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00002030-201007170-0002900002030_2010_24_1795_rice_infection_11letter< 48_0_2_1 >AIDS© 2010 Lippincott Williams & Wilkins, Inc.Volume 24(11)17 July 2010p 1795–1797HIV infection and suicide in the era of HAART in England, Wales and Northern Ireland[Correspondence]Rice, Brian D; Smith, Ruth D; Delpech, Valerie CDepartment of HIV and STI, Health Protection Agency Centre for Infections, Colindale, London, UK.Received 11 March, 2010Revised 7 April, 2010Accepted 14 April, 2010Correspondence to Dr Brian Rice, Department of HIV and STI, Health Protection Agency Centre for Infections, 61 Colindale Avenue, Colindale, London NW9 5EQ, UK. Tel: +44 20 8327 7566; fax: +44 20 8200 7868; e-mail: brain.rice@hpa.org.ukReported rates of suicidal ideation among the general population range between 2 and 25% [1–4], with somewhat higher rates reported among gay or bisexual men or women [5,6], and people with permanent sickness or medical illnesses [1,7,8]. Elevated rates of suicidal ideation have also previously been reported among persons living with HIV infection [9,10]. A recent study comprising five HIV clinics in south-east England reported 31% of attendees as having thought of suicide in the last week [11]. The authors highlight that suicidal ideation may precede suicide planning and attempted suicide, concluding that suicide remains a notable cause of death among people living with HIV [11].In light of these findings, we investigate suicide as a cause of death among adults diagnosed with HIV (aged 15 years or above at date of death) in England, Wales and Northern Ireland (E, W and NI). Causes of death are as reported directly to the national HIV and AIDS new diagnoses database [12,13], and the annual census of people accessing HIV-related care [12,14]. These data are supplemented by information provided by the Office of National Statistics [15].In addition to suicide being reported specifically as cause of death we identified the following causes as representing possible suicide: violent causes, open verdicts, drug overdoses and carbon monoxide poisoning (similar definition is applied by the Office of National Statistics) [16]. With HIV infection having predominately resulted in a fatal outcome from AIDS prior to the introduction of HAART, and with improved data completion over time, we focus on deaths during the HAART era (1997–2008).Between 1981 and end 2008, 95 075 adults were diagnosed with HIV in E, W and NI, among whom 16 744 (17.6%) deaths were reported (Table 1). Of these deaths, 34.7% (5807) occurred during the HAART era (1997–2008), for which cause of death was available for 97.6% (5666). The proportion of deaths owing to suicide and possible suicide was 0.9 (52) and 5.5% (312), respectively.Table 1. Causes of deaths among HIV-diagnosed adults in England, Wales and Northern Ireland.As a proportion of deaths in the HAART era (1997–2008), possible suicide was significantly higher among men (6.3%; 272/4321) than among women (3.0%; 40/1345), and among those diagnosed with a CD4 cell count more than 200 per μl (10.4%; 102/977) as compared to those with a count less than 200 (2.5%; 43/1755) (both P < 0.001). Possible suicide accounted for 9.9% (9/91) of deaths among adults aged 15–24, declining to 9.0% (112/1238) among 25–34-year-olds, 6.3% (137/2192) among 35–44-year-olds and 2.5% (54/2145) among adults aged 45 years or above (P < 0.001).Among the main HIV prevention groups [12,13,17], possible suicide, as a cause of death, was significantly higher among adults infected through injecting drug use (20.8%; 95/457) as compared with sex between men (6.4%; 155/2430) or those infected heterosexually (2.2%; 49/2199). Drug overdose accounted for 72.6% (69/95) of possible suicides among injecting drug users compared with 41.1% (86/209) among adults infected through other routes (P < 0.001).The overall rate of possible suicide among adults accessing HIV-related services has decreased from 137.7 per 100 000 (20/14 526) in 1997 to 31.6 (18/56 983) in 2008 (Table 1). In 2008, the rate of possible suicide was 40.1 per 100 000 (15/37 437) among HIV-diagnosed men and 15.3 (3/19 546) among HIV-diagnosed women, higher than rates seen among the general population (estimated 17.7 per 100 000 men and 5.4 per 100 000 women) [15].In summary, our findings indicate that suicide is an uncommon cause of death among HIV-diagnosed adults. Furthermore, the number of possible suicides identified in our population was largely driven by drug overdoses among HIV-infected injecting drug users. Many of these will be genuine overdoses, and it is therefore likely that our estimates of possible suicide overestimate true suicide.Our findings highlight an important discrepancy