1. Mortality and causes of death among women living with HIV in the UK in the era of highly-active antiretroviral therapy
Sara Croxford, A Kitching, M Kall, M Edelstein and V Delpech
Centre for Infectious Disease Surveillance and Control (CIDSC)
Public Health England
London, United Kingdom

2. Key findings
AIDS is still the most common cause of death among HIV positive women in the era of effective treatment.
This is mostly due to late diagnosis and the majority of deaths occurring within the first few months of diagnosis.
Classification of causes of death can be challenging.
Our cohort of women diagnosed since 1997 also had high rates of non-AIDS death causes which warrants further investigation.
Mortality and causes of death among women living with HIV in the UK in the era of HAART

3. Annual new HIV and AIDS diagnoses and deaths: UK, 1981-2012
First test for HIV
ART available
Mortality and causes of death among women living with HIV in the UK in the era of HAART

4. AIDS remains the silent killer: Ten-year mortality trends among persons diagnosed with HIV: England & Wales,
Simmons RD, Ciancio BC, Kall MM, Rice BD and Delpech VC. Ten-year mortality trends among persons diagnosed with HIV infection in England and Wales in the era of antiretroviral therapy: AIDS remains a silent killer. HIV Med 2013 Nov; 14(10):
Mortality and causes of death among women living with HIV in the UK in the era of HAART

5. Objectives
Explore survival among the cohort of women diagnosed with HIV in the UK after the introduction of effective treatment.
Describe AIDS and non-AIDS causes of death among this cohort and compare with general population
Mortality and causes of death among women living with HIV in the UK in the era of HAART

6. Women living with HIV in the UK
In 2012, there were 31,700 women living with HIV in the UK, a quarter of which were undiagnosed.
Late diagnosis among women is high.
Majority of diagnoses made in antenatal care and STI clinics.
Women are a population that is under studied
Mortality and causes of death among women living with HIV in the UK in the era of HAART

7. Methods
Population: Cohort of women (aged ≥15 years) diagnosed with HIV in England and Wales between and seen for HIV care.
Data sources: National surveillance data reported to PHE were linked to death record data from the Office of National Statistics.
Death categorisation: Deaths to the end of 2012 were categorised using a modified CoDe protocol* into AIDS and non-AIDS-related causes.
Statistical analysis: Cumulative mortality was examined using Kaplan-Meier, with censoring at death or date last seen.
* Kowalska JD, Friis-Moller N, Kirk O, Bannister W, Mocroft A, Sabin C, et al. The Coding Causes of Death in HIV (CoDe) Project: initial results and evaluation of methodology. Epidemiology. 2011;22(4):516-23
Mortality and causes of death among women living with HIV in the UK in the era of HAART

8. National HIV cohort of women: England & Wales, 1997-2012
32,400 women diagnosed with HIV
30,010 in HIV care
95% infected through heterosexual sex
73% black African
59% diagnosed under the age of 35
160,710 person years
1,575 died (5.2%)
All-cause mortality rate 9.8 per 1,000 person years
Mortality and causes of death among women living with HIV in the UK in the era of HAART

9. Cohort survival Women Men
Mortality and causes of death among women living with HIV in the UK in the era of HAART

10. Characteristics of patients that died: England & Wales, 1997-2012
Variables
Women
All cause mortality*
Total
1,575 (5.2%)
Median age at diagnosis [IQR]
37 [31-46]
Ethnicity
White
313 (22%)
Black Caribbean
76 (5.3%)
Black African
955 (66%)
Other
93 (6.7%)
Infection route
Sex between men
N/A
Heterosexual contact
1,278 (92%)
Injecting drug use
71 (5.1%)
44 (3.2%)
Median age at death [IQR]
40 [33-47]
Median survival post-diagnosis (months)[IQR]
4.6 [ ]
Previous AIDS diagnosis**
919 (58%)
Ever on treatment
744 (47%)
Diagnosed late (CD4 <350 cells/mm3 within 91 days)
566 (80%)
Men
All cause mortality*
3,727 (7.0%)
42 [34-51]
2,279 (66%)
122 (3.5%)
808 (23%)
243 (7.0%)
1,710 (51%)
1,370 (41%)
257 (7.6%)
27 (1.0%)
44 [37-54]
7.9 [ ]
2,058 (63%)
1930 (52%)
1,358 (74%)
* Proportions where data are known.
**Diagnosis with an AIDS-defining illness
Mortality and causes of death among women living with HIV in the UK in the era of HAART

