Impact of AIDS on premature mortality in Amsterdam, 1982-1992

Decline in incidence of HIV and hepatitis C virus infection among injecting drug users in Amsterdam; evidence for harm reduction?

AIMS

In Amsterdam, HIV prevalence has nearly halved among injecting drug users (IDU) since 1990. Hepatitis C virus (HCV) prevalence also declined; HIV and HCV incidence dropped to nearly zero. We examined possible explanations for these time trends, among which the implementation of harm reduction measures aimed at reducing the risk behaviour of IDU.

DESIGN

We used individual-based modelling of the spread of HIV and HCV. Information about demographic parameters was obtained from the Amsterdam Cohort Study (ACS) among drug users. The model included changes in inflow of new IDU and death rates over time, the latter dependent on age and time since HIV seroconversion. We considered different scenarios of risk behaviour.

SETTING

IDU in Amsterdam.

MEASUREMENTS

Simulated HIV and HCV incidence and prevalence were compared with ACS data.

FINDINGS

Assuming that harm reduction measures had led to a strong decrease in risk behaviour over time improved the model fit (squared residuals decreased by 30%). However, substantial incidence and HIV prevalence decline were already reproduced by incorporating demographic changes into the model. In particular, lowered disease spread might be a result of depletion of high-risk IDU among those at risk for disease, and a decrease in the number of high-risk individuals in the population due to HIV-related mortality.

CONCLUSIONS

Marked decreases in HIV and HCV in Amsterdam since 1990 could be due partly to harm reduction measures; however, they may also be attributable largely to changes in the IDU population. Future research aimed at quantifying the benefits of interventions should not neglect the impact of natural epidemic progression and demographic changes.

The AIDS epidemic in the city of Copenhagen, Denmark: potential years of life lost and impact on life expectancy

AIMS

This study seeks to describe the impact of AIDS on the city of Copenhagen by estimating potential years of life lost (PYLL) before the age of 65 years and to estimate the impact of AIDS deaths on life expectancy for males and females.

METHODS

All AIDS cases reported to the national AIDS surveillance register for residents in the city of Copenhagen in the period 1983-98 were included. For comparative purposes data were obtained on six other causes of death: accidents, suicide, lung cancer, ischaemic heart disease, testicular cancer, and breast cancer.

RESULTS

Overall, deaths from AIDS accounted for 8% of all PYLL in men and showed an increasing tendency from 1983 to 1991, when it became the leading cause of PYLL. AIDS had most impact in men in the age group 25-44 years and accounted for 29% of all PYLL in this group at the peak in 1993, decreasing significantly after the introduction of anti-retroviral treatments to 5% of PYLL in 1998. Other leading causes of PYLL, accidents and suicide, also showed a decreasing tendency over the years, but of a much smaller magnitude than AIDS. The impact of AIDS in women was more modest. In the entire study period suicide, accidents, and breast cancer were the leading causes of PYLL in women. It was shown that AIDS deaths at the top of the epidemic in 1991-95 were responsible for a loss of 0.76 years in life expectancy for men and 0.08 years for women.

CONCLUSIONS

AIDS has had a considerable impact on potential years of life lost. A significant decline in AIDS deaths has been seen since 1995 with an effect on life expectancy for men in the city of Copenhagen.

Declining AIDS mortality in Amsterdam: contributions of declining HIV incidence and effective therapy

INTRODUCTION

We aimed to evaluate the impact of highly active antiretroviral therapy (HAART) on AIDS mortality, taking into account earlier HIV incidence patterns.

METHODS

Using AIDS Surveillance data (1982-2000), we calculated the observed course of the AIDS epidemic among homosexual men in Amsterdam, The Netherlands. We used the HIV incidence patterns (1980-2000) among homosexual men participating in the hepatitis B vaccine trial and the Amsterdam Cohort Study and those attending the Amsterdam sexual transmitted infections clinic, together with the time from seroconversion to AIDS and death in the pre-HAART era, to estimate the natural course of the AIDS epidemic if HAART had not been introduced.

