Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment.

Abstract

Objective: Understanding mortality differences among HIV-infected patients can focus efforts to improve survival. Design: We evaluated death rates, causes and associated factors among treated patients in the HOPS, a large, prospective, multicenter observational cohort of HIV-infected persons seen at diverse U.S. sites of care. Methods: Among 3754 HOPS participants seen during 1996-2007 with > 6 months of follow-up after initiating HAART and ≥ 75% of time under observation receiving HAART (“substantially treated”), we calculated hazard ratios for death using proportional hazards regression models, death causes and comorbidities. Results: Substantially treated participants, followed a median 4.7 years (IQR, 2.2-8.5), experienced 331 deaths. In multivariable analyses, higher mortality was associated with index CD4 < 200 counts/mm3 (adjusted hazard ratio [aHR], 2.86; 95% CI, 1.95-4.21), older age (aHR, 1.50 per 10 years; 95% CI, 1.33-1.70), log10HIV RNA (aHR, 1.67 per log10; 95% CI, 1.51-1.85), but not race/ethnicity (aHR, 0.99 for blacks vs whites, p=0.92). Mortality was increased among publicly insured (PUB) vs privately insured participants (PRV ) when index CD4 >200 (aHR, 2.03; 95% CI, 1.32-3.14) but not when index CD4 < 200 cells/mm3 (aHR, 1.3, p=0.13). By death cause, PUB had significantly more cardiovascular events and hepatic disorders than PRV. Comorbidities more frequent among PUB vs PRV decedents included cardiovascular disease, renal impairment and chronic hepatitis. Conclusions: Among HAART treated participants with CD4 ≥ 200 cells/mm3, PUB experienced higher death rates than PRV. Non-AIDS death and disease causes predominated among publicly insured decedents, suggesting that treatable comorbidities contributed to survival disparities.