Despite a dramatic decline in AIDS-related deaths due to highly active antiretroviral therapy, deaths are still occuring in people with undetectable viral loads at the UK’s largest HIV clinic laregly due to liver disease, suicide, or cancer, according to research presented to the 2003 conference of the British HIV Association in Manchester last week.
The Kobler Centre at London's Chelsea and Westminster Hospital is the largest HIV treatment centre in the UK and since the introduction of HAART, rates of illness and death amongst its patients, who come from all the communities affected by HIV in the UK, have fallen dramatically.
However, deaths are still occurring, and investigators at the hospital conducted an analysis of the last 100 deaths amongst their HIV-positive patients to see if they could establish causes of death amongst the patients. The results were compared to two similar studies conducted in the clinic, one in the pre-HAART era (May to November 1994), and a second in the early years of HAART (November 1996 to November 1998).
The success of HAART in reducing mortality was demonstrated by the lengthening periods necessary for 100 deaths to occur amongst the hospital’s HIV-positive patients. In 1994, 100 deaths occurred within five months (average 22 per month), this was extended to two years for the early-HAART era (average eight deaths per month), and two years and three months for the most recent analysis (average of five deaths per month).
The investigators found that patients were increasingly likely to be dying with higher CD4 cell counts, and often with an undetectable HIV viral load. Although gay men made up 70% of the hospital’s patients, they only represented 60% of deaths, with heterosexuals over-represented, mainly due to late presentation by Africans who were already very unwell with HIV-related illnesses.
When the investigators looked at causes of death they found that deaths from KS had fallen from 17 in the earliest period of research to two between 2000 and 2002. Deaths from most other AIDS-defining opportunistic infections had also fallen.
However, mortality from the AIDS-defining cancer lymphoma increased from three in the pre-HAART era to twelve in the early-HAART and 13 in the latest period of analysis. In addition, non-AIDS defining cancers emerged as a cause of death. This finding adds to a conflicting body of research on whether or not non-AIDS defining cancers, such as lung, testicular and anal cancer, have become more frequent since HAART (see link below).
The number of deaths due to liver disease, caused by hepatitis B, and increasingly hepatitis C, increased from three in 1994 to 16 between 2000 -2002, and many of these patients had undetectable HIV viral loads at the time of death.
Suicide also emerged as a significant cause of death, increasing from one in the five month period of analysis in 1994 to ten between 2000 and 2002.
Average CD4 cell counts of patients dying also markedly increased over the three periods of the study. In 1994, the median CD4 was only 20 cells/mm3, this increased slightly to 35 cells/mm3 in the early HAART era and markedly to 116 cells/mm3 for the latest 100 deaths. The number of patients who had previous AIDS-defining illness fell significantly over the three periods. In 1994, 93% of deaths occurred in patients who had at least one earlier AIDS-defining illness, but by 2000-2002 this had fallen to just 44%. Investigators attributed this fall to the emerging importance of non-HIV related conditions as a cause of death in HIV-positive patients.
The investigators conclude that mortality has decreased markedly amongst their patient population since the advent of HAART. When deaths do occur, “the spectrum of causation is changing”, with higher rates due to lymphoma, non-AIDS cancers, liver disease and self-harm, and fewer from KS and other opportunistic infections.
Further information on this website
Cancers - overview
Hepatitis C - overview
Prognosis - factsheet
Mental health - factsheet
No higher risk of non-AIDS cancers in advanced HIV disease, says US National Cancer Institute - news story
Ashby J et al. Changing mortality patterns in the HAART era. 9th Annual Conference of the British HIV Association, oral presentation 024, 2003.