Reported 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 . 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 .
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 .
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) . 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.
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) .
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  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 . Our results support a US study showing that the vast majority of HIV-diagnosed persons reporting suicidal thoughts denied any suicidal intent . 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)  must be removed to ensure early and prompt diagnoses and treatment of those who remain unaware of their infection.
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