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All-cause and HIV-related Mortality Rates Among HIV-infected Patients After Initiating Highly Active Antiretroviral Therapy: The Impact of Aboriginal Ethnicity and Injection Drug Use

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Abstract

Background: Aboriginals are over-represented in Canada’s HIV epidemic and are commonly infected with HIV via injection drug use (IDU); however, little is known about the impact of Aboriginal ethnicity on mortality after starting highly active antiretroviral therapy (HAART). Therefore, we compared mortality rates between Aboriginal and non-Aboriginal HIV patients and between IDU and non-IDU HIV patients after they initiated HAART.

Methods: We conducted a retrospective cohort study of antiretroviral-naïve patients starting HAART January 1999–June 2005 (baseline), followed until December 2005. We constructed two Cox proportional hazards models, one to estimate all-cause and one to estimate HIV-related mortality hazard ratios (HRs), considering sex, and baseline age, CD4 cell count, HIV RNA level, calendar year, and HAART regimen as potential confounders.

Results: The 548 study patients were followed for 1,889.8 person-years; 194 (35%) were Aboriginal, 255 (46%) were IDUs. We observed 55 deaths; 47% were HIV-related. In multivariable models, Aboriginals experienced higher all-cause (HR=1.85, 95% CI=1.05-3.26, p=0.034) and HIV-related (HR=3.47, 95% CI=1.36-8.83, p=0.009) mortality rates compared to non-Aboriginals; and, compared to patients with other exposures, IDUs experienced higher all-cause (HR=2.45, 95% CI=1.31-4.57, p=0.005) but similar HIV-related (p=0.27) mortality rates.

Conclusions: Compared to non-Aboriginals, Aboriginal HIV patients suffer higher all-cause and HIV-related mortality rates after starting HAART. The strongest and most significant predictor of higher all-cause mortality was IDU. Future research should examine reasons for the observed poorer survival of Aboriginal and IDU HIV patients after initiating HAART to develop interventions to improve the prognosis for these vulnerable populations.

Résumé

Contexte: Les Autochtones sont surreprésentés dans l’épidémie de VIH qui sévit au Canada, le plus souvent en raison de l’utilisation de drogues par injection (UDI); pourtant, on sait peu de choses sur l’impact de l’ethnicité autochtone sur la mortalité après le début d’une thérapie antirétrovirale hautement active (TAHA). C’est pourquoi nous avons comparé les taux de mortalité de patients autochtones et non autochtones atteints du VIH et ceux d’UDI et de non-UDI atteints du VIH après le début d’une TAHA.

Méthode: Nous avons mené une étude de cohortes rétrospective auprès de patients naïfs de traitement antirétroviral ayant entamé une TAHA entre janvier 1999 et juin 2005 (groupe de référence), que nous avons suivis jusqu’en décembre 2005. Nous avons construit deux modèles de Cox (modèles des risques proportionnels), l’un pour estimer les coefficients de danger (QD) pour toutes les causes de mortalité et l’autre pour la mortalité liée au VIH, en tenant compte des facteurs confusionnels possibles (sexe, âge au départ, numération des lymphocytes CD4, niveaux d’ARN VIH, année civile et régime TAHA).

Résultats: Les 548 patients à l’étude ont été suivis sur 1 889,8 personnes-années; 194 (35 %) étaient Autochtones, et 255 (46 %) étaient des UDI. Nous avons observé 55 décès, dont 47 % liés au VIH. Dans les modèles multivariés, les Autochtones affichaient des taux supérieurs pour la mortalité toutes causes confondues (QD=1,85, IC de 95 %=1,05-3,26, p=0,034) et la mortalité liée au VIH (QD=3,47, IC de 95 %=1,36-8,83, p=0,009) comparativement aux Non-Autochtones. Par rapport aux patients ayant d’autres expositions, les UDI affichaient des taux supérieurs de mortalité toutes causes confondues (QD=2,45, IC de 95 %=1,31-4,57, p=0,005), mais leurs taux de mortalité liée au VIH étaient semblables (p=0,27).

Conclusion: À comparer aux Non-Autochtones, les patients autochtones atteints du VIH ont des taux supérieurs de mortalité toutes causes confondues et de mortalité liée au VIH après le début d’une TAHA. La variable prédictive la plus forte et la plus significative de la mortalité toutes causes confondues était le statut d’UDI. Dans les futurs travaux de recherche, il faudrait se pencher sur les raisons des moins bons taux de survie observés chez les patients autochtones et les UDI atteints du VIH après le début d’une TAHA afin d’élaborer des interventions susceptibles d’améliorer le pronostic de ces populations vulnérables.

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Authors and Affiliations

  1. Department of Public Health Sciences, School of Public Health, University of Alberta, Edmonton, AB, Canada

    Leah J. Martin PhD, Stan Houston MD, FRCPC, Yutaka Yasui PhD & L. Duncan Saunders MBBCh, PhD

  2. Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, AB, Canada

    Stan Houston MD, FRCPC

  3. Centre for Health Promotion Studies, School of Public Health, University of Alberta, Edmonton, AB, Canada

    T. Cameron Wild PhD

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  1. Leah J. Martin PhD
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  2. Stan Houston MD, FRCPC
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  3. Yutaka Yasui PhD
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  5. L. Duncan Saunders MBBCh, PhD
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Correspondence to Leah J. Martin PhD.

Additional information

Previous Presentations: A previous version of this analysis was presented in part at the 16th Annual Canadian Conference on HIV/AIDS Research, c]Toronto, s]ONtario, Canada April 26–29, 2007 and this work was presented at the XVII International AIDS Conference, Mexico City, Mexico, August 3–8, 2008. This work was also included as a chapter in LJ Martin’s PhD thesis (2009).

Conflict of Interest: None to declare.

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Martin, L.J., Houston, S., Yasui, Y. et al. All-cause and HIV-related Mortality Rates Among HIV-infected Patients After Initiating Highly Active Antiretroviral Therapy: The Impact of Aboriginal Ethnicity and Injection Drug Use. Can J Public Health 102, 90–96 (2011). https://doi.org/10.1007/BF03404154

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