(P12) Causes of Death in People Living with HIV (PLHIV) at Venhälsan, Södersjukhuset, Stockholm, 1996-2019
Kathleen, Smith Göran, Bratt Johanna, Brännström Catharina, Missailidis
Venhälsan, Department of Infectious Diseases/Venhälsan, South Hospital, Stockholm, Sweden
Since the introduction of combination antiretroviral therapy (cART) in 1996, mortality has decreased in people living with HIV (PLHIV), largely due to a decrease in deaths caused by AIDS. As PLHIV live longer age-related comorbidities, such as non-AIDS cancer and cardiovascular disease (CVD) increase. A higher incidence and earlier onset of these diseases, and a higher mortality rate has been reported in PLHIV as compared to the general population. It is unclear if this is caused by HIV-infection and/or its treatment per se or lifestyle factors. The decrease in AIDS and increase in comorbidities has changed the causes of death spectrum in PLHIV. The purpose of this study was to analyze the causes of death in a Venhälsan cohort after 1996.
We performed a qualitative cross-sectional study including 264 HIV-positive patients who died between January 1, 1996 and May 1, 2019 and received care at Venhälsan. Patient characteristics (age at death, history of smoking, comorbidity, AIDS, transmission group, CD4 nadir (x106/L), time to cART and time to death) were obtained from InfCareHIV and patient files. The main cause of death was assessed from patient files and categorized into the following groups: AIDS-related disease (AIDS opportunistic infection (AIDS-OI) and AIDS-cancer); non-AIDS cancer; CVD; liver disease; renal disease; accidental death; substance abuse; suicide; other and unknown.
Of a total of 264 patients 40 were excluded due to missing data, leaving 224 for analysis. 95% were men, 83% were MSM, 77% had a history of smoking, 47% had AIDS and 43% psychiatric disease. The median age at death was 52 years. Median time from HIV diagnosis to cART was 2,5 years and to death 12.2 years. Median nadir CD4 was 110 x106/L.
Causes of death were: AIDS 26%; non-AIDS cancer 18%; CVD 15%; suicide 9%; non-AIDS infection 9%; terminal liver or renal disease 5%; accidental death 3%; substance abuse 2%; other 7% and unknown 7%. The most common non-AIDS cancers were gastrointestinal, lung, anal and urinary tract.
To identify trends, we divided the data into three time periods: 1996 – 2000 (n=69); 2001 – 2009 (n=64); and 2010 – May 1, 2019 (n=91) and compared the first and the most recent period. Comparing the early and late groups, the median age at death changed from 44 to 58 years (<0.001 Fisher’s exact test). Median time from diagnosis to cART changed from 3.4 to 1.7 years and to death from 6.8 to 18.8 years. Nadir CD4 changed from 20 to 180 x106/L. Hypertension and diabetes type 2 (DM-2) changed from 3% to 43% (p<0.01) and from 4% to 18% (p<0.05), respectively. The proportion of smokers was unchanged.
The proportion of deaths caused by AIDS-OI decreased from 41% to 4% (p<0.001) and by AIDS-cancer from 19% to 3% (p<0.01). Non-AIDS cancer increased from 9% to 24% (p<0.05) and CVD and from 4% to 22% (p<0.005). There was no difference in suicide occurrence.
Both the age at death and time between HIV-diagnosis and death has increased significantly over the period. Hypertension and DM-2 increased as these patients age. As death caused by AIDS decreases, the proportion of death caused by non-AIDS cancer and CVD increases, making non-AIDS cancer the leading cause of death. It is challenging that patients still die from AIDS. The high proportion of smoking and psychiatric disease, including substance abuse, may contribute to the higher mortality even in the background of today’s 100% cART-coverage and relatively young age at death. This underlines the importance of lifestyle interventions.