between rates of suicidal ideation reported among clinic attendees [11] and annual rates of possible suicide among adults accessing HIV-related services. Attempting to quantify the association between suicide ideation and suicide, a general population survey in Britain found less than 0.5% of people reporting suicidal thoughts go on to kill themselves [18]. Our results support a US study showing that the vast majority of HIV-diagnosed persons reporting suicidal thoughts denied any suicidal intent [5]. Caution should therefore be exercised when linking rates of suicidal ideation with suicidal acts among persons diagnosed with HIV.HIV infection is today a chronic condition with a normal life span when diagnosed and treated promptly. Nevertheless, stigma and other psychosocial factors (such as poverty) continue to disproportionally impact on the lives of persons living with HIV [19–21]. Strategies to reduce suicidal ideation and prevent suicide among this group need to tackle these factors. In addition, barriers to testing (including the fear of death and stigma) [22] must be removed to ensure early and prompt diagnoses and treatment of those who remain unaware of their infection.References1. Walker J, Waters RA, Murray G, Swanson H, Hibberd CJ, Rush RW, et al. Better Off Dead: suicidal thoughts in cancer patients. J Clin Oncol 2008; 26:4725–4730. [CrossRef] [Medline Link] [Context Link]2. Casey PR, Dunn G, Kelly BD, Birkbeck G, Dalgard OS, Lehtinen V, et al, on behalf of the ODIN Group. Factors associated with suicidal ideation in the general population: five-centre analysis from the ODIN study. Br J Psychiatry 2006; 189:410–415. [CrossRef] [Full Text] [Medline Link] [Context Link]3. Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999; 29:9–17. [CrossRef] [Full Text] [Medline Link] [Context Link]4. Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, et al. Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey. Psychol Med 2005; 35:1457–1465. [Context Link]5. Carrico AW, Johnson MO, Morin SF, Remien RH, Charlebois ED, Steward WT, Chesney MA, and the NIMH Health Living Project Team. Correlates of suicidal ideation among HIV-positive persons. AIDS 2007; 21:1199–1203. [CrossRef] [Medline Link] [Context Link]6. Warner J, McKeown E, Griffin M, Johnson K, Ramsay A, Cort C, et al. Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: results from a survey based in England and Wales. Br J Psychiatry 2004; 185:479–485. [CrossRef] [Full Text] [Medline Link] [Context Link]7. Druss B, Pincus H. Suicidal ideation and suicide attempts in general medical illnesses. Arch Intern Med 2000; 160:1522–1526. [CrossRef] [Full Text] [Medline Link] [Context Link]8. Lewis G, Sloggett A. Suicide, deprivation, and unemployment: record linkage study. BMJ 1998; 317:1283–1286. [Context Link]9. Heckman TG, Miller J, Kochman A, Kalichman SC, Carlson B, Silverthorn M. Thoughts of suicide among HIV-infected rural persons enrolled in a telephone-delivered mental health intervention. Ann Behav Med 2002; 24:141–148. [CrossRef] [Full Text] [Medline Link] [Context Link]10. Kalichman SC, Heckman T, Kochman A, Sikkema K, Bergholte J. Depression and thoughts of suicide among middle-aged and older persons living with HIV-AIDS. Psychiatr Serv 2000; 51:903–907. [CrossRef] [Medline Link] [Context Link]11. Sherr L, Lampe F, Fisher M, Arthur G, Anderson J, Zetler S, et al. Suicidal ideation in UK HIV clinic attenders. AIDS 2008; 22:1651–1658. [CrossRef] [Full Text] [Medline Link] [Context Link]12. The UK Collaborative Group for HIV and STI Surveillance. Testing times. HIV and other sexually transmitted infections in the United Kingdom: 2007. London: Health Protection Agency, Centre for Infections; November 2007. [Context Link]13. Health Protection Agency Centre for Infections, New HIV Diagnoses. http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1201094588891 . [Accessed 18 August 2009] [Context Link]14. Health Protection Agency Centre for Infections, Numbers accessing HIV care. http://www.hpa.org.uk/web/HPAweb&Page&HPAwebAutoListName/Page/1201094588844 . [Accessed 18 August 2009] [Context Link]15. Office of National Statistics. http://www.statistics.gov.uk/default.asp . [Accessed 18 August 2009] [Context Link]16. Office of National Statistics, Suicides: UK suicides increase in 2008. http://www.statistics.gov.uk/cci/nugget.asp?id=1092 . [Accessed 9 March 2010] [Context Link]17. The UK Collaborative Group for HIV and STI Surveillance. HIV in the United Kingdom: 2008 report. London: Health Protection Agency, Centre for Infections; November 2008. [Context Link]18. Gunnell D, Harbord R, Singleton N, Jenkins R, Lewis G. Factors influencing the development and amelioration of suicidal thoughts in the general