SUMMARY: While effective combination antiretroviral therapy (ART) has reduced overall morbidity and mortality due to HIV/AIDS, everyone has not benefited equally. According to a San Francisco study presented at the XVIII International AIDS Conference (AIDS 2010) last month in Vienna, members of socially disadvantaged groups -- including injection drug users, heavy alcohol users, individuals with mental health problems, people of color, women, and transgender people -- were less likely to achieve undetectable HIV viral load and their all-cause mortality increased slightly rather than falling over time.

By Liz Highleyman

David Dowdy from the University of California at San Francisco and colleagues conducted a cohort study looking at treatment outcomes among patients at San Francisco General Hospital's HIV clinic, which offers free care and antiretroviral therapy to poor and marginalized patients.

A total of 1651 patients with a nadir (lowest-ever) CD4 cell count < 350 cells/mm3 who attended at least 2 primary care visits between January 1998 and August 2009 were included in the analysis.

Most (87%) were men, the mean age was 49 years, and 47% were white. One-quarter were injection drug users (IDUs) and about 60% were men who have sex with men. Nearly one-third were hepatitis C virus (HCV) coinfected and 40% had a mental health diagnosis. The average CD4 count was about 200 cells/mm3; most participants (80%) had prescriptions for antiretroviral medications and about 40% had taken ART before entering the study.

The researchers focused on 5 socially disadvantaged groups:

	Injection drug users;
	People with alcohol abuse or dependence;
	Individuals with mental health problems;
	People of non-white race/ethnicity;
	Women and transgender people.

They linked electronic clinic records with a national death index and Social Security records to compare mortality during 2000-2004 versus 2005-2009, determining causes of death based on available clinic notes, discharge summaries, and autopsy reports. Multivariate analysis adjusted for baseline demographic and HIV-related factors.

Results

	A total of 172 deaths were identified during the study period.
	The average all-cause mortality rate rose from 10% (or 2.6% per year) during 2000-2004 to 11% (or 2.7% per year) during 2005-2009.
	The lowest death rate was 1.75% in 2004, but there was no significant overall trend between 2001 and 2009.
	Patients enrolled during 2005-2009 were significantly older, less immunocompromised, and more likely to have a mental illness diagnosis than those enrolled during 2000-2004.
	Participants in all 5 disadvantaged groups experienced higher mortality in 2005-2009 compared with 1998-2004.
	After adjusting for other factors, the increase was significant for IDUs (hazard ratio [HR] 4.15; P = 0.009), with a trend for heavy alcohol users (HR 6.62; P = 0.07).
	A majority of participants (41%) died of AIDS-defining or infectious conditions.
	24% died of non-AIDS causes, including heart, liver, and kidney disease and non-AIDS cancers.
	34% of patients had an unknown cause of death.
	Deaths due to violence/suicide/trauma or overdose (18 combined) and non-AIDS cancers (including 7 cases of lung cancer) outnumbered deaths from chronic liver disease (5 cases), cardiovascular disease (3 cases), and kidney disease combined.
	About half of participants with an unknown cause of death had a CD4 count above 200 cells/mm3 at the time of death.
	58% of participants who died had no record of ever having an undetectable viral load, compared with 31% of survivors.

"Treatment advances since 2000 have not lowered mortality among socially-disadvantaged patients in an urban HIV clinic," the investigators concluded. "Mortality was high and did not improve over time."

"Deaths among these patients are still dominated by complications of AIDS, substance use, and violence, rather than other chronic conditions," they continued. "Most patients who died never suppressed their viral loads."

The fact that people who died were almost twice as likely to have never achieved an undetectable viral load suggests inconsistent care or poor adherence, Dowdy suggested.

"In developed countries, wide disparities in mortality still exist among people living with HIV/AIDS," with "high mortality in socially-disadvantaged populations despite linkage to highest-quality care," the researchers noted. They recommended that an "intensive, multi-dimensional approach" is needed to improve outcomes for these patients.

Investigator affiliations: University of California at San Francisco, Internal Medicine Residency Program, San Francisco, CA; San Francisco General Hospital, UCSF Positive Health Program, San Francisco, CA.

8/24/10

Reference
D Dowdy, E Geng, K Christopoulos, and others. Mortality trends among socially-disadvantaged ART-eligible patients. XVIII International AIDS Conference (AIDS 2010). Vienna, February 18-23, 2010. Abstract TUAC0105.

Launch Talking Slides™