People living with HIV still at higher risk of death by suicide, accident, violence, and substance use

The risk of death by suicide, substance use, accident, and violence remains higher among people living with HIV than in the general population. Research by a team of scientists working across 16 European countries, published in the journal AIDS, found that people who acquired HIV through injection drug use, men living with HIV, and people living with HIV in Eastern Europe had a higher risk of death by suicide or by accident/violence. They also found higher rates of death by suicide in the year following an AIDS diagnosis.

Rates of death by suicide among people living with HIV dropped after antiretroviral therapies became available, but remain high. Although the numbers and proportions vary across different studies, the most reliable conclusions are that suicide rates among people living with HIV are between twice as high and almost eight times as high as in the general population. A 2017 Public Health England study found that the suicide rate among people living with HIV was five times that of the global population in the first year after an HIV diagnosis. In that study, suicides in the first year after diagnosis represented four in ten of all deaths by suicide in the cohort.

Identifying cause of death

Distinguishing between deaths from suicide and deaths from other causes is notoriously difficult. If someone falls from a height, it might not be clear whether that was an accident, they intended to take their own life or another person pushed them off. Deaths by drug overdose, accidents and violence can all be confused with suicides. Because of the stigma of death by suicide, it has long been suspected that some deaths may not be officially classified as suicides to spare survivors’ feelings.

Find out more: The hardest outcome of all: HIV and suicide

Because deaths by these causes may share similar risk factors (for example, risk-taking behaviours, mental ill health, and other stigmas), the authors of the study sought to identify the rates of causes of death among people living with HIV by suicide, substance use, violence/accident, and any combination of these three causes (a composite outcome). They analysed data taken from EuroSIDA, a data set of clinical, demographic, and therapeutic information on over 23,000 people living with HIV, aged 18 and over and living across Europe and in Israel and Argentina. The team focused on participants who were followed up at least once (for example, through one or more recorded clinic visit, CD4 cell count or viral load) between 2007 to 2019. The total participant sample was 17,881, with participants followed up for an average of eight years.

They found that the overall death rate was 121 per 10,000 person years of follow up. In other words, in a group of 10,000 people living with HIV followed up for a year, one might expect there to be 121 deaths. Substance use accounted for 5%, violence/accident for 3%, and suicide for 2% of the approximately 1,800 deaths that occurred during these years. The rate of suicide was 2.7 per 10,000 person years of follow up: in a group of 10,000 people living with HIV followed up for a year, one might expect there to be fewer than three suicides per year.

Especially vulnerable groups of people living with HIV

Deaths by suicide among people living with HIV were especially high during the 12 months after an AIDS diagnosis: in this sample, the risk of suicide was nine times higher among those with an AIDS diagnosis in the past 12 months than it was among participants with no history of AIDS. No other factors were associated with suicide in multivariable analysis.

The researchers also found that men had twice the risk of death by accident or violence than women, and that participants who had acquired HIV through injection drug use had a higher risk of death from violence, accident, or substance use. Those who had acquired HIV through injection drug use had more than twice the risk of death by violence/accident than did gay and bisexual men in the sample. The same differences in risk of death applied to death due to the composite outcome.

Analysis also uncovered geographical differences. People living with HIV in in Eastern Europe had a higher risk of death from violence, accident, or substance use, likely due to higher rates of injection drug use in that region. The rates of death by suicide among people living with HIV across Europe and in Israel and Argentina was lower than found in studies of people living with HIV in Switzerland and France, but roughly similar to suicide rates among people living with HIV in the United Kingdom. Average rates of death among people living with HIV due to accident/violence or substance use were higher than those among people living with HIV in the UK.

Recommendations

The authors recommend that particular attention is paid to higher risk of death for people in who acquired HIV through injection drug use. They draw attention to the higher rate of injection drug use in Eastern Europe, possibly due to lower access to treatment for drug use, and to the region’s higher overall suicide rates and poorer access to and quality of care for people living with HIV.

They also recommend a greater focus on identifying and treating mental health challenges among people living with HIV that could lead to suicide. Given the high suicide rates among people with a recent AIDS diagnosis, they suggest that HIV providers should consider the mental health of individuals who had received an AIDS diagnosis within the previous 12 months.

If you are affected by this issue, Samaritans can be contacted in the UK on 116 123, and in the US, the National Suicide Prevention Lifeline is 1-800-273-8255. Other international helplines can be found at www.befrienders.org or via this Wikipedia page.