population. Br J Psychiatry 2004; 185:385–393. [CrossRef] [Full Text] [Medline Link] [Context Link]19. Crusaid, National AIDS Trust. Poverty and HIV: findings from the crusaid hardship fund 2006. London: Crusaid, National AIDS Trust; 2006. pp. 6–10. [Context Link]20. Flowers P, Davis M, Hart G, Rosengarten M, Frankis J, Imrie J. Diagnosis and stigma and identity amongst HIV positive Black Africans living in the UK. Psychol Health 2006; 21:109–122. [CrossRef] [Medline Link] [Context Link]21. Terrence Higgins Trust. Sector Summary Report: Mental Health and HIV. London: Terrence Higgins Trust; 2006. pp. 1–3. [Context Link]22. Fakoya I, Reynolds R, Caswell G, Shiripinda I. Barriers to HIV testing for migrant black Africans in Western Europe. HIV Med 2008; 9(s2):23–25. [CrossRef] [Full Text] [Medline Link] [Context Link]ovid.com:/bib/ovftdb/00002030-201007170-0002900005083_2008_26_4725_walker_suicidal_|00002030-201007170-00029#xpointer(id(R1-29))|11065213||ovftdb|SL00005083200826472511065213P24[CrossRef]10.1200%2FJCO.2007.11.8844ovid.com:/bib/ovftdb/00002030-201007170-0002900005083_2008_26_4725_walker_suicidal_|00002030-201007170-00029#xpointer(id(R1-29))|11065405||ovftdb|SL00005083200826472511065405P24[Medline Link]18695258ovid.com:/bib/ovftdb/00002030-201007170-0002900002405_2006_189_410_casey_associated_|00002030-201007170-00029#xpointer(id(R2-29))|11065213||ovftdb|00002405-200611000-00007SL00002405200618941011065213P25[CrossRef]10.1192%2Fbjp.bp.105.017368ovid.com:/bib/ovftdb/00002030-201007170-0002900002405_2006_189_410_casey_associated_|00002030-201007170-00029#xpointer(id(R2-29))|11065404||ovftdb|00002405-200611000-00007SL00002405200618941011065404P25[Full 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Text]00133448-200807001-00005ovid.com:/bib/ovftdb/00002030-201007170-0002900133448_2008_9_23_fakoya_barriers_|00002030-201007170-00029#xpointer(id(R22-29))|11065405||ovftdb|00133448-200807001-00005SL00133448200892311065405P45[Medline Link]18557866HIV infection and suicide in the era of HAART in England, Wales and Northern IrelandRice, Brian D; Smith, Ruth D; Delpech, Valerie CCorrespondence1124
00002030-201007170-0002900002030_2010_24_1795_rice_infection_11letter< 48_0_2_1 >AIDS© 2010 Lippincott Williams & Wilkins, Inc.Volume 24(11)17 July 2010p 1795–1797HIV infection and suicide in the era of HAART in England, Wales and Northern Ireland[Correspondence]Rice, Brian D; Smith, Ruth D; Delpech, Valerie CDepartment of HIV and STI, Health Protection Agency Centre for Infections, Colindale, London, UK.Received 11 March, 2010Revised 7 April, 2010Accepted 14 April, 2010Correspondence to Dr Brian Rice, Department of HIV and STI, Health Protection Agency Centre for Infections, 61 Colindale Avenue, Colindale, London NW9 5EQ, UK. Tel: +44 20 8327 7566; fax: +44 20 8200 7868; e-mail: brain.rice@hpa.org.ukReported rates of suicidal ideation among the general population range between 2 and 25% [1–4], with somewhat higher rates reported among gay or bisexual men or women [5,6], and people with permanent sickness or medical illnesses [1,7,8]. Elevated rates of suicidal ideation have also previously been reported among persons living with HIV infection [9,10]. A recent study comprising five HIV clinics in south-east England reported 31% of attendees as having thought of suicide in the last week [11]. The authors highlight that suicidal ideation may precede suicide planning and attempted suicide, concluding that suicide remains a notable cause of death among people living with HIV [11].In light of these findings, we investigate suicide as a cause of death among adults diagnosed with HIV (aged 15 years or above at date of death) in England, Wales and Northern Ireland (E, W and NI). Causes of death are as reported directly to the national HIV and AIDS new diagnoses database [12,13], and the annual census of people accessing HIV-related care [12,14]. These data are supplemented by information provided by the Office of National Statistics [15].In addition to suicide being reported specifically as cause of death we identified the following causes as representing possible suicide: violent causes, open verdicts, drug overdoses and carbon monoxide poisoning (similar definition is applied by the Office of National Statistics) [16]. With HIV infection having predominately resulted in a fatal outcome from AIDS prior to the introduction of HAART, and with improved data completion over time, we focus on deaths during the HAART era (1997–2008).Between 1981 and end 2008, 95 075 adults were diagnosed with HIV in E, W and NI, among whom 16 744 (17.6%) deaths were reported (Table 1). Of these deaths, 34.7% (5807) occurred during the HAART era (1997–2008), for which cause of death was available for 97.6% (5666). The