Decreasing mortality and changing patterns of causes of death in the Swiss HIV Cohort Study

Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
HIV Medicine (Impact Factor: 3.45). 04/2013; 14(4):195-207. DOI: 10.1111/j.1468-1293.2012.01051.x.

ABSTRACT BACKGROUND: Mortality among HIV-infected persons is decreasing, and causes of death are changing. Classification of deaths is hampered because of low autopsy rates, frequent deaths outside of hospitals, and shortcomings of International Statistical Classification of Diseases and Related Health Problems (ICD-10) coding. METHODS: We studied mortality among Swiss HIV Cohort Study (SHCS) participants (1988-2010) and causes of death using the Coding Causes of Death in HIV (CoDe) protocol (2005-2009). Furthermore, we linked the SHCS data to the Swiss National Cohort (SNC) cause of death registry. RESULTS: AIDS-related mortality peaked in 1992 [11.0/100 person-years (PY)] and decreased to 0.144/100 PY (2006); non-AIDS-related mortality ranged between 1.74 (1993) and 0.776/100 PY (2006); mortality of unknown cause ranged between 2.33 and 0.206/100 PY. From 2005 to 2009, 459 of 9053 participants (5.1%) died. Underlying causes of deaths were: non-AIDS malignancies [total, 85 (19%) of 446 deceased persons with known hepatitis C virus (HCV) status; HCV-negative persons, 59 (24%); HCV-coinfected persons, 26 (13%)]; AIDS [73 (16%); 50 (21%); 23 (11%)]; liver failure [67 (15%); 12 (5%); 55 (27%)]; non-AIDS infections [42 (9%); 13 (5%); 29 (14%)]; substance use [31 (7%); 9 (4%); 22 (11%)]; suicide [28 (6%); 17 (7%), 11 (6%)]; myocardial infarction [28 (6%); 24 (10%), 4 (2%)]. Characteristics of deceased persons differed in 2005 vs. 2009: median age (45 vs. 49 years, respectively); median CD4 count (257 vs. 321 cells/μL, respectively); the percentage of individuals who were antiretroviral therapy-naïve (13 vs. 5%, respectively); the percentage of deaths that were AIDS-related (23 vs. 9%, respectively); and the percentage of deaths from non-AIDS-related malignancies (13 vs. 24%, respectively). Concordance in the classification of deaths was 72% between CoDe and ICD-10 coding in the SHCS; and 60% between the SHCS and the SNC registry. CONCLUSIONS: Mortality in HIV-positive persons decreased to 1.33/100 PY in 2010. Hepatitis B or C virus coinfections increased the risk of death. Between 2005 and 2009, 84% of deaths were non-AIDS-related. Causes of deaths varied according to data source and coding system.

Download full-text


Available from: Justyna D Kowalska, Jul 14, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: We aimed at comparing overall and liver-related mortality rates, observed in HIV positive subjects followed-up in the Cohorts of Spanish Network on HIV/AIDS Research stratified by HCV co-infection status, with the expected mortality of the general population of same age and sex in Spain, for the period 1997 - 2008. We estimated standardized mortality ratio (SMR) and excess mortality, comparing death rates from our cohort (globally and by HCV co-infection) with death rates from the general population standardized by sex in 5year-age bands. Overall, 5914 HIV positive subjects were included, 37.3% of which were co-infected with HCV; 231 deaths occurred, 10.4% of which were liver-related. SMR for all causes mortality for the HIV positive subjects was 5.6 (CI 95% 4.9-6.4), 2.4 (1.9-3.1) for HCV negative subjects and 11.5 (9.9-13.4) for HCV positive ones. Having HCV co-infection and AIDS yielded an SMR of 20.8 (16.5-26.1) and having AIDS and being HCV negative had an SMR of 4.8 (3.5-6.7). SMR for liver-related mortality was 1.8 (0.6-5.7) for HCV negative subjects vs. 22.4 (14.6-34.3) for HCV positive ones. Overall, both mortality rates as SMR and excess mortality rates were higher for injecting drug users (IDUs) than men having sex with men (MSM) and heterosexuals, patients with AIDS, with and without cART and for subjects included between 1997 and 2003. There was an excess of all-cause and liver-related mortality in our cohorts compared with the general population. Furthermore, HCV co-infection in HIV positive patients increased the risk of death for both all causes and liver-related causes.
    Journal of Hepatology 06/2012; 57(4):743-51. DOI:10.1016/j.jhep.2012.06.010 · 10.40 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Morbidity and mortality from co-morbid hepatitis C (HCV) infection in HIV co-infected patients are increasing; hence, the management of hepatitis co-infection in HIV is now one of the most important clinical challenges. Therefore, the development of direct acting antivirals (DAAs) for treatment of HCV has been eagerly awaited to hopefully improve HCV treatment outcome in co-infected individuals. Indeed, the availability of the first HCV protease inhibitors (PI) boceprevir and telaprevir for HCV genotype 1 patients has changed the gold standard of treating hepatitis C allowing for substantially improved HCV cure rates under triple HCV-PI/pegylated interferon/ribavirin therapy. Moreover, numerous other new DAAs are currently being studied in co-infected patient populations, also exploring shorter treatment durations and interferon-free treatment approaches promising much easier and better tolerated treatment regimens in the near future. Nevertheless, numerous challenges remain, including choice of patients to treat, potential for drug-drug interactions and overlapping toxicities between HIV and HCV therapy. The dramatically improved rates of HCV cure under new triple therapy, however, warrant evaluation of these new treatment options for all co-infected patients.
    BMC Medicine 11/2013; 11(1):234. DOI:10.1186/1741-7015-11-234 · 7.28 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background. It is unclear whether PEG-IFN-induced severe neutropenia in HIV-HCV coinfected subjects is associated to increased risk of serious infections. Methods. Prospective cohort study between 2000-2012 in HIV-HCV coinfected subjects initiating treatment with PEG-IFN+RBV. Infections were defined as serious when patients required hospitalization, treatment discontinuation, or the patient died. Potential risk factors for infection and the association between neutropenia (severe, <500 cells/μL and non severe, 500-1500 cells/μL) and infections (serious infections and infections of any severity) were determined by logistic regression analysis. Results. From 418 subjects (3928 person-weeks of therapy), infections occurred in 123 (29%) subjects, accounting for 149 episodes (3.8 infections per 100 person-weeks of therapy). Most infections (47%) involved the upper respiratory tract and were minor. After a multivariate analysis adjusting by age, sex, CD4 count, AIDS, antiretroviral therapy, cirrhosis, neutrophil count, type of PEG-IFN and G-CSF use, none of these variables remained independently associated with the risk of infection. Twenty subjects developed a serious infection (5% of all the patients), accounting for 0.5 episodes per 100 person-weeks of therapy. The frequency of serious infections was higher in subjects with severe neutropenia compared to those with non-severe neutropenia and without neutropenia, although no statistically significant (8.6%, 4.8%, 3.6%, respectively; trend test P=0.281). After multivariate analyses, neutropenia was not independently associated to increased risk of serious infections. Conclusions. In this large prospective cohort of HIV-infected patients treated with PEG-IFN+RBV for chronic C hepatitis, serious infections were uncommon, non-fatal and unrelated to PEG-IFN induced severe neutropenia.
    Clinical Infectious Diseases 04/2013; 57(3). DOI:10.1093/cid/cit221 · 9.42 Impact Factor
Show more