Judith E. Sackoff, PhD; David B. Hanna, MS; Melissa R. Pfeiffer, MPH; Lucia V. Torian, PhD
Acknowledgments: The authors thank Richard Selik, MD, Centers for Disease Control and Prevention HIV Incidence and Case Surveillance Branch, for careful review of the manuscript; the field surveillance and data support staff, especially Sonny Ly and Walter Smith, New York City DOHMH HIV Epidemiology Program, for assistance with case reviews and data management; and the New York City DOHMH Office of Vital Statistics for sharing data and expertise.
Grant Support: Through a cooperative agreement between the New York City DOHMH HIV Epidemiology Program and the Centers for Disease Control and Prevention (U62/CCU223595).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Judith E. Sackoff, PhD, HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Sackoff and Torian, Mr. Hanna, and Ms. Pfeiffer: HIV Epidemiology Program, Bureau of HIV/AIDS Prevention and Control, New York City Department of Health and Mental Hygiene, 346 Broadway, Room 706, CN44, New York, NY 10013.
Author Contributions: Conception and design: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Analysis and interpretation of the data: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Drafting of the article: J.E. Sackoff, D.B. Hanna.
Critical revision of the article for important intellectual content: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Final approval of the article: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer, L.V. Torian.
Statistical expertise: D.B. Hanna.
Obtaining of funding: J.E. Sackoff.
Administrative, technical, or logistic support: J.E. Sackoff, D.B. Hanna, M.R. Pfeiffer.
Collection and assembly of data: D.B. Hanna, M.R. Pfeiffer.
Sackoff J., Hanna D., Pfeiffer M., Torian L.; Causes of Death among Persons with AIDS in the Era of Highly Active Antiretroviral Therapy: New York City. Ann Intern Med. 2006;145:397-406. doi: 10.7326/0003-4819-145-6-200609190-00003
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Published: Ann Intern Med. 2006;145(6):397-406.
Over the past 20 years, AIDS has been transformed from a disease that was almost inevitably fatal to a chronic condition that is manageable for many people in the United States (1). The evolution began modestly in the early 1990s with prophylaxis against common opportunistic illnesses and accelerated in the mid-1990s with the introduction of protease inhibitors and highly active antiretroviral therapy (HAART). Between 1996 and 1998, HIV-related morbidity and mortality decreased by 60% in the United States (2-4).
Adrian M. Di Bisceglie
Saint Louis University
December 20, 2006
Letter to Editor
We read with interest the recent article by Sackoff and colleagues on causes of death among persons with AIDS in the HAART era in New York City (1). This is a comprehensive analysis of non-HIV causes of death and may be representative of patterns in the United States as a whole. The authors conclude that the proportion of deaths due to non-HIV-related causes increased by 33% between 1999 and 2004 and they suggest that these findings require a shift in the provision of health care for persons with AIDS from a focus on HIV infection to a model that encompasses other aspects of physical and mental health.
This shift in causes of death represents a major triumph of medical care in the United States, but the authors' analysis exposes another significant health problem in persons with HIV infection, namely death due to hepatitis and liver disease. Although liver disease is not included specifically in the authors' top ten list of non-HIV causes of death, when the individual categories of hepatitis C, liver cancer and cirrhosis of the liver are combined, they account for the third largest category after complications of drug abuse and dependency and chronic ischemic heart disease. In addition, the contributions of alcohol abuse/ dependence and drug abuse/ dependence to liver disease are not accounted for and may increase this category substantially.
It is estimated that 30% of HIV-infected individuals in the United States are co-infected with the hepatitis C virus (HCV) and a further 5- 10% with the hepatitis B virus (HBV) (2,3,4). These chronic viral infections, together with alcohol abuse and diabetes, are major contributors to cirrhosis and liver cancer. Although current treatments for alcoholic liver disease and non-alcoholic steatohepatitis remain inadequate, considerable progress has been made towards developing effective therapies for chronic hepatitis B and hepatitis C and these therapies have the potential to reduce the rates of death and liver cancer. Further studies are needed to ascertain whether treatment of hepatitis C and hepatitis B viral will also reduce the mortality rate from liver disease in HIV positive persons. In summary, we feel it is important to recognize the significant contribution of hepatitis and liver disease to morbidity and mortality associated with HIV infection and AIDS. Clearly, considerable further research is needed into causes and treatment of chronic liver disease in persons with AIDS, and liver disease should be specifically addressed in future models of health care provision for persons infected with HIV.
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