Mortality Trends Among Socially-Disadvantaged Antiretroviral-Eligible Patients

1. Mortality Trends Among Socially-Disadvantaged Antiretroviral-Eligible Patients David Dowdy, Elvin Geng, KaterinaChristopoulos, James Kahn, C. Bradley Hare, Daniel Wlodarczyk, Diane Havlir Internal Medicine Residency Program, UCSF Positive Health Program, San Francisco General Hospital

2. Background • ART has shifted the spectrum of HIV-related mortality in the developed world. • <50% of deaths in ART-treated patients are AIDS-related. (ART-CC, Clin Infect Dis 2010, 50:1387) • Socially-disadvantaged patients die more often, and of AIDS. • New York AIDS registry: (Sackoff JE, Ann Int Med 2006,145:397) • 74% of deaths AIDS-related • Mortality 1.6 times higher in IDU • Is excess, AIDS-related mortality seen in such patients who have linked to care? • Is this story changing over time?

3. Objective • To characterize mortality among HIV-infected patients eligible for ART and linked to care at an urban public hospital • Has mortality decreased in the last decade? • Focus on 5 disadvantaged sub-populations: • Injection drug use • Alcohol abuse • Mental health diagnosis • Non-white race • Female/transgender

4. Methods: Design, Setting, Patients • Design: Cohort study • Setting: Urban safety-net HIV clinic • San Francisco, California, USA • Patients among the poorest in the city • Patients: All patients linked to care & eligible for ART • ≥2 primary care visits • CD4 nadir ≤350 cells/mm3 • Jan. 1998 through Aug. 2009 • N = 1651

5. Methods: Measurements, Analyses • Measurements: • At study entry: CD4/VL, HIV risk factors, prior ART • Mortality: chart review & death index • Analyses: • Cox proportional hazards with delayed entries • Primary comparison: mortality in 2000-2004 vs. 2005-2009 • 1/1/05: midpoint of study period & decade • Secondary analyses: • Disadvantaged subpopulations • Causes of death, viral suppression

6. Study Population

7. Mortality

8. Mortality ART-CC

9. Causes of Death

10. Disadvantaged Subgroups Had Higher Mortality in 2005-2009 Adjusted for age, initial CD4 count, baseline HIV viral load, HCV, and prior ART exposure

11. Mortality in Injection Drug Users 2000-2004 2005-2009

12. Causes of Death in IDUs Unknown 19 (31%) Not AIDS 17 (28%)

13. Viral Suppression at Any Point Deaths (n = 172) Survivors (n = 1479)

14. Summary of Findings • Mortality was high & did not improve over time. • 10% over 4 years (2.6% per person-year) in 2000-04 • 11% (2.7% per person-year) in 2005-09 • Increased among IDU and other disadvantaged groups • HIV-related mortality still dominates. • Liver, heart, renal + non-AIDS cancer: <10% of deaths • Most patients who died never suppressed their viral loads.

15. Conclusions • In developed countries, wide disparities in mortality still exist among PLWHA. • High mortality in socially-disadvantaged populations despite linkage to highest-quality care • Parallel research needed on “old” & “new” HIV epidemics • Intensive, multi-dimensional approach needed • Future research directions: • Comparing mortality among at-risk HIV-infected patients with non-infected peers • Impact of linkage vs. maintenance of care

16. Acknowledgments • Collaborators: • Elvin Geng • Kat Christopoulos • Jim Kahn • Brad Hare • Dan Wlodarczyk • Diane Havlir • UCSF Resident Research Program • Physicians & Patients of Ward 86

17. Thank You!