Prevalence and Correlates of Untreated HIV Type 1 Infection Among Persons Who Have Died in the Era of Modern Antiretroviral Therapy

The present study evaluated all HIV-related deaths from January 1, 1995 to December 31, 2001 in British Columbia, Canada, where HIV care and medications are free, provided by the British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program since 1992. British Columbia has a centralized death registry and keeps complete prospective records of the dispensation of antiretroviral medication. Pharmaceutical sales suggest that less than one percent of the province's residents purchase ART outside the program. Therefore, the investigators were able to precisely determine each individual's level of treatment before death.

The researchers used a logistic model to compare people who had received antiretroviral therapy before death to those who had not received HIV treatment. Overall, 1,239 deaths among those 18 years and older recorded HIV as either the cause of death or underlying cause of death. Four hundred-six occurred among those who had never received HIV treatment. Using adjusted analyses, the authors found aboriginal ethnicity, female sex, and lower median income to be negatively associated with receiving HIV treatment before death. Among the 833 people who did get treatment before death, only 379 (45.5 percent) had received antiretroviral medication = 75 percent of the time during their first year of therapy.

"Even in a setting where all health care is provided free of charge by the state, high HIV/AIDS death rates persist because of the lack of, or only marginal access to, antiretrovirals," the authors wrote. "In the present study, one-third of HIV-related deaths occurred among untreated individuals, and those who died without ever receiving HIV treatment were more likely to be aboriginal, to be female, and to reside in a neighborhood with a lower median income. Among those who accessed treatment, fewer than half received consistent treatment before death, and similar sociodemographic characteristics were associated with elevated rates of treatment discontinuation before death."

Since aboriginal people in North America "(including American Indians and Alaska natives)," may be at elevated risk of HIV, the authors stress the need for culturally sensitive interventions aimed at improving access to antiretrovirals among HIV-infected aboriginals. They also recommend interventions to improve antiretroviral access, and to reduce therapy discontinuation, for women and lower income people.

The authors point out that addiction has been shown to be a barrier to accessing adequate HIV care. They suggest strategies that may improve access to and adherence to ART among HIV-infected injection drug users: improved access to illicit drug treatment, directly observed therapy programs, access to medical services without appointment, and onsite pharmacists at medical clinics.

"Given that these data were derived in a universal health care setting in which all HIV/AIDS care and antiretrovirals are available free of charge, it is likely that similar problems exist in many other settings in the developed world. To prevent ongoing levels of HIV/AIDS mortality, novel health care interventions and the expansion of illicit drug treatment will be required to improve access to antiretrovirals and HIV/AIDS care among populations with poor access," the authors concluded.

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