Mortality amongst HIV-positive women in US has plateaued: treatable illness contributing to many deaths

The mortality rate in HIV-positive women in the US is ten times that seen in the general US population, investigators report in a study published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The researchers from the Women’s Interagency Health Study (WIHS) found that mortality rates fell dramatically after the introduction of potent antiretroviral therapy in the mid 1990s, but then plateaued between 2001 and 2004. Factors associated with an increased risk of death included depression, viral hepatitis, a detectable viral load and low body weight.

Although many of the deaths were attributed to HIV-related causes, the investigators found that violence and suicide were also important causes of mortality. “Factors in the WIHS that may contribute to this high rate of violent death and suicides are the prevalence of depressive symptoms, the high rates of physical abuse suffered by WIHS women, and the ongoing vulnerability associated with poverty and substance abuse”, comment the authors.

Following the introduction of effective HIV treatment in 1996, the number of deaths seen in HIV-infected patients fell dramatically. In the US, however, this fall in mortality was not as marked in HIV-positive women as in HIV-positive men, and especially high mortality rates were seen in African American women with HIV.

Investigators from the WIHS study therefore examined mortality trends in HIV-positive women over a ten year period between 1995 and 2004. They also sought to determine the predictors of mortality.

A total of 2054 women were included in the analysis. By the end of 2004, 710 women had died. The mortality rate fell from 8 per 100 person-years in 1996 to a plateau of 3 per 100 person-years between 2001 and 2004.

The standardised mortality ratio, which compared deaths amongst women in the WIHS cohort to those in the general US female population, showed that this fell from a peak of 25 in 1996 to a low of eight in 2001. However, it then stabilised at approximately ten between 2001 and 2004, meaning that mortality rates amongst WIHS individuals are ten times those seen in the age-matched US population.

Between 1995 and 1996, approximately 85% of deaths were due to AIDS. This gradually fell after effective HIV treatment became available. Between 2001 and 200q4, however, 53% of deaths were still attributable to AIDS.

During the ten years of the study, the most common cause of non-HIV-related death was violence of suicide (55 deaths). The next most common was liver disease (42 deaths), followed by cardiovascular disease (33 deaths) and non-HIV-related cancers (31 deaths).

Of the 61 women who died whilst receiving potent antiretroviral therapy, only four had an undetectable viral load.

The investigators then looked to see if they could find any factors associated with the four major causes of non-HIV-related death listed above.

Death from any causes was related to increasing age, infection with hepatitis B, hepatitis C, a CD4 cell count below 350, viral load, depression, and a body mass index (BMI) below 18.5m². Obesity was protective against death (all p

AIDS-related deaths were predicted by age, co-infection with hepatitis B, viral load, a history of AIDS-defining illnesses, depression, and a low body mass index. Once again, obesity was protective.

For non-AIDS-related deaths, the following factors were all significant (p

“We found that the death rate has plateaued after a substantial decrease during the early HAART [highly active antiretroviral therapy] era…mortality from non-AIDS causes has become increasingly common; with major causes of non-HIV related death being violence or self-harm, non-HIV associated cancers, cardiac and liver disease”, write the investigators.

Although the researchers found that HIV-related factors contributed to mortality “a number of treatable conditions, most notably depression and viral hepatitis were also associated with mortality across time and analyses.”

They conclude “further gains in reducing mortality among HIV-infected women may require broader access to available therapies for depression, viral hepatitis, and HIV itself.”