Ongoing impact of HIV infection on mortality among people who inject drugs despite free antiretroviral therapy

Abstract

Aims To determine the impact of HIV infection on mortality over time among persons who inject drugs (PWID) in settings with free HIV/AIDS care. Design and Setting Prospective cohort study of PWID in Vancouver, Canada, recruited between May 1996 and December 2011. We ascertained morality rates and causes of death through a confidential linkage with the provincial vital statistics registry. Participants 2283 individuals were followed for a median of 60.9 months (Interquartile range: 34.4 – 113.1) among whom 622 (27.2%) individuals were HIV-positive at baseline, and 179 (7.8%) seroconverted during follow-up. Measurements The primary and secondary outcomes of interests were all-cause mortality and cause of death, respectively. The main independent variable of interest was HIV serostatus (positive vs. negative). We used Cox proportional hazards regression to determine factors associated with mortality, including socio-demographic variables, drug use behaviors and other risk behaviors. Findings Over the study period, 491 (21.5%) individuals died. In multivariate analyses, HIV infection remained independently associated with all-cause mortality (adjusted hazard ratio = 3.15; 95% CI: 2.59 – 3.82). While all-cause mortality rates declined markedly during the study period (p < 0.001, the independent effect of HIV infection on mortality remained unchanged over time (p = 0.640). Among HIV-positive individuals, significant changes in causes of death from infectious and AIDS-related causes to non-AIDS-related etiologies were observed. Conclusions HIV infection continues to have a persistent impact on mortality rates among persons who inject drugs in settings with free HIV/AIDS care, though causes of death have shifted markedly from infectious and AIDS-related causes to non-AIDS-related etiologies.

Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs

“…Recent data from The Joint United Nations Programme on HIV/AIDS described a 19% decline in AIDS-related deaths from 2011 to 2014, and a 35% decline from 2005 to 2014 [1**]. Among HIV-positive PWID however, the leading cause of death remains HIV/AIDS-related causes [2,3**,7,29,30,31*,32–34,35*,36**,37], reflecting suboptimal levels of ART access, and adherence in this population.…”

“…Additionally, PWID systemically experience disproportionate levels of homelessness [9,25*,29], untreated mental health comorbidities [37], polysubstance use [32] (including alcohol use [33]), and lower levels of healthcare engagement [9], all of which shape access and adherence to ART, as well as progression to AIDS and death. Additionally, incarceration [1**,43] and personal violence [3**,7,10*] remain persistent issues among HIV-positive PWID, with research demonstrating increased rates of suicides [7,44] being independently associated with a history of IDU (adjusted hazard ratio: 3.95; confidence interval: 1.99 – 7.86) [44].…”

“…Studies undertaken in Vancouver, Canada, between 1996 and 2011 report a marked decline in rates of all-cause mortality among PWID [3**,29]. For example, Lappalainen and colleagues [29] found that rates of accidental death, inclusive of overdose, fell from 12.79 deaths per 1000 person-years from 1996 to 1999 to 8.56 deaths per 1000 person-years in 2008 – 2011. The shift is credited to significant investments in harm reduction approaches in this setting, including North America’s first legal supervised injection site.…”

“…The shift is credited to significant investments in harm reduction approaches in this setting, including North America’s first legal supervised injection site. Researchers have also hypothesized that positive interactions between clients and staff at harm reduction facilities and shifts in type of drug use might partially explain the declines in drug overdose during the study period [29]. …”

Predictors of mortality within prison and after release among persons living with HIV in Indonesia

“… 6 HIV prevalence in Indonesia has remained consistently high (>50%) among PWID, 7 , 8 who experience significant drug-related comorbidities, 9 and HIV-related mortality, even in settings where ART is provided at no cost to patients. 10 In Jakarta, over half (56.4%) of PWID are HIV-infected, 2 and a third (~29.7%) have been in prison. 7 Incarceration of PWID has resulted in elevated HIV prevalence (6.5%) in prisons, 11 – 13 where high-risk drug injection and needle sharing facilitate ongoing transmission.…”