Review mortality trends to reveal emerging picture

Mortality increased for some complications

By Imtiaz A. Choudhary, MD
Assistant Professor
Division of Infectious Diseases
Safraz A. Choudhary, MD
Division of Infectious Diseases
V.R. Mody, MD
Division of Infectious Diseases
Howard University Hospital
Washington, DC

[Editor’s note: This article is based on a presentation the authors gave at the 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), held Sept. 14-17, 2003, in Chicago.]

We conducted this study on HIV-infected patients, between 1994 and December 2002, to assess the mortality rate in our patient population, trends in mortality, and to compare the antemortem and postmortem diagnoses. We also looked for emerging complication, if any, in this patient population.

This study was conducted in an inner-city university hospital at Washington DC, which has the highest AIDS incidence rate in USA. The majority of the population was African-American (83%). Among these, 68.4% were males and 34.6% were females and the average age was 39.

A total of 3,785 patients died during the 1994-2002 period, and 555 (14.66%) had HIV, according to medical records and autopsy records of the hospital.

The mortality in our patients decreased by more than 3% in these years, while the number of admissions of HIV-infected patients remained steady at about 9% of total hospital admissions.

Awareness regarding the HIV testing also increased. All the patients who died with HIV in last three years of study period were aware of their diagnosis before admission. There also was a 15% decrease in autopsy rate in HIV-infected patients. About 26% patients were on antiretroviral medications, and more patients were receiving medications in the later years. There was a downward mortality trend secondary to opportunistic infections and an upward trend secondary to sepsis, hepatic, and renal complications. Prostatitis, therosclerosis, disseminated cytomegalovirus, mycobacterium avium complex, and disseminated fungal infections were the most commonly missed diagnoses.

When comparing antemortem to postmortem diagnoses, missed diagnoses were in endocrine, gastrointestinal systems, renal and electrolyte, central nervous system, cardiovascular systems, infectious diseases, respiratory system followed by hematology and oncology in decreasing order.

We looked at different organ systems and separate disease processes to assess the yearly increase or decrease in mortality.

Over all mortality from sepsis increased by 9.6%; disseminated candida decreased by 55%; disseminated cytomegalo virus infection decreased by 18% while the adrenal cytomegalo virus infection increased by 16%; cryptococcal meningitis increased by 7%, while bacterial meningitis decreased by 34%.

In gastrointestinal complications, liver cirrhosis increased by 31%, whereas gastrointestinal bleed increased by 2%. About 50% of the patients were found to have severe atherosclerosis of one or more of their coronary arteries.

In respiratory complications, the incidence of bronchopneumonia increased, while Pneumocystis carinii pneumonia, Mycobacterium tuberculosis, and Mycobacterium avium complex infection decreased.

The mortality from the nonopportunistic infections may not be more than the non-HIV cohort; but there is a change in mortality trend, as the mortality from opportunistic infection decreased significantly.

The mortality from opportunistic infection decreased probably secondary to decreased threshold by clinicians for diagnosing and treating these infections. So the physicians who are taking care of HIV patient, while they have low threshold for opportunistic infections, should not forget the other infections not traditionally associated with HIV.

If we look at different infections, the mortality decreased from Pneumocystis carinii (Pearson’s R –0.51), Mycobacterium avium complex (Pearson’s R –0.04), Mycobacterium tuberculosis (Pearson’s R –0.62). The mortality from disseminated fungal infections decreased by 55% and disseminated cytomegalovirus by 18%.

The overall mortality in HIV-infected patients decreased by more than 3%.

HIV is a complicated disease, and some of the complications now are emerging as the patients are living longer. Some of the complications may not add directly to the mortality but may add to morbidity and affect the quality of life.

In our analysis, about 50% patients were found to have severe atherosclerosis of one or more of their coronary arteries, but only very few had any kind of work-up for coronary artery disease. About 47% patient had testicular atrophy, but few were worked up and were on replacement therapy.

So taking care of HIV patients should be a model-based group approach including involvement of expertise from every discipline, because these patients not only have psychological and social issues but also variety of complications from treatment and disease itself. As the mortality is decreasing, patients and physicians taking care of them are experiencing some of the new challenges. Be vigilant for coinfections and associated complications, like as in our analysis, the mortality from liver cirrhosis increased tremendously. Try to keep the pill burden as low as possible with special emphasis on prophylaxis medications and vaccinations.

As new complications are emerging from HIV therapy as well as disease itself, clinicians should be very vigilant to look for not only the complication which are associated with HIV but others also, which are not traditionally associated with HIV.

Recommended reading

1. Farthing C, Khanlou H, Yeh V, et al. Early virologic failure in a pilot study evaluating the efficacy of once daily abacavir (ABC), lamivudine (3TC), and tenofovir DF (TDF) in treatment naïve HIV-infected patients (oral presentation). Presented at the 2nd International AIDS Society Meeting. Paris; July 2003.

2. Gallant JE, Rodriguez A, Weinberg W, et al. Early nonresponse to tenofovir DF (TDF) + abacavir (ABC) and lamivudine (3TC) in a randomized trial compared to efavirenz (EFV) + ABC and 3TC: ESS30009 unplanned interim analysis (oral presentation # H-1722a). Presented at the 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy. Chicago; September 2003.

3. Gerstoft J, Kirk O, Obel N, et al. Low efficacy and high frequency of adverse events in a randomized trial of the triple nucleoside regimen abacavir, stavudine, and didanosine. AIDS 2003, 17:2,045-2,052.

4. Gulick RM, Ribaudo HJ, Shikuma CM, et al. ACTG 5095: A comparative study of 3 protease inhibitor-sparing antiretroviral regimens for the initial treatment of HIV infection. Abstract 41. Presented at 2nd IAS Conference on HIV Pathogenesis and Treatment. Paris; July 2003.