RESULTS

The estimated course of the AIDS epidemic without the benefits of HAART showed a decline in AIDS mortality, but this estimated decline was not as strong as the observed decline. Taking into account the HIV incidence over calendar time, we estimated that 331 deaths among homosexual men were prevented by HAART between 1996 and 2000 in Amsterdam.

CONCLUSION

The decline in AIDS mortality was the result of both HAART and a decline in the HIV incidence in the early 1980s. When evaluating the effect of HAART on mortality, changes in HIV incidence must also be considered.

Trends in causes of death in the Aquitaine cohort of HIV-infected patients, 1995-1997

OBJECTIVE

To describe trends in the evolution of causes of death in a cohort of HIV-infected patients before and after the introduction of highly active antiretroviral treatment (HAART).

METHODS

This descriptive study concerned all the patients of the Aquitaine cohort who died between 1995 and 1997. Causes of deaths were grouped into 13 'deaths due to an AIDS-defining underlying cause', and eight 'non AIDS' categories. Comparisons were performed between two comparable periods of 18 months, January 1995-June 1996 and July 1996-December 1997 to focus on changes introduced by the prescription of HAART in June 1996.

RESULTS

Five hundred and thirty-two deaths were notified in 36 months for a total of 3687 patients. The comparison between causes of deaths before and after June 1996 showed a significant difference between the two periods with a decreasing proportion of AIDS causes of death, from 82.7% to 72.2% (p = 0.007).

CONCLUSION

HAART treatment has reduced the number and percentage of deaths due to AIDS-related causes among persons who died with HIV infection in South-western France.

[AIDS mortality in the State of Rio de Janeiro, 1991-1995]

This article focuses on the AIDS mortality profile as related to socioeconomic and geographic variables, as well as evaluating the impact of deaths from AIDS in the State of Rio de Janeiro. The analysis included all death certificates for residents of the State from 1991-1995, 10,024 of which had AIDS recorded as the primary cause of death. In the 20-49-year age bracket, among individuals who had died of AIDS, the proportion of those with university schooling (14%) and the proportion of single individuals (75%) were greater than the respective proportions for all other causes of death (5.4% and 56.3%). For the population as a whole, the AIDS mortality rate increased from 1991 to 1995, from 20.6/100,000 to 30.2/100,000 for males and from 3.7/100,000 to 7.9/100,000 for females. For the year 1995 in the 20-49-year bracket, considering the 17 groups of causes from the ICD-9, AIDS was the third most common cause of death among men and the fifth most common among women. The proportion of Potential Loss of Life Years up to 65 years as a function of AIDS increased from 1991 to 1995, from 3.4% to 4.7% for men and from 1.4% to 2.9% for women. During this same period there was also an increase in the number of counties in the State of Rio de Janeiro with reported deaths from AIDS.

Pre-AIDS mortality and its association with HIV disease progression in haemophilic men, injecting drug users and homosexual men

OBJECTIVE

To study pre-AIDS mortality and its association with HIV disease progression in different exposure groups with known intervals of HIV seroconversion.

DESIGN AND METHODS

The type and rate of pre-AIDS deaths were assessed in 111 HIV-infected haemophilic men followed in London, and 118 injecting drug users and 158 homosexual men followed in Amsterdam. In each group, the association between CD4+ T-cell count, HIV RNA and pre-AIDS mortality was studied using proportional hazards analysis.

RESULTS

By 10 years after seroconversion 7.3% of the haemophilic men had died without AIDS and 38.2% had developed AIDS. These figures were 20.2 and 30.5% for injecting drug users, and 8.0 and 55.0% for homosexual men. The major causes of pre-AIDS mortality appear to differ in the three exposure groups. The risk of pre-AIDS death tended to increase with decreasing CD4 cell count and increasing HIV RNA levels in injecting drug users and homosexual men. In men with haemophilia the associations were less obvious, although the log-transformed CD4 cell count was predictive for pre-AIDS death.

CONCLUSIONS

Pre-AIDS deaths occur and are at least partially related to HIV disease progression irrespective of how individuals became infected. Because of the longer life expectancy due to highly active antiretroviral therapy (HAART), pre-AIDS deaths are likely to show a further increase. Methods to incorporate these intermediate outcomes should be considered in the estimation of the size of the HIV epidemic and in the survival analysis of HIV-infected individuals. Prevention and treatment of non-AIDS infections, especially hepatitis C virus infection, and cancers will become increasingly important in HIV-infected individuals. The interaction between these therapies and HAART should be closely monitored.

