Am Fam Physician. 2023;108(4):413-414
Author disclosure: No relevant financial relationships.
Clinical Question
What association exists between people living with HIV/AIDS and suicide attempts?
Evidence-Based Answer
People living with HIV/AIDS should be screened regularly for suicidal thoughts because suicide attempts are significantly higher in this cohort compared with the general population. (Strength of Recommendation: A, systematic review of cross-sectional and cohort studies.) In people living with HIV/AIDS, depression and a family history of suicide increase the risk of future attempts.
Evidence Summary
A 2022 systematic review and meta-regression of 43 studies (10 cohort and 33 cross-sectional studies) from 16 countries examined the suicidality rates and risk factors among people living with HIV/AIDS (n = 170,234).1 Patients had a mean age of 56 years and 67% were male. Primary outcomes were the prevalence of suicidal ideation, suicide attempts, and suicide completions. The studies included self-identified risk factors of sex, age, sexual orientation, marital status, education level, and other contributing factors. Among people living with HIV/AIDS, the prevalence of suicidal ideation was 22% (33 studies; n = 24,939; 95% CI, 17% to 28%). The prevalence of suicide attempts was 9.6% (17 studies; n = 9,149; 95% CI, 6.3% to 15%), and the prevalence of suicide completions was 1.7% (eight studies; n = 144,723; 95% CI, 1% to 2.8%). The rate of suicide completion was higher in people living with HIV/AIDS than in the general population (0.3 vs. 0.1 per 100 person-years). The most significant risk factors for suicide attempts in people living with HIV/AIDS were a diagnosis of depression (four studies; n = 1,783; relative risk [RR] = 1.7; 95% CI, 0.7 to 2.7) and family history of suicide (two studies; n = 738; RR = 1.1; 95% CI, 0.16 to 2.06). Suicidality was more common in people living with HIV/AIDS who were not receiving HIV treatment (nine studies; n = 95,575; RR = 2.9; 95% CI, 0.69 to 5.15) vs. patients who were on highly active antiretroviral therapy (seven studies; n = 14,610; RR = 2.6; 95% CI, 0.28 to 4.86). Limitations were mostly cross-sectional design studies and heterogeneity, including diverse samples and effect sizes.
A 2021 meta-analysis of 40 studies (12 cohort and 28 case-control studies) from 14 countries evaluated suicidality in people living with HIV/AIDS (n = 185,199).2 This analysis reported on patients with advanced HIV disease (i.e., AIDS) and had minimal overlap with the previous systematic review.1,2 The analysis included people of all ages and sexes diagnosed with HIV. Participants were 71% male, with a mean age of 41 years. The primary outcome was the incidence of death by suicide in people living with HIV/AIDS. The incidence of suicide attempts in people living with HIV/AIDS was 20 per 1,000 people (five studies; n = 38,210; 95% CI, 2.4 to 155 per 1,000 people). Studies showed that people living with HIV/AIDS had a significantly higher lifetime prevalence of suicide attempts (16%) compared with 3% in the general population (16 studies; n = 9,444; 158 per 1,000 people; 95% CI, 107 to 228). Suicidal ideation was also higher in people living with HIV/AIDS compared with the general population (23% vs. 9%; 16 studies; n = 7,793; 228.3 per 1,000 people; 95% CI, 150.8 to 330.1).2 The incidence of death from suicide among people living with HIV/AIDS was significantly higher than in the general population (10.2 per 1,000 people; 95% CI, 4.5 to 23.1 vs. 0.11 per 1,000 people). For every 10 percentage-point increase in the population living with AIDS compared with the general population, a 3.4% increase was found in suicide completion. Reporting and methodology were heterogeneous in the studies, and only English-language databases were included, limiting the generalizability of this review.
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