Cancers, Liver Failure and Other Problems Now Leading Causes of Death in Swiss HIV Study

The hallmark of AIDS is an array of life-threatening infections and cancers. Fortunately, with the arrival of potent combination anti-HIV therapy (commonly called ART or HAART) in most high-income countries in 1996, deaths due to AIDS-related causes began to decline. Since that time, AIDS-related deaths have generally fallen even lower and have now stabilized. However, deaths continue to occur among HIV-positive people for several possible reasons, including the following:

• Some HIV-positive people delay seeking care and treatment until they are seriously ill. As a result, treatment may fail to repair their immune system.
• HIV treatment only partially reduces inflammation associated with this chronic infection.
• Co-infection with certain viruses causes complications, including cancers. These viruses include the following: hepatitis B and C; human papilloma virus (HPV), and members of the herpes virus family such as EBV (Epstein Barr Virus) and HHV-8 (human herpes virus-8).
• Prolonged use of street drugs.
• Lack of access to care and treatment.
• Obesity.
• Insufficient exercise.

Different Types of Studies

Most clinical trials for testing new or reformulated HIV medicines tend to be relatively small and of relatively short duration. Moreover, such trials (usually of a randomized, controlled design) tend to enroll relatively healthy people who have minimal pre-existing conditions. As a result, deaths in such trials, particularly in the past decade, tend to be uncommon.

In many high-income countries, large numbers of HIV-positive people have been enrolled in studies of a different design -- observational, or cohort, studies. Such studies, with their large and diverse populations and prolonged duration of monitoring, can provide a better overall picture of the health of HIV-positive people.

The Swiss HIV Cohort Study (SHCS) has been keeping track of the cause of deaths of participants since 1988. In 1999 and again in 2005 Swiss researchers further refined its data collection and analysis, expanding its ability to classify possible causes of death.

In recently reviewing their data, Swiss researchers confirmed a pattern in the cause of death that is being seen across high-income countries. In the time before HAART, deaths were usually due to complications arising from AIDS-related infections and cancers. In the present era (2005 to 2010) AIDS-related deaths have greatly decreased, accounting for 16% of deaths. In contrast, causes unrelated to AIDS now account for 84% of deaths in HIV-positive people These causes of death were as follows:

• cancers unrelated to AIDS (including liver cancer)
• liver failure
• infections unrelated to AIDS
• complications arising from substance use
• suicide
• heart attacks

These findings underscore the need to focus future care initiatives on helping HIV-positive people maintain and improve their overall health and quality of life. Such initiatives could include the following:

• early initiation of ART
• help for coping with and recovery from addictions
• support to overcome mental health issues
• screening for pre-cancer and cancer
• monitoring and treatment for hepatitis B and C viral infections
• vaccinations against hepatitis B virus and HPV
• support and encouragement for quitting smoking and practicing safer sex
• advice about changes to the diet and making exercise a part of daily life

Study Details

In addition to monitoring participants via the Swiss HIV Cohort Study, the researchers used software developed by Statistics Canada to link the SHCS database with that of the Swiss National Cohort to capture any data that might have been initially missing concerning cause of death.

Results

Starting in 1988, the SHCS amassed a huge trove of data collected from 16,134 HIV-positive people. Between 1988 and 2010, 5,023 of these people died.