October 16, 2012
The hallmark of AIDS is an array of life-threatening infections and cancers. Fortunately, with the arrival of potent combination anti-HIV therapy (commonly called ART or HAART) in most high-income countries in 1996, deaths due to AIDS-related causes began to decline. Since that time, AIDS-related deaths have generally fallen even lower and have now stabilized. However, deaths continue to occur among HIV-positive people for several possible reasons, including the following:
Most clinical trials for testing new or reformulated HIV medicines tend to be relatively small and of relatively short duration. Moreover, such trials (usually of a randomized, controlled design) tend to enroll relatively healthy people who have minimal pre-existing conditions. As a result, deaths in such trials, particularly in the past decade, tend to be uncommon.
In many high-income countries, large numbers of HIV-positive people have been enrolled in studies of a different design -- observational, or cohort, studies. Such studies, with their large and diverse populations and prolonged duration of monitoring, can provide a better overall picture of the health of HIV-positive people.
The Swiss HIV Cohort Study (SHCS) has been keeping track of the cause of deaths of participants since 1988. In 1999 and again in 2005 Swiss researchers further refined its data collection and analysis, expanding its ability to classify possible causes of death.
In recently reviewing their data, Swiss researchers confirmed a pattern in the cause of death that is being seen across high-income countries. In the time before HAART, deaths were usually due to complications arising from AIDS-related infections and cancers. In the present era (2005 to 2010) AIDS-related deaths have greatly decreased, accounting for 16% of deaths. In contrast, causes unrelated to AIDS now account for 84% of deaths in HIV-positive people These causes of death were as follows:
These findings underscore the need to focus future care initiatives on helping HIV-positive people maintain and improve their overall health and quality of life. Such initiatives could include the following:
In addition to monitoring participants via the Swiss HIV Cohort Study, the researchers used software developed by Statistics Canada to link the SHCS database with that of the Swiss National Cohort to capture any data that might have been initially missing concerning cause of death.
Starting in 1988, the SHCS amassed a huge trove of data collected from 16,134 HIV-positive people. Between 1988 and 2010, 5,023 of these people died.
Focusing on the period from 2005 to 2010, a total of 459 HIV-positive members of the SHCS died. The average profile of these people at their time of death was as follows:
Major causes of death were as follows:
Generally, men and women died from similar causes. One major exception was suicide: The overall rate in the modern era was 6%, but when broken down by gender, suicide was responsible for 8% of deaths in men and 3% in women.
It is noteworthy that in the pre-ART era the overall suicide rate was about 3% but rose up to 6% in the modern era. This doubling of the suicide rate underscores the need for more vigilance in screening and treating depression.
Although the majority of deaths occurred in people with 499 or less CD4+ cells, 20% of deaths occurred in people who had 500 or more CD4+ cells.
Common causes of death among people co-infected with hepatitis-causing viruses included the following:
Taking many factors into account, the following were linked to an increased risk of death among the 459 people who died:
The results of the Swiss study are important because they document the shifting causes of death among people with HIV over the past 20 years. Such shifts are being seen to varying degrees across high-income countries -- such as Canada, Denmark, France and the U.S. -- and the Swiss study may be a harbinger of the future for some HIV-positive people if additional steps are not taken.
ART has tremendously improved the chances of survival among HIV-positive people, with some studies predicting near-normal life expectancies. However, if the survival benefit of ART is to be extended, then causes of death mentioned in the Swiss study need to be addressed. Medical and psychosocial interventions are necessary to improve the health of HIV-positive people, particularly those co-infected with HBV and HCV infections, some of whom are also struggling with addiction and mental and emotional health issues. Metabolic complications such as pre-diabetes and type 2 diabetes and cardiovascular disease risks also need to be addressed.