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Association between Modifiable and Non-modifiable Risk Factors and Specific Causes of Death in the HAART Era: The Data Collection on Adverse Events of Anti-HIV Drugs Study
Colette Smith and D:A:D Study Group
Univ Coll London Med Sch, UK
Background: Excess
mortality remains for HIV+ individuals compared to the general
population. Identifying modifiable risk factors associated with specific causes
of death could guide interventions.
Methods: Patients
were followed from date of entry into the D:A:D study until death or last
follow-up (through October 1, 2007). Cause of death was ascertained using the
CoDe system. Adjusted rate ratios (RR) for the association between potential
modifiable risk factors (hepatitis C and B virus [HCV, HBV], body mass index,
smoking, hypertension [systolic BP≥140 or diastolic BP≥90 or anti-hypertensive
use], diabetes, ART use, current CD4 count, current HIV RNA [current variables
lagged by 3 months]) and death were obtained with Poisson regression, adjusted
for other potential confounders (sex, race, risk for HIV infection,
calendar year, age, prior cardiovascular disease (CVD) or AIDS).
Results: There
were 2192 deaths in 33,347 people followed for 158,959 person-years (rate = 1.4/100
person-years). Underlying causes were AIDS (32%), liver-related (14%), non-AIDS
cancers (12%), CVD (11%), and other (31%). Risk factors for overall death were smoking,
low body mass index (<18 kg/m2), hypertension, diabetes, HBV/HCV-co-infection,
low current CD4, and higher HIV RNA (table; for comparison, results for the 2
main demographic variables are also shown) although the strength of
associations of the modifiable risk factors with the cause-specific death rates
varied substantially. Smoking was associated with CVD and
non-AIDS cancers, HBV and HCV co-infection with liver-related deaths, and hypertension
with liver-related and CVD deaths. Diabetes was a risk factor for all specific
causes of death except non-AIDS cancers, and higher current HIV RNA for
AIDS-related and liver-related deaths. Lower CD4 counts were associated with a
higher risk of death from all specific causes of death.
Conclusions:
Multiple potentially modifiable risk factors for deaths in HIV-infected
persons were identified. These factors must be addressed to further reduce
mortality. Maintaining higher CD4 cell counts is likely to have the broadest
effect on decrease in deaths.
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