-
The advent of antiretroviral therapy (ART) has markedly increased life expectancy and decreased mortality rates in individuals living with human immunodeficiency virus (HIV). Before, or at the onset of, the ART era, the predominant causes of death were acquired immune deficiency syndrome (AIDS)-related illnesses, including defining opportunistic infections and malignant tumors. However, with the progression of the ART era, there has been a significant shift towards non-AIDS-related mortality. Data from the United Nations Programme on AIDS (UNAIDS) indicates a global reduction of 43% in AIDS-related deaths, falling from 1,100,000 in 2010 to 630,000 in 2022 (1). Within China, AIDS has emerged as a principal cause of death from infectious diseases in recent times. Earlier research emphasizes that initiating ART at early stages significantly diminishes the mortality rates (2). By 2020, ART coverage among those infected with HIV peaked at 92.9%. Over the past decade, China’s implementation of a universal ART access strategy has occurred without a comprehensive analysis of mortality rates and changing patterns of cause of death among the national HIV-infected population. Utilizing data from the nationwide HIV/AIDS Comprehensive Response Information Management System (CRIMS), this retrospective analysis investigates mortality rates across the HIV-infected cohort from 2013 to 2022. The insights gained from this study are instrumental in pinpointing challenges and enhancing health outcomes moving forward.
Data for this study were obtained from the CRIMS database, administered by the National Center for AIDS/STD Control and Prevention (NCAIDS). The system mandates the reporting of all confirmed HIV-positive individuals, encompassing initial diagnosis and follow-up data. In the event of a patient’s death, local healthcare workers must submit a specialized death registration form. Further, data specific to patients commencing ART should be entered into the ART database subsystem. This study implemented a multiple cross-sectional design to investigate changes in mortality rates and causes of death from 2013 to 2022. Data extraction for the manuscript occurred on June 30, 2023, allowing a six-month period to account for any reporting delays in death records. Due to modifications in the death registration system in 2012, consistent reporting of death causes only commenced in 2013. We calculated annual mortality rates using the total number of survivors and new diagnoses for the year as the denominator, and the total deaths in the same year as the numerator. The Cochran-Armitage trend test was employed to assess changes in the mortality rate, while the normal approximation method provided the 95% confidence intervals (CI) for these rates. ART coverage rate was defined as the percentage of patients on treatment at year-end relative to all living HIV-positive patients, ascertained from historical data. We analyzed the correlation between ART coverage rate and mortality rate using Pearson’s correlation coefficient.
During the study period, the eligibility criteria for initiating ART were modified: the threshold for CD4+T cell counts was raised from 350 cells/mm3 to 500 cells/mm3 in 2014 and then removed entirely in 2016, allowing initiation of ART regardless of CD4+T cell counts. These adjustments have potential implications for trends in ART coverage and mortality rates. Deaths related to AIDS and those not associated with AIDS were categorized based on the presence of specific diseases or events at the time of death, in accordance with the reporting guidelines of the system. AIDS-related diseases encompass pneumocystis pneumonia, cryptococcosis, tuberculosis, recurrent bacterial pneumonia, candidiasis, cytomegalovirus disease, AIDS-defining cancers (ADCs), toxoplasmosis, and HIV wasting syndrome, among others. Non-AIDS related events include cardiovascular and cerebrovascular diseases (CCVDs), non-AIDS defining cancers (NADCs), viral hepatitis, and various respiratory diseases, as well as fatalities due to accidents, which comprise suicide, drug overdose, and other non-disease related causes of death. China’s geographical landscape is segmented into seven regions for the purposes of this research: northeastern China [comprising Heilongjiang, Jilin, and Liaoning provincial-level administrative divisions (PLADs)], northern China (including Beijing, Tianjin, Hebei, Shanxi, and Inner Mongolia PLADs), central China (Hubei, Hunan, and Henan PLADs), southern China (Guangdong, Guangxi, and Hainan PLADs), eastern China (encompassing Shanghai, Shandong, Jiangsu, Anhui, Jiangxi, Zhejiang, and Fujian PLADs), northwestern (Shaanxi, Gansu, Ningxia, Xinjiang, and Qinghai PLADs), and southwestern (Chongqing, Sichuan, Guizhou, Yunnan, and Xizang PLADs). Data analysis for this study was conducted using SAS software (version 9.4, NC, SAS Institute Inc., USA).
