Advances in therapy have markedly changed the medical care of patients with acquired immunodeficiency syndrome (AIDS) over the past two decades. Increasingly effective antiretroviral drugs and prophylaxis against opportunistic infections make it possible for patients with AIDS to experience relatively good health for many years after diagnosis. As mortality related to human immunodeficiency virus (HIV) infection has become less common, the prevention and treatment of non–HIV-related conditions has increased in importance. Sackoff and colleagues conducted a population-based cohort analysis to characterize common causes of death in patients with AIDS.
The analysis used data from the New York City HIV/AIDS Reporting System and Vital Statistics Registry. The study population included 68,669 patients who were 13 years or older, had an AIDS diagnosis, and resided in New York City any time between 1999 and 2004. Most patients were black (46.9 percent) or Hispanic (33.4 percent), and 69.9 percent were men. One in three patients was diagnosed with AIDS before 1996, the year that highly active antiretroviral therapy became a standard of care. Death certificate information was used to identify causes of death as HIV related or non-HIV related. Non–HIV-related causes of death were classified into 16 subcategories, including deaths from substance abuse and non–HIV-related cancers. The underlying cause of death could be determined in 98.2 percent of cases.
During the study, 12,715 patients died and had known causes of death. Of these deaths, 9,613 were determined to be HIV related and 3,102 were non-HIV related. Three out of four deaths from non–HIV-related causes could be attributed to substance abuse, cardiovascular disease, or cancer. Between 1999 and 2004, the HIV-related mortality rate decreased by 54.9 percent, and the non–HIV-related mortality rate decreased by 34.3 percent. Consequently, the proportion of deaths from non–HIV-related causes rose by one third during this period (from 19.8 to 26.3 percent of all deaths). Ischemic heart disease, hypertension, diabetes, and lung cancer were significant contributors to non–HIV-related deaths in women and men older than 55 years.
The authors conclude that although the overall mortality rate in patients with AIDS has declined, non–HIV-related illnesses now represent a larger percentage of all causes of death. In light of these findings, they suggest that physicians who provide care to HIV-infected patients place increased emphasis on the primary and secondary prevention of chronic non–HIV-related conditions.
editor’s note: In the same issue, an editorial written by one of the authors of the 2004 Infectious Diseases Society of America guideline for primary care of patients with HIV infection1 notes the transformation of HIV care from subspecialist-oriented to primary care.2 The expertise of family physicians in behavioral counseling and management of multiple chronic diseases is essential to providing comprehensive care for these patients. Hopefully, the recent recommendation by the Centers for Disease Control and Prevention to routinely screen all patients 13 to 64 years of age for HIV infection will increase the proportion of patients who are diagnosed at an early stage of disease, when prevention can be of greatest benefit.3—k.w.l.