Non-AIDS-related deaths becoming more common in Rio de Janeiro HIV patients

Non-AIDS-related causes of death are an increasingly important cause of mortality amongst HIV-positive patients in Rio de Janeiro, investigators report in the August 15^th edition of the Journal of Acquired Immune Deficiency Syndromes. Mortality rates remained stable throughout the study, but the investigators found that the proportion of deaths attributable to immune deficiency declined, whereas those due to non-AIDS-related causes increased.

“Our findings have major programmatic implications for developing countries”, comment the investigators, “as access to HAART [highly active antiretroviral therapy] improves and HIV becomes a chronic condition, integration with other public health programs such as smoking cessation and control of hypertension will become critically important for the long-term success of HIV/AIDS programs in developing countries.”

Following the introduction of effective antiretroviral therapy in 1996 there was a marked reduction in mortality amongst patients with HIV. The life-expectancy of many patients taking HIV treatment is now considered normal.

However, investigators in industrialised countries such as the UK and US have noted that the number of HIV-related deaths has stabilised in recent years and that diseases that are not normally considered to be HIV-related are causing an increasingly large proportion of deaths.

Investigators from Brazil therefore examined changes in the causes of death between 1999 and 2006 amongst a cohort of HIV-positive patients in Rio de Janeiro. The study was retrospective and included 1538 patients. Causes of death were analysed in two-year time blocks and attributed to AIDS-related or non-AIDS-related causes. The non-AIDS-related deaths were further categorised according to the condition that caused them.

There were a total of 226 deaths (15%), providing a mortality rate of 3.2 per 100 person years. Individuals were followed for a median of 4.61 years. Follow-up was longer for patients dying of non-AIDS-defining causes than AIDS-defining conditions (3.39 years vs 1.45 years, p < 0.001). However, the overall mortality rate from AIDS-related (1.58 per 100 person years) and non-AIDS-related causes (1.39 per 100 person years) was similar.

Patients who were alive had higher CD4 cell counts than those who died, regardless of whether the cause of death was AIDS-related or non-AIDS related (p < 0.001) for both comparisons.

AIDS-defining opportunistic infections were the leading cause of death (38%). Of the non-AIDS-defining causes of death, infectious diseases were the most common cause (8%), followed by accident or violence (5%) and cardiovascular disease (4%).

Overall mortality rates were stable throughout the period of the study. However, AIDS-related deaths fell from 1.85 per 100 person years in 1999/2000 to 1.24 per 100 person years in 2005/06, a statistically significant fall (p < 0.001). By contrast, the death attributable to non-AIDS-related causes increased from 1.02 per 100 person years to 1.59 per 100 person years. This increase was not, however, significant. Deaths from cardiovascular disease also increased during the period of study (from 0 to 0.20 per 100 person years), an increase that was of borderline significance.

“Our results show that overall mortality rates in a large cohort of HIV-infected patients in Rio de Janeiro, Brazil, remained fairly stable between 1999 and 2006”, comment the investigators.

However, the investigators add, “when AIDS and non-AIDS-related causes of death were examined separately, a decrease in AIDS-related causes of death and an increase in non-AIDS-related causes of death were observed.

They note that the shifting patterns of mortality revealed by their study, especially the increasing importance of non-AIDS-related causes of death, accords with what has been seen in the industrialised world.