Massive decline in suicides of HIV-positive people since the introduction of combination therapy, but rate remains high

Massive decline in suicides of HIV-positive people since the introduction of combination therapy, but rate remains high

An analysis of deaths over 30 years in Switzerland shows that suicides fell dramatically after 1996, but have not declined further in men in more recent years as HIV treatment has continued to improve. People with HIV remained three times more likely than people in the general population to die by suicide, according to an analysis of the Swiss HIV Cohort Study report in the Journal of the International AIDS Society.

Among 20,139 people with HIV included in the study, 204 people with HIV died by suicide over 184,402 person‐years – a rate of 111 per 100,000 person‐years. In other words, there was around one suicide for each 1000 people followed each year.

Data were taken from the Swiss HIV Cohort Study (which enrols around half the people living with HIV in the country) between 1988 and 2017. They were compared with data on the general population, from the Swiss National Cohort.

Glossary

person years

In a study “100 person years of follow-up” could mean that information was collected on 100 people for one year, or on 50 people for two years each, or on ten people over ten years. In practice, each person’s duration of follow-up is likely to be different.

tolerability

Term used to indicate how well a particular drug is tolerated when taken by people at the usual dosage. Good tolerability means that drug side-effects do not cause people to stop using the drug.

The suicide rates of people with HIV (per 100,000 person-years) were much higher before the introduction of effective HIV treatment in 1996:

  Men Women
1988 - 1995 446 149
1996 - 1998 99 75
2009 - 2017 72 34

Rates were also falling in the general population, but not so dramatically: from 33 to 20 (per 100,000 person years) in men, and from 13 to 7 in women.

Rates in people with HIV can be compared with those in the general population in terms of standardised mortality rates (SMR). The SMR for men with HIV fell from 12.9 in the pre-antiretroviral therapy (ART) era, to 2.4 after the introduction of ART, increasing slightly to 3.1 in more recent years. The SMR for women with HIV fell from 14.2 to 10.2 and 3.3. In other words, suicide rates remain three times higher both in men and women with HIV than in the general population.

“The biggest drop in rates was thus observed after combination antiretroviral therapy was introduced in 1996,” say the authors. “Since then no important decline in rates was observed in men, despite the more tolerable, efficacious and simpler antiretroviral drug regimens that became available.”

A recent study from England and Wales found a suicide SMR in men with HIV of 2.2, while the rate was not higher in women with HIV than in the general population.

Comparing people who died of suicide with other people with HIV who did not, they were more likely to be male, of Swiss nationality, a gay or bisexual man, have a history of injecting drug use, have had psychiatric treatment, or be at a more advanced HIV clinical stage.

These associations – previously seen in French and Danish studies – did not substantially change over time. Studies of lesbian, gay and bisexual people (not necessarily living with HIV) have shown higher suicide rates than in the general population.

There was no association between taking efavirenz (a drug that can affect mood and mental health) and suicide in this cohort. This may be because doctors have avoided prescribing it to those with mental health difficulties. Similarly, there was no association between dolutegravir and suicide.

“Continued emphasis on suicide prevention among men and women living with HIV is important,” conclude the authors.

References

Ruffieux Y et al. Mortality from suicide among people living with HIV and the general Swiss population: 1988‐2017. Journal of the International AIDS Society 22: e25339.