Despite living longer, HIV-positive people still die primarily from underlying infections and not just old age factors
A review of 252 autopsy reports of those who died of AIDS in New York City between 1984 and 2016 shows that preventative medicine is still crucial in keeping patients from developing infections due to reduction in the efficacy of the immune system
HIV-positive people are living longer but they are still dying from underlying infection, and not just from old age. Other diseases are now emerging as the leading causes of death, says the research team at NYU School of Medicine and NYU Long Island School of Medicine.
The findings - a review of the autopsy reports of 252 men and women who died of acquired immunodeficiency syndrome (AIDS) in New York City between 1984 and 2016 - reveal several long-term trends in combating the epidemic. The infectious disease is known for drastically reducing the body’s immune defenses and is spread by the human immunodeficiency virus or HIV.
The analysis shows that infections such as pneumonia (pneumocystis pneumonia) in the lungs are still the leading cause of death, accounting for 100% of deaths between 1984 and 1987, 52% between 1996 and 1999, and 86% from 2012 to 2016. This, says the team, shows that even a treated HIV-positive patient is immunocompromised and at increased risk of dying from pneumonia.
“Preventative medicine is still key in keeping patients from developing infections due to immunosuppression (in which the efficacy of the immune system is reduced). The implications of our study are that the natural history of HIV is evolving and not completely understood as it relates to diagnosis and changes/complications of therapy. Therefore, autopsy still plays a role in confirming the etiologically specific cause of death in patients dying with/from HIV,” senior study investigator Amy Rapkiewicz told MEA WorldWide (MEAWW).
This is the longest longitudinal autopsy study for HIV patients, beginning soon after the onset of the epidemic in 1984 and continuing through the increasing use of antiretroviral therapy in 2016. The research team retrieved and reviewed a total of 286 autopsies for patients with HIV and/or AIDS that were performed between 1984 and 2016. Among these, seven fetuses and 27 children under seven years of age were excluded from the study. The remaining 252 patients were included in the final analysis.
The researchers state that their study has been designed in part to educate more clinicians, not just physicians, but also physician assistants and nurse practitioners, about the importance of accurately documenting death certificates to properly reflect people’s HIV status and the main cause of death.
“Our study accurately reflects the history of the epidemic in New York City, which still has the highest number of new HIV infections per year in the US. Autopsy reports reliably tell the whole disease story and why people are still dying from it. This is because there is often a difference between the immediately reported cause of death, such as a heart attack, and the actual cause of death, whether from obesity, drug use, or HIV/AIDS,” says Dr. Rapkiewicz, who is an associate professor in the Department of Pathology at NYU Langone Health and vice-chair of pathology at NYU Winthrop Hospital on Long Island.
Experts estimate that more than 100,000 New Yorkers have died of AIDS-related causes since the epidemic began, and 125,000 are currently living with HIV. In 2017, says the study, the city recorded more than 2,100 new cases of HIV infection.
For their study, published in the Archives of Pathology & Laboratory Medicine, the researchers examined autopsy reports performed at Bellevue Hospital, New York City. One of the key findings of the study is that early in the HIV epidemic in 1984, the average age of death in the city from AIDS was 36. By 2010, the average age had risen to 54.
The researchers credit this increase in lifespan to the development of combination antiviral drug therapies in the 1990s that prevent HIV from reproducing and infecting other cells. “With increasing use and efficacy of antiretroviral therapy, the mortality associated with human immunodeficiency virus infection (HIV) has decreased,” says the study. However, the researchers say, despite the advancements, people are still dying predominantly from the underlying disease and not just factors related to old age.
According to the researchers, now that people are living longer with HIV, other common co-infections, such as viral hepatitis C, which takes years to damage the liver, are starting to emerge as causes and contributors of death. Three-quarters of those autopsied between 2014 and 2016 had hepatitis C and cirrhosis, a severe and potentially deadly scarring of the liver. The researchers, however, add that recent advances in drug therapies for hepatitis C are expected to reduce these numbers in the near future.
“In contrast to the decline in AIDS-defining infections, the frequency of non-AIDS defining infections increased over the study period, from 37% in 1984-87 to 73% in 2008-11 and 57% in 2012-2016. These infections included bacteremia, endocarditis, pneumonia, Mycobacterium tuberculosis, Hepatitis C, Aspergillus, and Clostridium difficile, with nearly all patients having co-infections. We also assessed the overall prevalence of infections as a direct cause of death, including both opportunistic and non-opportunistic infections, and excluding patients with trauma or other predominant factor leading to death. This frequency was very high in the initial study years - 100% during 1984-1987. It declined over the next decade to a nadir of 52% by 1996-1999, and then increased again,” says the study.
It further adds, “Other causes of death found in this study included hemorrhagic shock, cardiac arrest of unclear etiology, myocardial infarction, pulmonary embolism, and necrotizing pancreatitis. There was no overall pattern of increasing deaths from cardiovascular disease among the patients.”
The study also found a sharp increase in hardened and fat-narrowed arteries due to a condition called atherosclerosis among those dying with HIV. Between 1988 and 1991, atherosclerosis was found in 21% of those autopsied, but for the years 2008 to 2011, the condition was found in 54%, shows analysis. The researchers state the reason behind this increase remains to be explained by future autopsy reports.
According to lead study investigator Dr. Sobia Nizami, a clinical fellow in infectious diseases at NYU Langone, it is difficult to assess if this trend is due to HIV-positive people simply living longer, overeating, and adopting the sedentary lifestyles widely seen among non-infected Americans, or if something more worrisome, such as long-term side effects of antiviral medications, are at the root of the problem. Body fat deposits seen with earlier anti-HIV drugs were, she says, mostly eliminated with later versions of the drugs.