From 2013 to 2022, there was a marked decline in the all-cause mortality rate among Chinese HIV-infected patients, decreasing from 5.4% to 2.7% (P<0.05 for trend) (Figure 1). Simultaneously, ART coverage in China saw a substantial rise, from 58.4% to 92.8% (P<0.05 for trend), exhibiting a strong inverse relationship with the mortality rate (r=−0.964, P<0.05). Subgroup analyses based on ART status were carried out across various categories, including age, gender, transmission route, geographical regions, and CD4+T cell counts in 2022 (Table 1). In the same year, the subgroups with the highest all-cause mortality rates included individuals with CD4+T cell counts below 200 cells/mm3 (7.5%), those aged 50 years or older (4.8%), people contracting HIV via heterosexual transmission (3.4%), residents of Southwest China (3.3%), and males (2.9%). Cause-specific mortality rates among ART recipients were lower compared to the overall patient population (all-cause mortality: 1.6% vs. 2.7%; AIDS-related mortality: 0.3% vs. 0.4%; non-AIDS related mortality: 1.1% vs. 1.8%; deaths from unknown causes: 0.3% vs. 0.4%). Between 2013 and 2022, pneumocystis pneumonia remained the most frequent cause of AIDS-related deaths, accounting for 15.4% to 19.9% of cases. Tuberculosis and recurrent bacterial pneumonia, both trending downward, were the second and third most common causes, respectively. Among non-AIDS causes of death, respiratory diseases, CCVDs, and NADCs were predominant from 2013 to 2018, but by 2019 CCVDs had emerged as the leading cause (Figure 2). Notably, the proportion of deaths attributable to CCVDs increased from 16.3% in 2013 to 26.1% in 2022.
Figure 1.The trend of mortality rate and ART coverage among HIV-infected patients in China, 2013–2022.
Abbreviation: ART=antiretroviral therapy; HIV=human immunodeficiency virus.Characteristic MR of total HIV infected patients (100.0%)
% (95% CI)MR of patients on ART (92.8%)
% (95% CI)Proportion All cause AIDS related Non-AIDS
relatedUnknown cause Proportion All cause AIDS related Non-AIDS related Unknown cause Total 100 2.7 (2.66, 2.71) 0.4 (0.44, 0.46) 1.8 (1.78, 1.82) 0.4 (0.39, 0.41) 100 1.6 (1.62, 1.67) 0.3 (0.28, 0.30) 1.1 (1.08, 1.12) 0.3 (0.29, 0.31) Current age, years <15 0.6 1.0 (0.76, 1.22) 0.3 (0.17, 0.41) 0.5 (0.36, 0.69) 0.2 (0.10, 0.30) 0.6 0.6 (0.42, 0.78) 0.2 (0.08, 0.27) 0.3 (0.18, 0.44) 0.1 (0.03, 0.17) 15–24 4.9 0.5 (0.46, 0.57) 0.1 (0.09, 0.15) 0.3 (0.25, 0.33) 0.1 (0.08, 0.12) 4.8 0.3 (0.22, 0.31) 0.1 (0.06, 0.11) 0.1 (0.10, 0.16) 0.0 (0.00, 0.00) 25–49 54.7 1.3 (1.30, 1.35) 0.3 (0.29, 0.31) 0.8 (0.79, 0.84) 0.2 (0.19, 0.21) 54.7 0.7 (0.72, 0.76) 0.2 (0.18, 0.20) 0.4 (0.43, 0.46) 0.1 (0.09, 0.11) ≥50 39.8 4.8 (4.79, 4.90) 0.7 (0.67, 0.72) 3.4 (3.31, 3.41) 0.8 (0.78, 0.82) 39.9 3.1 (3.01, 3.11) 0.5 (0.44, 0.48) 2.1 (2.09, 2.17) 0.5 (0.48, 0.52) Gender Male 74.7 2.9 (2.88, 2.95) 0.5 (0.47, 0.50) 2.0 (1.93, 1.99) 0.5 (0.49, 0.51) 74.3 1.8 (1.77, 1.83) 0.3 (0.30, 0.33) 1.2 (1.19, 1.23) 0.3 (0.29, 0.31) Female 25.3 2.0 (1.97, 2.07) 0.3 (0.32, 0.36) 1.3 (1.29, 1.37) 0.4 (0.38, 0.42) 25.7 1.2 (1.16, 1.24) 0.2 (0.20, 0.24) 0.8 (0.76, 0.82) 0.2 (0.18, 0.22) Transmission route Heterosexual contact 65.4 3.4 (3.38, 