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Mortality in the Highly Active Antiretroviral Therapy Era: Changing Causes of Death and Disease in the HIV Outpatient Study

Palella, Frank J. Jr MD*; Baker, Rose K. MA; Moorman, Anne C. BSN, MPH; Chmiel, Joan S. PhD*; Wood, Kathleen C. BSN; Brooks, John T. MD; Holmberg, Scott D. MD, MPHHIV Outpatient Study Investigators

JAIDS Journal of Acquired Immune Deficiency Syndromes: September 2006 - Volume 43 - Issue 1 - p 27-34
doi: 10.1097/01.qai.0000233310.90484.16
Clinical Science

Background: AIDS-related death and disease rates have declined in the highly active antiretroviral therapy (HAART) era and remain low; however, current causes of death in HAART-treated patients remain ill defined.

Objective: To describe mortality trends and causes of death among HIV-infected patients in the HAART era.

Design: Prospective, multicenter, observational cohort study of participants in the HIV Outpatient Study who were treated from January 1996 through December 2004.

Measurements: Rates of death, opportunistic disease, and other non-AIDS-defining illnesses (NADIs) determined to be primary or secondary causes of death.

Results: Among 6945 HIV-infected patients followed for a median of 39.2 months, death rates fell from 7.0 deaths/100 person-years of observation in 1996 to 1.3 deaths/100 person-years in 2004 (P = 0.008 for trend). Deaths that included AIDS-related causes decreased from 3.79/100 person-years in 1996 to 0.32/100 person-years in 2004 (P = 0.008). Proportional increases in deaths involving liver disease, bacteremia/sepsis, gastrointestinal disease, non-AIDS malignancies, and renal disease also occurred (P = <0.001, 0.017, 0.006, <0.001, and 0.037, respectively.) Hepatic disease was the only reported cause of death for which absolute rates increased over time, albeit not significantly, from 0.09/100 person-years in 1996 to 0.16/100 person-years in 2004 (P = 0.10). The percentage of deaths due exclusively to NADI rose from 13.1% in 1996 to 42.5% in 2004 (P < 0.001 for trend), the most frequent of which were cardiovascular, hepatic, and pulmonary disease, and non-AIDS malignancies in 2004. Mean CD4 cell counts closest to death (n = 486 deaths) increased from 59 cells/μL in 1996 to 287 cells/μL in 2004 (P < 0.001 for trend). Patients dying of NADI causes were more HAART experienced and initiated HAART at higher CD4 cell counts than those who died with AIDS (34.5% vs 16.8%, respectively, received HAART for 4 of more years, P < 0.0001; 22.4% vs 7.8%, respectively, initiated HAART with CD4 cell counts of more than 350 cells/μL, P < 0.001).

Conclusions: Although overall death rates remained low through 2004, the proportion of deaths attributable to non-AIDS diseases increased and prominently included hepatic, cardiovascular, and pulmonary diseases, as well as non-AIDS malignancies. Longer time spent receiving HAART and higher CD4 cell counts at HAART initiation were associated with death from non-AIDS causes. CD4 cell count at time of death increased over time.

From the *Feinberg School of Medicine, Northwestern University, Chicago, IL; †Cerner Corporation, Vienna, VA; and ‡Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.

Received for publication January 20, 2006; accepted June 9, 2006.

This work was supported by Centers for Disease Control and Prevention.

The HIV Outpatient Study investigators are listed in Appendix A.

Reprints: Frank Palella, Jr., MD, Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Suite 200, 676 North Saint Clair, Chicago, IL 60611 (e-mail: f-palella@northwestern.edu).

© 2006 Lippincott Williams & Wilkins, Inc.