11. Mortality among women by cause of death: England & Wales, 1997-2012
Mortality and causes of death among women living with HIV in the UK in the era of HAART

12. Mortality by cause of death and sex: E&W, 1997-2012
Mortality and causes of death among women living with HIV in the UK in the era of HAART

13. Mortality among women by cause of death: E&W, 1997-2012
Pneumocystis (PCP)
Lymphoma
Tuberculosis
90%
Median age of death 39 IQR [33-46]
90% diagnosed late
Median survival of 55 days [9-374]
72%
Median age of death 41 [34-49]
72% diagnosed late
Median survival of 424 days [23-1,652]
Mortality and causes of death among women living with HIV in the UK in the era of HAART

14. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
Unspecified or non-recurrent pneumonia
Sepsis
79% diagnosed late – AIDS?
Mortality and causes of death among women living with HIV in the UK in the era of HAART

15. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
Breast cancer (21%)
Lung cancer (15%)
Median age of death was 44 [39-53]
Mortality and causes of death among women living with HIV in the UK in the era of HAART

16. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
Mortality and causes of death among women living with HIV in the UK in the era of HAART

17. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
Progression to complications of viral hepatitis (30%; 15)
Alcoholic liver disease (35%; 17)
1/5 infected through injecting drug use.
Poster MOPE179 – Monday
Deaths due to viral hepatitis and other causes of liver disease among a large national HIV cohort, England and Wales ( )
A. Kitching, S. Croxford, M. Edelstein, M. Kall, V. Delpech
Mortality and causes of death among women living with HIV in the UK in the era of HAART

18. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
58% of all deaths due to substance abuse were among people infected with HIV through injecting drug use.
Low median age of death
Accident/suicide 28 [25-42]
Substance abuse 33 [24-39]
Mortality and causes of death among women living with HIV in the UK in the era of HAART

19. Non-AIDS related mortality among women by cause of death: E&W, 1997-2012
COPD
Renal failure
Pancreatitis
Gastro-intestinal haemorrhage
Mortality and causes of death among women living with HIV in the UK in the era of HAART

20. Limitations & future work
Challenges classifying deaths - AIDS vs. non-AIDS
This analysis focuses on women diagnosed since 1997.
Under-reporting of deaths
Current and future work:
Age-standardised mortality rates
London Death Audit
Improve quality of HIV care by reviewing the patient pathway of those who die with HIV in London, i.e. remediable factors
Identify particular scenarios that are worthy of further case investigation, including periodic public case presentation and audit
Mortality and causes of death among women living with HIV in the UK in the era of HAART

21. Conclusions
Despite high uptake of antenatal screening, there are high rates of late diagnosis and deaths among HIV positive women.
The large majority of deaths are preventable.
Our findings highlight the need for increased and expanded HIV testing in general practice and community settings.
Good surveillance data on deaths and cause of deaths is crucial in monitoring the response to HIV epidemic
Mortality and causes of death among women living with HIV in the UK in the era of HAART

22. NO ONE SHOULD DIE OF AIDS IN 2014

23. Acknowledgements
The continuing collaboration of those who contribute to HIV surveillance in the UK is gratefully acknowledged. Without their generosity, time and effort the current level of understanding of the epidemic could not have been obtained.
HIV/AIDS Reporting Team particularly Rajani Raghu and Graeme Rooney
All contributors to STI, HIV and AIDS research and surveillance, and to all those involved in providing treatment and care to persons diagnosed with HIV in the UK.
The Office of National Statistics for providing death data.
Mortality and causes of death among women living with HIV in the UK in the era of HAART