least 20 years old, have CD4 and viral load measured when they began ART, and have at least 1 day of follow-up. Researchers tracked participants until the last day 2017, their last contact with the Drug Treatment Program, or death.
The UBC team defined overdose mortality as fatal unintentional overdose with an illicit (nonprescription) drug or a legal (prescription) drug. They used ICD-10 codes to assign the primary cause of death. And they considered death from other causes as a competing risk event. The researchers used abridged life tables to estimate potential gains in life expectancy in a counterfactual scenario that eliminates overdose mortality. A subdistribution hazard model to identify risk factors for overdose mortality accounted for competing risks and adjusted for gender, age, year ART began, CD4 count, HIV acquisition risk factor, maintenance of HIV suppression, and epidemic phase (1996-2001, 2002-2007, 2008-2013, 2014-2017).
Among 10,362 eligible people with HIV, 82% were men, 26% injected drugs, and 39% had a CD4 count below 200. Median age stood at 40, median year when ART began was 2006, and median follow-up measured 6.93 years. During follow-up, 266 people (3%) met criteria for overdose mortality and 1989 (19%) died of other causes. The 266 overdose deaths included 162 (61%) from narcotics and hallucinogens, 85 (32%) from other and unspecified drugs, and 19 (7%) from antiepileptic, sedative-hypnotic, antiparkinsonism, and psychotropic drugs.
Overall potential gain in life expectancy without overdose mortality stood at 3.7 years for a 20-year-old starting ART between 1996 and 2017. Without overdose mortality, potential gains in life expectancy at age 20 rose from 1.5 additional years for people starting ART in 1996-2001, to 1.9 additional years when starting ART in 2002-2007, to 3.6 additional years when starting in 2008-2013, and to 9.7 additional years when starting in 2014-2017.
An adjusted multivariable subdistribution hazard model identified two variables that lowered the risk of overdose mortality and six variables that raised the risk:
Lowered overdose mortality risk
-- Every 10 years of age: aSDHR* 0.80 (95% confidence interval [CI] 0.70 to 0.92)
-- Each later year of ART initiation: aSDHR 0.93 (95% CI 0.86 to 0.99)
Raised overdose mortality risk
-- Injecting drugs as HIV risk (vs MSM): aSDHR 7.88 (95% CI 4.82 to 12.87)
-- MSM/injecting drugs as HIV risk (vs MSM): aSDHR 2.76 (95% CI 1.54 to 4.93)
-- Unknown HIV risk (vs MSM): aSDHR 2.56 (95% CI 1.47 to 4.46)
-- Below100% (vs 100%) HIV suppression maintenance: aSDHR 1.68 (95% CI 1.20 to 2.36)
-- Unmeasured (vs 100%) HIV suppression maintenance: aSDHR 4.73 (95% CI 3.54 to 6.31)
-- Epidemic phase 2014-2017 (vs 2002-2007): aSDHR 4.86 (95% CI 2.07 to 11.38)
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*aSDHR, adjusted subdistribution hazard ratio
While overdose mortality sliced an estimated 9.7 years off a 20-year-old’s life expectancy during the “overdose epidemic” (2014-2017 in this analysis), dying by overdose took 3.6 years off a 20-year-old’s life expectancy in the preceding 6 years, 2008-2013. The UBC team stressed that “overdose prevention and substance use treatment are necessary components of quality HIV care programs.”
Reference
1. St-Jean M, Dong X, Moore DM, et al. Drug overdoses are reducing the gains in life expectancy of people living with HIV (PLWH) in British Columbia, Canada. AIDS 2020: 23rd International AIDS Conference Virtual. July 6-10, 2020. Abstract OAC0302.
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