proportion of deaths owing to suicide and possible suicide was 0.9 (52) and 5.5% (312), respectively.Table 1. Causes of deaths among HIV-diagnosed adults in England, Wales and Northern Ireland.As a proportion of deaths in the HAART era (1997–2008), possible suicide was significantly higher among men (6.3%; 272/4321) than among women (3.0%; 40/1345), and among those diagnosed with a CD4 cell count more than 200 per μl (10.4%; 102/977) as compared to those with a count less than 200 (2.5%; 43/1755) (both P < 0.001). Possible suicide accounted for 9.9% (9/91) of deaths among adults aged 15–24, declining to 9.0% (112/1238) among 25–34-year-olds, 6.3% (137/2192) among 35–44-year-olds and 2.5% (54/2145) among adults aged 45 years or above (P < 0.001).Among the main HIV prevention groups [12,13,17], possible suicide, as a cause of death, was significantly higher among adults infected through injecting drug use (20.8%; 95/457) as compared with sex between men (6.4%; 155/2430) or those infected heterosexually (2.2%; 49/2199). Drug overdose accounted for 72.6% (69/95) of possible suicides among injecting drug users compared with 41.1% (86/209) among adults infected through other routes (P < 0.001).The overall rate of possible suicide among adults accessing HIV-related services has decreased from 137.7 per 100 000 (20/14 526) in 1997 to 31.6 (18/56 983) in 2008 (Table 1). In 2008, the rate of possible suicide was 40.1 per 100 000 (15/37 437) among HIV-diagnosed men and 15.3 (3/19 546) among HIV-diagnosed women, higher than rates seen among the general population (estimated 17.7 per 100 000 men and 5.4 per 100 000 women) [15].In summary, our findings indicate that suicide is an uncommon cause of death among HIV-diagnosed adults. Furthermore, the number of possible suicides identified in our population was largely driven by drug overdoses among HIV-infected injecting drug users. Many of these will be genuine overdoses, and it is therefore likely that our estimates of possible suicide overestimate true suicide.Our findings highlight an important discrepancy between rates of suicidal ideation reported among clinic attendees [11] and annual rates of possible suicide among adults accessing HIV-related services. Attempting to quantify the association between suicide ideation and suicide, a general population survey in Britain found less than 0.5% of people reporting suicidal thoughts go on to kill themselves [18]. Our results support a US study showing that the vast majority of HIV-diagnosed persons reporting suicidal thoughts denied any suicidal intent [5]. Caution should therefore be exercised when linking rates of suicidal ideation with suicidal acts among persons diagnosed with HIV.HIV infection is today a chronic condition with a normal life span when diagnosed and treated promptly. Nevertheless, stigma and other psychosocial factors (such as poverty) continue to disproportionally impact on the lives of persons living with HIV [19–21]. Strategies to reduce suicidal ideation and prevent suicide among this group need to tackle these factors. In addition, barriers to testing (including the fear of death and stigma) [22] must be removed to ensure early and prompt diagnoses and treatment of those who remain unaware of their infection.References1. Walker J, Waters RA, Murray G, Swanson H, Hibberd CJ, Rush RW, et al. Better Off Dead: suicidal thoughts in cancer patients. J Clin Oncol 2008; 26:4725–4730. [CrossRef] [Medline Link] [Context Link]2. Casey PR, Dunn G, Kelly BD, Birkbeck G, Dalgard OS, Lehtinen V, et al, on behalf of the ODIN Group. Factors associated with suicidal ideation in the general population: five-centre analysis from the ODIN study. Br J Psychiatry 2006; 189:410–415. [CrossRef] [Full Text] [Medline Link] [Context Link]3. Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Joyce PR, et al. Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999; 29:9–17. [CrossRef] [Full Text] [Medline Link] [Context Link]4. Bertolote JM, Fleischmann A, De Leo D, Bolhari J, Botega N, De Silva D, et al. Suicide attempts, plans, and ideation in culturally diverse sites: the WHO SUPRE-MISS community survey. Psychol Med 2005; 35:1457–1465. [Context Link]5. Carrico AW, Johnson MO, Morin SF, Remien RH, Charlebois ED, Steward WT, Chesney MA, and the NIMH Health Living Project Team. Correlates of suicidal ideation among HIV-positive persons. AIDS 2007; 21:1199–1203. [CrossRef] [Medline Link] [Context Link]6. Warner J, McKeown E, Griffin M, Johnson K, Ramsay A, Cort C, et al. Rates and predictors of mental illness in gay men, lesbians and bisexual men and women: results from a survey based in England and Wales. Br J Psychiatry 2004; 185:479–485. 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