Medical Discussions

by Raj Khandwalla

Background

• With the introduction of HAART therapy and prophylaxis  against common opportunistic disease, the morbidity and mortality associated with HIV/AIDS has decreased dramatically
  • Between 1996 and 1998, HIV-related morbidity and mortality  decreased by 60 percent in the United States
• Over time, the portion of deaths among patients with HIV from non-HIV causes has increased
• This is a population based analysis of the causes of death among HIV positive patients from 1999 through 2004
  •  the study is made up of two registries – the New York City HIV/AIDS Reporting System and Vital Statistics Registry

Methods

• Inclusion criteria: age of 13 years old or older who recieved a diagnosis of AIDS and were alive between 1999 and 2004. 
  • Patients had to be reported to the New York City HIV/AIDS Reporting System as of Sept 30, 2005
  • Patients had to be residents of New York City at the time of diagnosis
  • Among those who died, patients needed a known underlying cause of death
• The registry – The New York City HIV/AIDS Reporting System is a population based registry who recieved a diagnosis of AIDS as defined by the CBC
  • The reporting system recieves reports of possible AIDS diagnosis through an electronic  laboratory reporting system or through physician report and chart review 
• Defining AIDS
  • CD4 < 0.200 x 10^9 cells/L or less than 14 percent of total lymphocytes or
  • 1 of more 26 opportunistic illnesses
• Patients were classified by zip code and by ethnicity including Hispanic, non Hispanic people of European origin, non Hispanic African American, or other
• HIV transmission categories
  • Injection drug use
  • Men who have sex with men
  • High-risk heterosexual sex
  • Sex with an HIV positive partner, IV drug user, or with a bisexual man
• Outcome – underlying cause of death.  Persons with an unknown cause of death (1.8% of the total) were excluded from the anaylsis.

Baseline Demographics

• Median age 46 yo
• Gender, Male – 69.9 %
• Ethnicity
  • African American 46.9 %
  • Hispanic 33.4 %
  • Non Hispanic people of European origin 18.2%
  • Other 1.5%
• HIV transmission category
  • Men who have sex with men 23.6 %
  • IV drug users 33.2 %
  • High-risk heterosexual 14.4 %
  • Other transmission risk 1.7 %
  • Unknown 27.2 %
  • Among men with a known transmission category, 44.8% had sex with other men and 44.5% used injection drugs.
  • Among women with a known transmission category, 48.3% used injection drugs and 47.4% had high risk heterosexual sex.
• Socioeconomic status by zip code
  • Poverty 60.3 %
  • Nonpoverty 35.7%
  • Unknown 4 %
• Time of AIDS diagnosis
  • Before 1996 32.4%
  • 1996-1998 24.6%
  • 1999-2004 43%

Results

• Deaths
  •  74.2 percent of patients with known AIDS and known causes of death in NYC between 1999 and 2004, died of HIV related causes
  • 24 percent of patients with known AIDS died of non-HIV related causes
    • 7.4 percent died of substance abuse related deaths
    • 5.7 percent died of cardiovascular disease
    • 5 percent died of cancer
    • Accidents, chronic lower respiratory airway disease, cancer, diabetes, suicide, kidney disease each made up less 0.8 percent of deaths
• Trends in Deaths
  • Both the rate of HIV related deaths and the rate of non HIV related death decreased each year of the study
    • 54.9 percent decrease in HIV related deaths from 1999 to 2004
    • 34.3 percent decrease in non HIV related deaths from 1999 to 2004
  • Mortality rate for HIV related causes of death increased with age
  • Rates of HIV related deaths were higher for
    • women compared to men
    • African American men followed by Hispanic, and non Hispanic people of European heritage or other in both the HIV related and non HIV related groups.
  • Mortality rates were lowest for men who have sex with men and highest for injection drug users for both HIV related and non HIV related causes of death
  • The strongest predictor of death was a CD4 count <50 x 10^6
  • IV drug use was the strongest nonclinical predictor of death for both HIV related or non HIV related causes of death

 Discussion

• Between 1999 and 2004 in New York City, the rate of HIV related and non HIV related deaths has declined in people with AIDS
• HIV related deaths continue to account for the vast majority (74%) of deaths, but the proportion of non HIV related causes of death increased by 33% during this five year time period.
• The paper recommends that physicians taking care of HIV/AIDS patients should treat patients with “standard practices appropriate  for their age and sex” in addition to their HIV status.

THE BOTTOM LINE: People with AIDS are living longer.  While HIV related causes of deaths, still make up a majority mortalities in this population, non HIV related causes of death are quickly increasing among AIDS patients.  The advent of HAART is clearly helping people live longer.  As such, physicians should treat their patients for common causes of death among the general population.