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Rates and risk factors for suicidal ideation, suicide attempts and suicide deaths in persons with HIV: a systematic review and meta-analysis
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Pooled incidence and prevalence of suicide attempts in PLWHA
The overall pooled incidence of suicide attempts per 1000 population was 20.4 (95%CI: 2.4 to 154.9) (figure 3). The incidence in North America was 50 times as high compared with that in Europe. Likewise, in PLWHA, the lifetime prevalence of suicide attempts was 158.3 per 1000 persons (95%CI: 106.9 to 228.2). The prevalence was higher in the Americas and Australia than in Africa and Asia (figure 4). Displayed in online supplemental figure 2 are the country-specific prevalence of suicide attempts. Egger’s test for publication bias was significant (p<0.001) and funnel plots displayed asymmetry (online supplemental figure 3).
Pooled incidence of suicide deaths in PLWHA
The pooled incidence of suicide completion was 10.2 per 1000 population (95%CI: 4.5 to 23.1) (figure 2). Between-study heterogeneity for the cumulative incidence was large (I2=99%; p<0.01). Only North American and European studies reported suicide completion. We carried out subgroup analysis by continent to explore regional differences in suicide completion. The pooled incidence of suicide in studies conducted in North America was twice as high as that in Europe, although the difference was not statistically significant. Egger’s test for publication bias was significant (p<0.001) and funnel plots displayed asymmetry (online supplemental figure 1).
Pooled prevalence of suicidal ideation in PLWHA
The overall pooled lifetime prevalence of suicidal ideation per 1000 population was 228.3 (95%CI: 150.8 to 330.1) (figure 5). Africa and Europe displayed lower prevalence in suicidal ideation compared with that in North America, South America and Asia. However, these differences were not statistically significant.
Main findings

About 40 million people of the global population are currently living with HIV/AIDS.3 32 The era of HAART treatment has brought significant improvements in patient longevity and quality of life; however, PLWHA experience a heavy burden of psychosocial conditions that are frequently undiagnosed and untreated. In our study, the pooled incidence of suicide completion among PLWHA globally was 10.2 per 1000 (95%CI: 4.5 to 23.1), translating to a 100-fold greater suicide completion rate compared with the global population rate of 0.11/1000.33 While the suicide completion rate was twice as high in North America (20.4/1000, 95%CI: 2.43 to 150.16), compared with that in Europe (8.4/1000, 95%CI: 3.69 to 19), this difference was not significant. Importantly, the most striking difference found was between the prevalence of suicide attempts across the geographic regions. While we found a pooled global prevalence of suicide attempts at 158.3/1000 in PLWHA, the pooled prevalence of suicide attempt in this cohort was highest in North America, South America and Australia at 212.6/1000 (95%CI: 123.5 to 314.2), 232.2/1000 (95%CI: 180.2 to 294.0) and 213.4/1000 (95%CI: 157.4 to 282.7), respectively. This is in striking comparison to a global lifetime suicide attempt prevalence of 3% in the general population.34
Additionally, the overall pooled prevalence of suicidal ideation in PLWHA was 228.3/1000 (95%CI: 150.8 to 330.1). This is markedly increased compared with the global suicidal ideation rate of 9% in the general population.34Collectively, these data suggest that PLWHA are at high risk for attempting suicide. Such observation requires appropriate interventions in those at the highest risk.


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