HIV

4. Monitoring Death Certificate Data Key outcome indicator of advanced HIV disease. Assists researchers, policy makers and clinicians to assess/ “red-flag”: treatment success, access, acceptance, adherence, resistance, toxicity; patterns of shifting or ‘competing’ causes of death; prioritization of resource allocation (e.g., to address disparities). Consistent data through 1998. Inconsistent data when coding rules changed in 1999. Objective: To gain a better understanding of the trend between 1998 and 1999, adjusting for this change. Direct comparison of unadjusted data in 1999 with 2000, 2001, etc. Reliable demographic data on age, race, sex, county. Fairly reliable data on multiple causes of death. No risk factor or clinical data.

5. Key Changes from ICD-9 to ICD-10*Study Findings Beginning January 1999, death certificates showing HIV/AIDS plus one of the following diseases have been coded to HIV as underlying cause: Pneumonia, unspecified. Malignancies (most). Viral hepatitis. Severe forms of these diseases have become more common while ‘classic’ OI’s have become less common since the advent of HAART in 1996. In 1999, the effect of these ‘competing’ causes of death on HIV mortality trends essentially disappeared because of the new coding rules. Suspecting a significant impact of ICD-10 on HIV mortality trends, we re-coded according to ICD-9 all death certificates from 1999 with any mention of HIV or AIDS. This yielded an ICD-10/ICD-9 comparability ratio of 1.14. Thus, the effect of the new ICD-10 coding rules was an ‘artificial’ increase of 14% in the number of HIV deaths in 1999.

8. HIV/AIDS Mortality Case-Control StudyObjective and Study Population Objective: Identify risk factors for death in a clinic population. Setting: 4 urban public health department HIV clinics: Duval, Hillsborough, Orange, Palm Beach: N=4,190 clients. Cases: All clients who died in 1999: N=120 cases. Controls: Alive as of 12/31/99: N=240 controls. 2 controls for each case were selected at random from the list of all patients seen on date of the case’s last visit. The selected controls were similar to the client population by race/ethnicity and sex. This enabled generalization of the findings to all clients in the 4 clinics.

9. HIV/AIDS Mortality Case-Control StudyAbstraction of Medical Records Data primarily abstracted for 12-month period preceding the date of the case’s last clinic visit. Socio-demographic variables: age, race, sex, HIV risk factor, income, living situation, insurance type. Behavioral variables: adherence, appointment-keeping, substance abuse. Clinical variables: Opportunistic infections (OI’s), CD4 counts. Non-HIV medical conditions, e.g., anemia, liver failure, etc. Antiretroviral treatment, anti-viral therapy, vaccinations.

10. HIV/AIDS Mortality Case-Control StudyStatistical Analysis Univariate analysis: evaluates association with death of one factor at a time. Multivariate (matched logistic regression) analysis: identifies independent effect of risk factors for death, evaluating multiple variables, each one adjusted for all others. Study design: 3 separate multivariate models, entering variables in conceptually related groups to address a series of specific, public health questions: Model 1: social, demographic and behavioral variables. Model 2: added in measures of significant comorbidity and degree of initial immune system suppression. Model 3: added in HAART, vaccinations and treatment-related variables

11. HIV/AIDS Mortality Case-Control StudyStatistical AnalysisQuestions Posed by the Multivariate Models Model 1: social, demographic and behavioral variables. Question: Who will benefit most from social and psychological support services? Model 2: added in measures of significant comorbidity and degree of initial immune system suppression. Question: Who will benefit most from medical follow-up and support, accounting for the effects of the first set of variables? Model 3: added in HAART, vaccinations and treatment-related variables. Question: Are the beneficial effects of these factors on mortality evident when all the other variables are accounted for?

12. HIV/AIDS Mortality Case-Control StudyResults of Univariate Analysis Sociodemographic and Behavioral Variables Statistically significant differences among cases and controls: Adherence problem OR, 3.21 (p < .001) >2 missed appointments OR, 2.44 (p < .001) Medicaid OR, 3.09 (p < .001) Unmarried/no partner OR, 2.70 (p < .01) Injection drug use OR, 2.17 (p < .05) Homelessness OR, 2.93 (p < .05) Non-Hispanic black OR, 1.70 (p < .05) Not significant: sex, age, HIV risk factor other than IDU, income, Medicare/HMO/private insurance. Note: OR=unadjusted matched odds ratio (the odds of the cases having a given condition divided by the odds of the controls having the condition). If p < .001, the probability that the given OR differs from 1.00 due to chance alone is less than 1 in 1,000.

13. HIV/AIDS Mortality Case-Control Study Results of Univariate Analysis (continued) Clinical Risk Factors, Part I Any AIDS-defining condition: Odds Ratio (OR), 12.7 (p < .001). Wasting and 6 OI’s were each significantly associated with death: MAC, CMV retinitis, herpes simplex, candidiasis esophageal, recurrent pneumonia and PCP. Non-HIV medical conditions (co-morbidities): Liver failure OR, 26.0 (p = .002) Anemia OR, 6.5 (p < .001) Heart disease OR, 3.3 (p = .009) Alcoholism OR, 2.8 (p = .001) Diarrhea OR, 2.2 (p = .001) Hepatitis C disease OR, 1.7 (p = .09)* * Marginally significant

14. HIV/AIDS Mortality Case-Control Study Results of Univariate Analysis (continued)  Clinical Risk Factors, Part II Each of the following risk factors was significantly associated with increased risk of death with a p-value < .001: Not on HAART OR, 2.8 Not on any ART OR, 3.4 No flu vaccine OR, 2.5 No pneumovax OR, 2.2 Initial CD4 <200 OR, 5.1

16. HIV/AIDS Mortality Case-Control StudyMean CD4 CountBy Number of Months fromHIV Diagnosis to Initial CD4 Count

18. HIV/AIDS Mortality Case-Control Study Comparison of Cases (Deaths) With and Without an AIDS-Defining Condition (ADC)  Clinical Risk Factors, Part III

19. HIV/AIDS Mortality Case-Control StudyResults of Multivariate AnalysisMatched, Adjusted Odds Ratios (AOR’s)For Variables Entered in Three Multivariate Models

20. HIV/AIDS Mortality Case-Control StudyResults of Multivariate AnalysisModel 3: Matched, Adjusted Odds Ratios (AOR’s)

21. HIV/AIDS Mortality Case-Control StudyLimitations of the Data Caution should be used in generalizing the findings beyond the 4 study sites. These clinics, and the clients they serve, may not be representative of all Florida public health clinics. If information was missing, incomplete or erroneously recorded in the medical record, a client could have been misclassified concerning the presence or absence of a condition or risk factor. Abstractors were not blinded as to the case/control status of clients, so this potential source of bias cannot be ruled out.

22. HIV/AIDS Mortality Case-Control StudyConclusions and Recommendations Multivariate data showed that non-Hispanic black race/ethnicity influenced risk through its association with other risk factors. Early intervention and linkage to care should reduce mortality. HIV clinical and social work staff should pay particular attention to those who present with advanced HIV infection or who are homeless or living without a partner in the household. Policy makers and clinicians should continue to prioritize access to HAART, including intensive, team-oriented programs facilitating medication adherence. Establish referral systems to community agencies that provide psychosocial and substance abuse treatment services. Devote further attention to the mechanisms and therapy of end-organ causes of death such as liver failure.