Longitudinal trends in causes of death among adults with HIV in Europe and North America on antiretroviral therapy from 1996 to 2020: a collaboration of cohort studies
Bibliographic record
Abstract
BACKGROUND Mortality rates among persons with HIV (PWH) have fallen since 1996 following the widespread availability of effective antiretroviral therapy (ART). Patterns of cause-specific mortality are evolving as the population of PWH ages. We aimed to investigate longitudinal trends in cause-specific mortality rates among PWH starting ART in Europe and North America. METHODS We used data on PWH aged ≥16 years old when starting ART between 1996 and 2020 from 17 European and North American HIV cohorts contributing data to the Antiretroviral Therapy Cohort Collaboration. Causes of death were classified by both a clinician and an algorithm if ICD9/10 data were available, or independently by two clinicians. Disagreements were resolved through panel discussion. We used Poisson models to compare cause-specific mortality rates during calendar periods 1996-99, 2000-03, 2004-07, 2008-11, 2012-15 and 2016-20, adjusted for time-updated age, CD4 count, and whether ART-naïve at the start of each period. FINDINGS Among 189,301 PWH, 16,832 (8.9%) died. Causes of death were classified for 13180 (78%) deaths: the most common causes were AIDS (4203 deaths; 25%), non-AIDS non-hepatitis malignancy (2311; 14%) and cardiovascular (1403; 8%). The proportion of deaths due to AIDS declined from 49% during 1996-9 to 16% during 2016-20. Rates of all-cause mortality per 1000 person-years decreased from 16.8 (95%CI: 15.4-18.4) during 1996-99 to 7.9 (7.6-8.2) during 2016-20. Rates of all-cause mortality declined with time: the average adjusted mortality rate ratio [aMRR] per calendar period was 0.86 (95%CI 0.85-0.87). Rates of cause-specific mortality also declined: the most pronounced reduction was for AIDS-related mortality (average aMRR per period 0.82; 95%CI 0.80-0.85). There were also reductions in rates of cardiovascular-related, liver-related, non-AIDS infection-related, non-AIDS-non-hepatocellular carcinoma malignancy-related, and suicide/accident-related mortality (average aMRRs per period 0.83 (0.79-0.87), 0.90 (0.85-0.94), 0.92 (0.88-0.97), 0.95 (0.91-0.98), and 0.89 (0.83-0.95), respectively). Mortality rates among people who acquired HIV through injecting drug use were stable among men and increased among women. INTERPRETATION There have been reductions over time in rates of most major causes of death, particularly AIDS-related deaths, among PWH on ART. However, such reductions were not seen for all subgroups. Interventions targeted at high-risk groups, substance use, and comorbidities may further increase life expectancy in PWH towards that in the general population. FUNDING US National Institute on Alcohol Abuse and Alcoholism.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.010 | 0.011 |
| Meta-epidemiology (narrow) | 0.000 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.002 |
| Bibliometrics | 0.003 | 0.004 |
| Science and technology studies | 0.001 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".