Decline in suicides since introduction of cART, but rate remains high

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An analysis of deaths over thirty years in Switzerland shows that suicides fell dramatically after 1996, but have not declined further in men in more recent years as HIV treatment has continued to improve. People with HIV remained three times more likely than people in the general population to die by suicide, according to an analysis of the Swiss HIV Cohort Study report by researchers led by Matthias Egger at the Institute of Social and Preventive Medicine, University of Bern, Switzerland and the Centre of Infectious Disease Epidemiology and Research (CIDER), University of Cape Town, South Africa.

Among 20,139 people with HIV included in the study, 204 people with HIV died by suicide over 184,402 person‐years – a rate of 111 per 100,000 person‐years. In other words, there was around one suicide for each 1,000 people followed each year.

Data were taken from the Swiss HIV Cohort Study (which enrols around half the people living with HIV in the country) between 1988 and 2017. They were compared with data on the general population, from the Swiss National Cohort.

Rates were also falling in the general population, but not so dramatically: from 33 to 20 (per 100,000 person years) in men, and from 13 to 7 in women. Rates in people with HIV can be compared with those in the general population in terms of standardised mortality rates. The SMR for men with HIV fell from 12.9 in the pre-ART era, to 2.4 after the introduction of ART, increasing slightly to 3.1 in more recent years. The SMR for women with HIV fell from 14.2 to 10.2 and 3.3. In other words, suicide rates remain three times higher both in men and women with HIV than in the general population.

“The biggest drop in rates was thus observed after combination antiretroviral therapy was introduced in 1996,” say the authors. “Since then no important decline in rates was observed in men, despite the more tolerable, efficacious and simpler antiretroviral drug regimens that became available.”

A recent study from England and Wales found a suicide SMR in men with HIV of 2.2, while the rate was not higher in women with HIV than in the general population. Comparing people who died of suicide with other people with HIV who did not, they were more likely to be male, of Swiss nationality, a gay or bisexual man, have a history on injecting drug use, have had psychiatric treatment, or be at a more advanced HIV clinical stage.

These associations – previously seen in French and Danish studies – did not substantially change over time. Studies of lesbian, gay and bisexual people (not necessarily living with HIV) have shown higher suicide rates than in the general population.

There was no association between taking efavirenz (a drug that can affect mood and mental health) and suicide in this cohort. This may because doctors have avoided prescribing it to those with mental health difficulties. Similarly, there was no association between dolutegravir and suicide.

“Continued emphasis on suicide prevention among men and women living with HIV is important,” conclude the authors.

Introduction: In many countries, mortality due to suicide is higher among people living with HIV than in the general population. We aimed to analyse trends in suicide mortality before and after the introduction of triple combination antiretroviral therapy (cART), and to identify risk factors associated with death from suicide in Switzerland.
Methods: We analysed data from the Swiss HIV Cohort Study from the pre‐cART (1988‐1995), earlier cART (1996‐2008) and later cART (2009‐2017) eras. We used multivariable Cox regression to assess risk factors for death due to suicide in the ART era and computed standardized mortality ratios (SMRs) to compare mortality rates due to suicide among persons living with HIV with the general population living in Switzerland, using data from the Swiss National Cohort.
Results and Discussion: We included 20,136 persons living with HIV, of whom 204 (1.0%) died by suicide. In men, SMRs for suicide declined from 12.9 (95% CI 10.4‐16.0) in the pre‐cART era to 2.4 (95% CI 1.2‐5.1) in the earlier cART and 3.1 (95% CI 2.3‐4.3) in the later cART era. In women, the corresponding ratios declined from 14.2 (95% CI 7.9‐25.7) to 10.2 (3.8‐27.1) and to 3.3 (95% CI 1.5‐7.4). Factors associated with death due to suicide included gender (adjusted hazard ratio 0.58 (95% CI 0.38‐0.87) comparing women with men), nationality (1.95 (95% CI 1.34‐2.83) comparing Swiss with other), Centers for Disease Control and Prevention clinical stage (0.33 (95% CI 0.24‐0.46) comparing stage A with C), transmission group (2.64 (95% CI 1.71‐4.09) for injection drug use and 2.10 (95% CI 1.36‐3.24) for sex between men compared to other), and mental health (2.32 (95% CI 1.71‐3.14) for a history of psychiatric treatment vs. no history). There was no association with age.
Conclusions: Suicide rates have decreased substantially among people living with HIV in the last three decades but have remained about three times higher than in the general population since the introduction of cART. Continued emphasis on suicide prevention among men and women living with HIV is important.

Yann Ruffieux, Liis Lemsalu, Karoline Aebi‐Popp, Alexandra Calmy, Matthias Cavassini, Christoph A Fux, Huldrych F Günthard, Catia Marzolini, Alexandra Scherrer, Pietro Vernazza, Olivia Keiser, Matthias Egger

Aidsmap material
Journal of the International AIDS Society abstract

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