HIV factors not associated with increased risk of suicide in France

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Approximately 4% of deaths among people with HIV in France are due to suicide, investigators report. Suicide incidence remained stable over 13 years of follow-up, but HIV-related factors were not associated with an increased risk of suicide. “We found that most factors associated with suicide mortality among PLHIV (people living with HIV) were similar to those in the general population,” comment researchers at the department of internal medicine, clinical immunology and infectious diseases, Reims University Hospital, University of Reims, Champagne‐ArdenneReims and EA‐4684/SFR CAP‐SANTE, University of Reims. “Suicide prevention measures should target PLHIV with the psychological morbidities identified in our cohort.”

European studies have shown that the suicide rate fell among HIV-positive individuals after the introduction of effective antiretroviral therapy. Nevertheless, it still remains between three- and five-fold higher than that seen in the general population.

In France, suicide is the sixth most common cause of death among people with HIV, accounting for 5% of deaths in 2010, compared to 1.7% in the general French population. But factors associated with increased suicide risk in HIV-positive people in the era of modern HIV therapy are poorly understood.

A team of French investigators designed a study comparing the characteristics of HIV-positive people who died from suicide between 2000 and 2013 with those of closely matched HIV-positive controls. Each suicide was matched with four controls. Patients received care at 19 hospitals across France.

Overall, suicide accounted for 4% of all recorded deaths among HIV-positive people. The incidence of suicide mortality was 45.9/100,000 person-years for the period 2000 to 2006 and 46.5/100,000 person-years between 2007 and 2013.

“Between 1990 and 2010, a decrease of > 20% in suicide mortality in the general population was observed in France and some other European countries. In the multicohort European DAD study among PLHIV, rates of suicide fell by around half between the early cART era (1999-2000) and the 2007-2008 period,” note the authors.

“In contrast, since 2000, the rate of suicide among PLHIV in France has remained stable, accounting for 4%, 5% and 5% of causes of death in 2000, 2005 and 2010, respectively.”

The investigators suggest that the continuing high rate of death from suicide seen among people with HIV can be explained by the high prevalence of mental health problems among these individuals.

The study included 70 people who died from suicide and 279 controls.

Patients who died from suicide had a mean age of 45 years and 80% were men. Most (91%) were born in France and 73% lived alone. A quarter had children. The majority (83%) were taking antiretrovirals. The mean CD4 cell count was 487 cells/mm3 and just under two-thirds had an undetectable viral load. Active or substitute drug use was noted in 25% of cases and 76% had a history of a psychiatric disorder.

After controlling for potential confounders, several risk factors were associated with an increased risk of death from suicide, including living alone (p = 0.02), not having children (p = 0.008), active or substituted drug use (p = 0.03), alcohol abuse (p = 0.007), history of depression (p = 0.007), a past suicide attempt (p = 0.008) and treatment with psychotropic drugs (p < 0.0001). No HIV-related factor was associated with death from suicide. “Identifying risk factors associated with dying by suicide in PLHIV is necessary to improve quality of care and may help to identify patients who could benefit the most from interventions aimed at preventing suicide,” conclude the authors. “In the cART era, HIV-related factors are no longer associated with a higher risk of suicide mortality.”

Abstract
Objectives: People living with HIV (PLHIV) are at a higher risk of dying by suicide than the general population. Epidemiological data regarding determinants of suicide in PLHIV are scarce. The aim of this study was thus to study demographic, socio‐economic, psychiatric history and immunovirological characteristics associated with death from suicide in the French multicenter Dat’AIDS cohort, from January 2000 to July 2013.
Methods: This was a nested case–control study. All deceased PLHIV during the study period who died by suicide and whose medical files could be checked were included as cases. Controls were selected using incidence density sampling. For each case, up to four controls were selected among all actively followed PLHIV at the index date (date of death of cases). Controls were matched for time from HIV diagnosis (5‐year periods) and clinical centre.
Results: Seventy cases and 279 controls were included in the study. By multivariable analysis, the factors significantly associated with death from suicide were: not having children, active or substituted drug consumption, alcohol intake > 20 g/day or history of alcohol abuse, history of depressive disorder and/or of attempted suicide, and psychotropic drug intake. Conversely, age, gender, country of birth, positive HCV serology and HIV‐related factors, such as AIDS status, use of combination antiretroviral therapy (cART), nadir and current CD4 counts and HIV viral load, were not significantly associated with the risk of death from suicide.
Conclusions: In the cART era, HIV‐related factors are not associated with a higher risk of suicide mortality. Suicide prevention measures should target PLHIV with the psychological morbidities observed in our cohort.

Authors
M Hentzien, A Cabie, P Pugliese, É Billaud, I Poizot‐Martin, C Duvivier, MA Valantin, A Kaladjian, M Dramé, F Bani‐Sadr

Aidsmap material
HIV Medicine abstract


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