Causes of Death among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City

19 September 2006 | Volume 145 Issue 6 | Pages 397-406

Background: Monitoring the full spectrum of causes of death among persons with AIDS is increasingly important as survival improves because of highly active antiretroviral therapy.

Objective: To describe recent trends in deaths due to HIV-related and non–HIV-related causes among persons with AIDS, identify factors associated with these deaths, and identify leading causes of non–HIV-related deaths.

Design: Population-based cohort analysis.

Setting: New York City.

Patients: All adults (age 13 years) living with AIDS between 1999 and 2004 who were reported to the New York City HIV/AIDS Reporting System and Vital Statistics Registry through 2004 (n = 68 669).

Measurements: Underlying cause of death on the death certificate.

Results: Between 1999 and 2004, the percentage of deaths due to non–HIV-related causes increased by 32.8% (from 19.8% to 26.3%; P = 0.015). The age-adjusted mortality rate decreased by 49.6 deaths per 10 000 persons with AIDS (P < 0.001) annually for HIV-related causes but only by 7.5 deaths per 10 000 persons with AIDS (P = 0.004) annually for non–HIV-related causes. Of deaths due to non–HIV-related causes, 76% could be attributed to substance abuse, cardiovascular disease, or a non–AIDS-defining type of cancer. Compared with men who have sex with men, injection drug users had a statistically significantly increased risk for death due to HIV-related causes (hazard ratio, 1.59 [95% CI, 1.49 to 1.70]) and non–HIV-related causes (hazard ratio, 2.54 [CI, 2.24 to 2.87]).

Limitations: Compared with autopsy and chart review, death certificates may lack specificity in the underlying cause of death or detailed clinical and treatment-related information.

Conclusions: Non–HIV-related causes of death account for one fourth of all deaths of persons with AIDS. Cardiovascular disease, non–AIDS-defining cancer, and substance abuse account for most non–HIV-related deaths. Reducing deaths from these causes requires a shift in the health care model for persons with AIDS from a primary focus on managing HIV infection to providing care that addresses all aspects of physical and mental health.

Editors' Notes Context As HIV treatment becomes more effective, AIDS-related deaths are decreasing and HIV-infected patients are dying of other causes. Better information about these other causes will help to determine appropriate health care for this population. Contribution The authors used death certificates to identify the causes of death in 68 669 residents of New York City reported with AIDS. The percentage of deaths from non–HIV-related causes increased from 19.8% to 26.3% between 1999 and 2004. The principal causes of non–HIV-related deaths were cardiovascular disease, substance abuse, and non–AIDS-defining cancer. Cautions Death certificates are an imperfect way to identify cause of death. Implications Health care for HIV-infected patients must include prevention and management of common diseases as well as HIV-focused care. —The Editors

 

Author and Article Information

From the New York City Department of Health and Mental Hygiene, New York, New York.

Acknowledgments: The authors thank Richard Selik, MD, Centers for Disease Control and Prevention HIV Incidence and Case Surveillance Branch, for careful review of the manuscript; the field surveillance and data support staff, especially Sonny Ly and Walter Smith, New York City DOHMH HIV Epidemiology Program, for assistance with case reviews and data management; and the New York City DOHMH Office of Vital Statistics for sharing data and expertise.

Grant Support: Through a cooperative agreement between the New York City DOHMH HIV Epidemiology Program and the Centers for Disease Control and Prevention (U62/CCU223595).

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Judith E. Sackoff, PhD, HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013; e-mail, jsackoff{at}health.nyc.gov.

Current Author Addresses: Drs. Sackoff and Torian, Mr. Hanna, and Ms. Pfeiffer: HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013.

Author Contributions: Conception and design: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.

Analysis and interpretation of the data: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.

Drafting of the article: J.E. Sackoff, D.B. Hanna.

Critical revision of the article for important intellectual content: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.

Final approval of the article: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.

Statistical expertise: D.B. Hanna.

Obtaining of funding: J.E. Sackoff.

Administrative, technical, or logistic support: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer.

Collection and assembly of data: D.B. Hanna, M.R. Pfeiffer.

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Letter to Editor

Adrian M. Di Bisceglie, et al.

Annals Online, 20 Dec 2006 [Full text]