ABSTRACT
Combination antiretroviral therapy reduces mortality of HIV-infected persons. In Spain, where this therapy is widely available, we aim to evaluate mortality trends and causes of death in HIV-infected adults, and to estimate the excess mortality compared to the general population. From 1999 to 2018 mortality by causes was analyzed in a population-based cohort of adults aged 25 to 74 years diagnosed with HIV infection in Spain. Observed deaths and expected deaths according mortality in the general population of the same sex and age were compared using standardized mortality ratios (SMRs). HIV-infected people increased from 839 in 1999-2003 to 1059 in 2014-2018, median age increased from 37 to 47 years, the annual mortality rate decreased from 33.5 to 20.7 per 1000 person-years and the proportion of HIV-related deaths declined from 64% to 35%. HIV-related mortality declined from 21.4 to 7.3 (p < 0.001), while non-HIV-related mortality remained stable: 12.1 and 13.4 per 1000, respectively. Mortality decreased principally in persons diagnosed with AIDS-defining events. In the last decade, 2009-2018, mortality was still 8.1 times higher among HIV-infected people than in the general population, and even after excluding HIV-related deaths, remained 4.8 times higher. Excess mortality was observed in non-AIDS cancer (SMR = 3.7), cardiovascular disease (SMR = 4.2), respiratory diseases (SMR = 7.9), liver diseases (SMR = 8.8), drug abuse (SMR = 47), suicide (SMR = 5.3) and other external causes (SMR = 6). In conclusion, HIV-related mortality continued to decline, while non-HIV-related mortality remained stable. HIV-infected people maintained important excess mortality. Prevention of HIV infections in the population and promotion of healthy life styles in HIV-infected people must be a priority.
Subject(s)
HIV Infections/mortality , Adult , Aged , Case-Control Studies , Cause of Death , Female , Humans , Male , Middle Aged , Mortality , Spain/epidemiologyABSTRACT
AIM OF THE REVIEW: Efficacy estimations of drug clinical trials have been based on clinical measurements and survival rates. However, advances in psychometric techniques have allowed to incorporate a new dimension based on quality of life. Questionnaires aimed at measuring patients' health status outlook, now enable us to quantify the loss of quality of life caused by disease and the improvement that can be achieved by pharmacological treatments. The Aim of this study is to make a quantitative evaluation of the use of health related quality of life (HRQL) measures in drug clinical trials. METHODS: A systematic review was performed, in duplicate, of the five journals with highest contribution to the ACP Journal Club, i.e. New England Journal of Medicine, JAMA, The Lancet, Annals of Internal Medicine and the British Medical Journal. HRQL measures were evaluated in published articles referring to drug clinical trials. RESULTS: We identified 193 articles that reported the results of clinical trials, of which 28 included QOL measures as secondary end points and two as primary end points: in total, these comprised 16% of the articles analysed. Discussion Without considering the relevance of HRQL measures as a tool in the allocation of resources, it should be included as a health outcome dimension in drug clinical trials. The absence of this evaluation in studies about chronic diseases that affects patients' daily life activities would not be justified. CONCLUSIONS: HRQL measures are not used on a regular basis in drug clinical trials that are reported in the relevant literature. Systematic incorporation of QOL measures into clinical trials would make it possible to measure the benefit obtained from drug treatments taking into account the patients' perceptions. Moreover, it would encourage the development of prospective cost-effectiveness studies with patient recorded data in the context of clinical trials. Our findings have a direct impact on practice. Being conscious of the low use of HRQL in clinical trials, it could contribute to increase the demand for these measures by health care professionals. The manuscript is also a useful tool to identify where basic concepts about HRQL measures can be found.