3.46) 0.5 (0.53, 0.56) 2.3 (2.28, 2.35) 0.6 (0.58, 0.62) 65.3 2.1 (2.06, 2.13) 0.4 (0.34, 0.37) 1.4 (1.39, 1.44) 0.3 (0.29, 0.31) Male-to-male sexual contact 26.0 0.8 (0.75, 0.81) 0.2 (0.18, 0.21) 0.5 (0.45, 0.49) 0.1 (0.09, 0.11) 26.4 0.4 (0.41, 0.46) 0.1 (0.11, 0.13) 0.3 (0.24, 0.28) 0.1 (0.09, 0.11) Injection drug use 4.9 3.2 (3.05, 3.33) 0.5 (0.41, 0.52) 2.2 (2.09, 2.33) 0.5 (0.44, 0.56) 4.6 2.2 (2.07, 2.32) 0.3 (0.28, 0.38) 1.5 (1.41, 1.62) 0.4 (0.35, 0.45) Blood receptor or donor 2.0 2.1 (1.97, 2.33) 0.5 (0.40, 0.58) 1.4 (1.29, 1.58) 0.2 (0.14, 0.26) 2.1 2.1 (1.88, 2.23) 0.5 (0.40, 0.58) 1.4 (1.21, 1.50) 0.2 (0.14, 0.26) MTCT 0.8 0.8 (0.72, 0.91) 0.2 (0.19, 0.29) 0.4 (0.34, 0.47) 0.2 (0.15, 0.25) 0.8 0.6 (0.41, 0.72) 0.2 (0.09, 0.26) 0.3 (0.18, 0.40) 0.1 (0.03, 0.17) Unknown 1.0 4.1 (3.73, 4.44) 0.7 (0.53, 0.82) 2.4 (2.17, 2.72) 1.0 (0.82, 1.18) 0.9 1.7 (1.41, 1.90) 0.3 (0.23, 0.46) 1.0 (0.79, 1.17) 0.3 (0.19, 0.41) Geographical units Southern 16.3 3.2 (3.09, 3.24) 0.6 (0.59, 0.65) 2.0 (1.91, 2.03) 0.6 (0.57, 0.63) 15.7 1.6 (1.57, 1.69) 0.4 (0.33, 0.38) 1.0 (0.96, 1.05) 0.3 (0.27, 0.33) Northern 5.9 1.1 (1.01, 1.16) 0.3 (0.26, 0.34) 0.6 (0.55, 0.66) 0.2 (0.17, 0.23) 5.9 0.6 (0.55, 0.67) 0.2 (0.12, 0.18) 0.4 (0.32, 0.42) 0.1 (0.08, 0.12) Eastern 15.3 1.8 (1.73, 1.85) 0.4 (0.35, 0.40) 1.2 (1.15, 1.25) 0.2 (0.18, 0.22) 15.6 1.1 (1.01, 1.10) 0.2 (0.22, 0.27) 0.7 (0.65, 0.73) 0.1 (0.09, 0.11) Central 12.6 2.7 (2.65, 2.81) 0.6 (0.52, 0.59) 1.8 (1.77, 1.90) 0.3 (0.27, 0.33) 12.7 1.8 (1.71, 1.85) 0.4 (0.37, 0.43) 1.2 (1.10, 1.21) 0.2 (0.18, 0.22) Southwestern 38.5 3.3 (3.25, 3.35) 0.4 (0.39, 0.43) 2.3 (2.24, 2.33) 0.6 (0.58, 0.62) 39.1 2.1 (2.11, 2.19) 0.3 (0.27, 0.30) 1.5 (1.46, 1.53) 0.4 (0.38, 0.42) Northwestern 7.4 2.2 (2.08, 2.26) 0.5 (0.43, 0.52) 1.5 (1.37, 1.53) 0.2 (0.17, 0.23) 7.1 1.3 (1.22, 1.38) 0.3 (0.27, 0.35) 0.9 (0.81, 0.94) 0.1 (0.08, 0.12) Northeastern 4.1 1.5 (1.35, 1.56) 0.3 (0.21, 0.30) 1 (0.95, 1.13) 0.2 (0.16, 0.24) 4.0 0.8 (0.69, 0.84) 0.1 (0.11, 0.18) 0.5 (0.47, 0.60) 0.1 (0.07, 0.13) Current CD4+T cell counts, cells/mm3 ≥200 81.5 0.7 (0.70, 0.73) 0.1 (0.07, 0.08) 0.5 (0.52, 0.55) 0.1 (0.10, 0.11) 85.8 0.6 (0.57, 0.60) 0.1 (0.06, 0.07) 0.5 (0.43, 0.45) 0.1 (0.07, 0.08) <200 10.7 4.7 (4.63, 4.85) 1.3 (1.25, 1.37) 2.7 (2.62, 2.79) 0.7 (0.69, 0.78) 10.9 3.6 (3.51, 3.71) 1.0 (0.91, 1.02) 2.1 (2.00, 2.16) 0.6 (0.52, 0.61) Missing 7.8 20.5 (20.25, 20.76) 3.1 (3.03, 3.25) 13.9 (13.63, 14.06) 3.5 (3.41, 3.64) 3.3 23.1 (22.65, 23.50) 4.0 (3.81, 4.21) 15.3 (14.95, 15.68) 3.8 (3.56, 3.95) Abbreviation: ART=antiretroviral therapy; AIDS=acquired immunodeficiency syndrome; HIV=human immunodeficiency virus; MTCT=mother-to-child transmission of HIV; MR=mortality rate; CI=confidence interval. Table 1. Cause-specific mortality rates among HIV-infected patients in China, 2022.
Figure 2.Detailed cause composition of reported AIDS related and non-AIDS related deaths in China, 2013–2022. (A) AIDS related deaths; (B) non-AIDS related deaths.
Abbreviation: AIDS=acquired immunodeficiency syndrome; HIV=human immunodeficiency virus; ADCs=AIDS-defining cancers; NADCs=non-AIDS-defining cancers; CCVDs=cardiovascular and cerebrovascular diseases.
HTML
Citation: |