Longitudinal trends in causes of death among adults with HIV on antiretroviral therapy in Europe and North America from 1996 to 2020: a collaboration of cohort studies. Lancet HIV
Trickey et al. aimed to investigate longitudinal trends in rates of cause-specific mortality among adult people with HIV who started ART in Europe and North America between 1996 and 2020.
The authors used data from 17 European and North American HIV cohorts contributing data to the Antiretroviral Therapy Cohort Collaboration. They included data for people with HIV who started ART between 1996 and 2020. Causes of death were classified into a single cause by both a clinician and using a specific algorithm, or independently by two clinicians. Disagreements were resolved through panel discussion. The analysis was adjusted for time-updated age, CD4 count, and whether the individual was ART-naive at the start of each period.
Among 189’301 people with HIV included in this study, 16’832 (8·9%) deaths were recorded during 1’519’200 person-years of follow-up. 13’180 (78·3%) deaths were classified by cause: the most common causes were AIDS (4203 deaths; 25·0%), non-AIDS non-hepatitis malignancy (2311; 13·7%), and cardiovascular or heart-related (1403; 8·3%) mortality. The proportion of deaths due to AIDS declined from 49% during 1996–99 to 16% during 2016–20. Rates of all-cause mortality per 1000 person-years decreased from 16·8 deaths (95% CI 15·4–18·4) during 1996–99 to 7·9 deaths (7·6–8·2) during 2016–20. Rates of all-cause mortality declined with time: the average adjusted mortality rate ratio per calendar period was 0·85 (95% CI 0·84–0·86). Rates of cause-specific mortality also declined: the most pronounced reduction was for AIDS-related mortality (0·81; 0·79–0·83). There were also reductions in rates of cardiovascular-related (0·83, 0·79–0·87), liver-related (0·88, 0·84–0·93), non-AIDS infection related (0·91, 0·86–0·96), non-AIDS-non-hepatocellular carcinoma malignancy-related (0·94, 0·90–0·97), and suicide or accident-related mortality (0·89, 0·82–0·95). Mortality rates among people who acquired HIV through injecting drug use increased in women (1·07, 1·00–1·14) and decreased slightly in men (0·96, 0·93–0·99).
In conclusion, this study shows that rates of most categories of cause-specific mortality declined between 1996 and 2020: the largest reductions were in rates of AIDS-related and cardiovascular or heart-related mortality. Rates of all-cause mortality declined over calendar time for men who have sex with men and for both men and women who acquired HIV through heterosexual sex, but they did not decline in women who acquired HIV through injection drug use. In this group, rates of mortality related to substance use, suicide or accident, and respiratory disease increased over time.