1. David Dowdy, Elvin Geng, Katerina Christopoulos, James Kahn, C. Bradley Hare, Daniel Wlodarczyk, Diane Havlir Internal Medicine Residency Program, UCSF Positive Health Program, San Francisco General Hospital

2. ART has shifted the spectrum of HIV-related mortality in the developed world. – <50% of deaths in ART-treated patients are AIDS- related. (ART-CC, Clin Infect Dis 2010, 50:1387) Socially-disadvantaged patients die more often, and of AIDS. New York AIDS registry: (Sackoff JE, Ann Int Med 2006,145:397) – 74% of deaths AIDS-related – Mortality 1.6 times higher in IDU Is excess, AIDS-related mortality seen in such patients who have linked to care? – Is this story changing over time?

3.  To characterize mortality among HIV-infected patients eligible for ART and linked to care at an urban public hospital ◦ Has mortality decreased in the last decade? ◦ Focus on 5 disadvantaged sub-populations:  Injection drug use  Alcohol abuse  Mental health diagnosis  Non-white race  Female/transgender

4. Design: Cohort study Setting: Urban safety-net HIV clinic San Francisco, California, USA Patients among the poorest in the city Patients: All patients linked to care & eligible for ART – ≥2 primary care visits – CD4 nadir ≤350 cells/mm 3 – Jan. 1998 through Aug. 2009 – N = 1651

5. Measurements: At study entry: CD4/VL, HIV risk factors, prior ART Mortality: chart review & death index Analyses: Cox proportional hazards with delayed entries Primary comparison: mortality in 2000-2004 vs. 2005-2009 1/1/05: midpoint of study period & decade Secondary analyses: Disadvantaged subpopulations Causes of death, viral suppression

6. VariableValue Age (years)49 (43-56) Male Gender1432 (87%) White Race779 (47%) HIV Risk Factor Men having Sex with Men (MSM) Injection Drug Use (IDU) Heterosexual Sex 981 (59%) 408 (25%) 419 (25%) CD4 at Eligibility (cells/mm 3 )205 (78-289) Exposed to ART before Eligibility672 (41%) Mental Health Diagnosis (in chart)664 (40%)

8. ART-CC

9. Causes of Death

10. Disadvantaged Subgroups Had Higher Mortality in 2005-2009 Subpopulation HR for mortality: 2005-09 vs. 2000-04 HR (95% CI) p Female/Transgender1.73 (0.47-6.33) 0.41 Injection Drug Use4.15 (1.41-12.2) 0.009 Non-White Race1.70 (0.87-3.28) 0.12 Alcohol Abuse6.62 (0.83-52.9) 0.07 Mental Health Diagnosis2.68 (0.78-9.13) 0.12 Adjusted for age, initial CD4 count, baseline HIV viral load, HCV, and prior ART exposure

11. Mortality in Injection Drug Users 2000-20042005-2009

12. Unknown 19 (31%) Not AIDS 17 (28%)

13. Viral Suppression at Any Point Deaths (n = 172) Survivors (n = 1479)

14. Mortality was high & did not improve over time. 10% over 4 years (2.6% per person-year) in 2000-04 11% (2.7% per person-year) in 2005-09 Increased among IDU and other disadvantaged groups HIV-related mortality still dominates. Liver, heart, renal + non-AIDS cancer: <10% of deaths Most patients who died never suppressed their viral loads.

15.  In developed countries, wide disparities in mortality still exist among PLWHA. ◦ High mortality in socially-disadvantaged populations despite linkage to highest-quality care ◦ Parallel research needed on “old” & “new” HIV epidemics  Intensive, multi-dimensional approach needed  Future research directions: ◦ Comparing mortality among at-risk HIV-infected patients with non-infected peers ◦ Impact of linkage vs. maintenance of care

16.  Collaborators: ◦ Elvin Geng ◦ Kat Christopoulos ◦ Jim Kahn ◦ Brad Hare ◦ Dan Wlodarczyk ◦ Diane Havlir  UCSF Resident Research Program  Physicians & Patients of Ward 86

17. Thank You!