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: 3.99). 04/2013; 14(4):195-207. DOI: 10.1111/j.1468-1293.2012.01051.x.


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.

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.

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.

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.

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Available from: Justyna D Kowalska, Jul 14, 2015
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    • "Smith et al., [7] in particular, found a statistically significant decrease of adjusted IR of both liver-related deaths and cardio-vascular deaths, but the adjusted IR of non-AIDS-cancers relative to recent cART years vs. early cART years always resulted nearly equal to unity, i.e., non-AIDS-related cancer rates have remained stable over time. These types of cancer seem now be the most common cause of non-AIDS death [8,17]. An important caveat to this study is that, being observational in nature, we cannot rule out the possibility of unmeasured confounding. "

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    • "Only patients with more than 14 months of potential follow-up, before closure of the database, were included in the analysis of LTFU. Causes of deaths were classified according to the Causes of Death in HIV (CoDe) protocol (Version 2.3)[20], or based on ICD-10 codes from the death certificate (Table S1, We considered patients as exposed to hepatitis C virus (HCV) if they had positive anti-HCV or HCV-RNA tests and exposed to hepatitis B virus (HBV) in the presence of positive anti- HBc, HBs-antigen or HBV-DNA tests. "
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    • "The use of antiretroviral treatment (ART) for HIV infection has led to a dramatic reduction of HIV-related morbidity and mortality, and the life expectancy of HIV-infected individuals is now approaching that of the general population [1-4]. As HIV-related mortality has decreased, there has been a relative increase in the proportion of deaths attributable to other complications such as renal disease, liver disease, neurocognitive impairment, and cardiovascular disease (CVD) [5]. For reasons that are not yet fully understood, HIV-infected individuals, even those on stable suppressive treatment, have a higher prevalence of atherosclerosis than age-matched HIV-negative adults [6-9]. "
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