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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,

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Presentation on theme: "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,"— Presentation transcript:

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 2Mortality and causes of death among women living with HIV in the UK in the era of HAART 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.

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

4 4Mortality and causes of death among women living with HIV in the UK in the era of HAART 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):

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 5Mortality and causes of death among women living with HIV in the UK in the era of HAART

6 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

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. 7Mortality and causes of death among women living with HIV in the UK in the era of HAART * 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

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

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

10 Characteristics of patients that died: England & Wales, Mortality and causes of death among women living with HIV in the UK in the era of HAART Variables Women All cause mortality* Total1,575 (5.2%) Median age at diagnosis [IQR]37 [31-46] Ethnicity White313 (22%) Black Caribbean76 (5.3%) Black African955 (66%) Other93 (6.7%) Infection route Sex between menN/A Heterosexual contact1,278 (92%) Injecting drug use71 (5.1%) Other44 (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 treatment744 (47%) Diagnosed late (CD4 <350 cells/mm 3 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

11 Mortality among women by cause of death: England & Wales, 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, 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, Mortality and causes of death among women living with HIV in the UK in the era of HAART 1.Pneumocystis (PCP) 2.Lymphoma 3.Tuberculosis 90% Median age of death 39 IQR [33-46] 90% diagnosed late Median survival of 55 days [9-374] Median age of death 41 [34-49] 72% diagnosed late Median survival of 424 days [23-1,652] 72%

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

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

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

17 17Mortality and causes of death among women living with HIV in the UK in the era of HAART Non-AIDS related mortality among women by cause of death: E&W, 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 Progression to complications of viral hepatitis (30%; 15) Alcoholic liver disease (35%; 17) 1/5 infected through injecting drug use.

18 18Mortality and causes of death among women living with HIV in the UK in the era of HAART Non-AIDS related mortality among women by cause of death: E&W, % 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]

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

20 Limitations & future work Challenges classifying deaths - AIDS vs. non-AIDS This analysis focuses on women diagnosed since 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 20Mortality 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 21Mortality 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 23Mortality and causes of death among women living with HIV in the UK in the era of HAART 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.


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