Mortality in young adults in England and Wales: the impact of the HIV epidemic

OBJECTIVE

To quantify the contribution of the HIV epidemic to premature mortality in England and Wales 1985-1996.

DESIGN

Surveillance of deaths in HIV-infected individuals and causes of death from death certificates.

MAIN OUTCOME MEASURES

Time trends in age-specific mortality rates among 15-44 year olds and years of potential life lost (YPLL) to age 65 associated with HIV infection and other important causes of death in young adults.

RESULTS

The crude age-specific mortality rates for all causes of death in the 15-44 year age band remained fairly constant between 1985 and 1996: in other age bands a decrease was seen. Deaths from both suicide and HIV increased in men aged 15-44 years. Although suicide accounted for a greater number of deaths throughout the period investigated, the largest proportional and absolute increase was seen for deaths in HIV-infected people. By 1996, the contribution of HIV to YPLL to age 65 varied from less than 0.5% in most rural localities to 20% of total YPLL in one London health authority.

CONCLUSIONS

While part of the adverse trend in mortality in younger adults since 1985 was attributable to suicide, most resulted from HIV infection. The impact of HIV infection on mortality was greatest in London.

Morbidity and mortality related to human immunodeficiency virus in Canadian men and women, 1987-94

OBJECTIVE

To assess the impact of HIV/AIDS on hospitalization and mortality patterns in Canada.

METHODS

Hospitalizations and deaths due to HIV/AIDS were compared with select causes of morbidity and mortality among men and women across provinces, regions and select cities between 1987-94. Patterns of hospitalization and mortality were characterized by calculating age-specific, standardized rates, rate ratios and potential years of life lost before 65 years.

RESULTS

A total of 28,462 hospitalizations (26,153 in men and 2,309 in women) and 8,739 deaths (8,192 in men and 547 in women) were attributed to HIV/AIDS during the study period. Rates of HIV/AIDS hospitalization were highest for men in Ontario, Quebec and British Columbia, and in Montreal, Toronto and Vancouver; while among women they were highest in Quebec and in Montreal, Toronto and Vancouver. Mortality rates followed a pattern similar to the rates found for hospitalization.

CONCLUSIONS

Our analysis reveals the considerable impact of HIV/AIDS on patterns of morbidity and mortality in Canada.

Changing patterns of mortality across Europe in patients infected with HIV-1. EuroSIDA Study Group

BACKGROUND

The introduction of combination antiretroviral therapy and protease inhibitors has led to reports of falling mortality rates among people infected with HIV-1. We examined the change in these mortality rates of HIV-1-infected patients across Europe during 1994-98, and assessed the extent to which changes can be explained by the use of new therapeutic regimens.

METHODS

We analysed data from EuroSIDA, which is a prospective, observational, European, multicentre cohort of 4270 HIV-1-infected patients. We compared death rates in each 6 month period from September, 1994, to March, 1998.

FINDINGS

By March, 1998, 1215 patients had died. The mortality rate from March to September, 1995, was 23.3 deaths per 100 person-years of follow-up (95% CI 20.6-26.0), and fell to 4.1 per 100 person-years of follow-up (2.3-5.9) between September, 1997, and March, 1998. From March to September, 1997, the death rate was 65.4 per 100 person-years of follow-up for those on no treatment, 7.5 per 100 person-years of follow-up for patients on dual therapy, and 3.4 per 100 person-years of follow-up for patients on triple-combination therapy. Compared with patients who were followed up from September, 1994, to March, 1995, patients seen between September, 1997, and March, 1998, had a relative hazard of death of 0.16 (0.08-0.32), which rose to 0.90 (0.50-1.64) after adjustment for treatment.

INTERPRETATION

Death rates across Europe among patients infected with HIV-1 have been falling since September, 1995, and at the beginning of 1998 were less than a fifth of their previous level. A large proportion of the reduction in mortality could be explained by new treatments or combinations of treatments.