Chin-Hui Yang, M.D. Hui-Rong Liu, Sung-Yin Chen, Yen-Fang Huang, Shih-Yan Yang Third Division, Centers for Disease Control, Department of Health,

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1 Comparison of ff Factors affecting the mortality rate of Injecting Drug Users with HIV infection in Taiwan Chin-Hui Yang, M.D. Hui-Rong Liu, Sung-Yin Chen, Yen-Fang Huang, Shih-Yan Yang Third Division, Centers for Disease Control, Department of Health, Taiwan

2 Background Taiwan remains a low HIV prevalent area till now and dthe estimated t dhiv prevalence rate among adults aged years was 0.07% in Before 2004, the majority of HIV-infected cases were through h sexual transmission, i with men who have sex with men (MSM) accounting for the largest proportion (48.2%), followed by heterosexual contacts (39.9%). However, the number of newly reported HIV infections has been rising sharply since 2004, mainly among injecting drug users (IDUs).

3 Cumulative HIV/AIDS Reported Cases by Gender and Mode of Transmission, Mode of Transmission Female Male Total Heterosexual contact 564 3,009 3,573 Homosexual contact (MSM) 0 5,347 5,347 Injecting drug users (IDUs) 757 5,028 5,785 Hemophiliacs Blood transfusion Vertical transmission Unknown HIV Total 13 1,358 13, ,011 Blood transfusion 0.1% Heterosexual contact 23.8% Vertical Hemophiliacs transmission 0.4% 0.2% Unknown 1.4% IDUs 38.5% MSM 35.6%

4 Introduction There is evidence that, t even in the period of HAART, mortality rate is higher and life expectancy is shorter in HIV-infected IDUs 1-2. Active drug use has been reported to be associated with non-adherence to HAART and poorer virologic response to therapy. The current study tries to access the mortality rate of HIV-infected IDUs and analyze factors contribute to the excess mortality rate. 1. Lioyd-Smith E, et al. AIDS 2006; 20: Lucas GM, et Al. Am J Epidemiol 2006; 163:

5 Method Using registered HIV/AIDS data in Taiwan CDC, medical records and death certificates of newly reported HIV-infected cases between 2001 and 2005 were reviewed. The end date of the observation period is Dec 31, We compared the mortality rate between the three main transmission groups (MSM, heterosexual contacts and IDUs). We further examined the mortality rate, causes of death, and predictors of mortality in HIVinfected IDUs.

6 Demographic data Among the 7,208 newly reported HIV-infected cases, 3,185 cases(44%) infected via injecting drug use were enrolled for analysis. The other two major transmission routes were MSM 32% and heterosexual contacts 21%. The mean age at HIV diagnosis f HIV-infected IDUs was 32.4 years old (range 16~77) and 87.3% were males. The mean age is younger than heterosexual transmitted group and older than MSM group, 38.0 and 30.7 years old respectively, p<0.05.

7 Mortality of Three Main Risk Groups There were 133 deaths(4.2%) among HIVinfected IDUs. The mean age at death is 36.6 years old, the youngest in compared with the other two groups. MSM Heterosexual IDU contacts Crude Mortality 6.4% 15.5% 4.2% Mortality rate ( per 100 person-year)

8 Survival Patterns of HIV-infected cases of the three transmission groups with adjustment for age at HIV diagnosis, gender and AIDS status Cumulat tive Surviva al transmission group heterosexual MSM ID U days

9 Causes of Death of HIV-infected IDUs HIV/AIDS related conditions : 7.5% Other medical illness (hepatic disease, cardiovascular disease, non-aids related malignancy, etc.): 14.3% Bacterial infection : 30.8% Significantly higher e.g. infective endocarditis, faciitis, than sexual pneumonia, etc.) transmitted group Accidents (include suicide, overdose, etc.): 36.1% Unknown or under investigation : 11.3%.

10 Predicted Risk Factor for Mortality of HIV-infected IDUs In a multivariate Cox model of subjects, factors independently associated with mortality included : develop AIDS (HRadj, 17.56; 95%CI, ) older age at HIV diagnosis (HRadj, 1.04; 95% CI, ). Whereas persons who ever receive antiretroviral therapy had a significant better impact on survival (HRadj, 0.21; 95% CI, ).

11 Impact of MMT on Mortality of HIV-infected IDUs Taiwan CDC has implemented the Harm Reduction Program for IDUs since late 2005, which include "Needle-Syringe Programming", "Drug Substitution Treatment, and etc. By the end of 2007, there were 13,264 persons ever joined methadone maintenance treatment (MMT) clinics. Among them, 1,929 cases(15%) were HIVinfected. In HIV-infected IDUs, ever join MMT clinics had a lower crude mortality as compared with those never joined MMT clinics, i 0.6% vs. 2.9%, p<

12 Discussion(1) ssion(1) After adjustment for age at HIV diagnosis, gender and AIDS status, HIV-infected IDUs had highest mortality rate in compared with MSM and heterosexual contact groups. Further analyze the causes of death revealed that deaths due to bacterial infections and accidents accounted for a significant higher proportion in HIV-infected didus than sexual transmission i groups. Harm reduction program to offer clean needle and syringes, preventive health heducation and timely management of treatable conditions, such as bacterial linfections, needs emphasis.

13 Discussion(2) Analyze factors contribute to the excess mortality rate among HIV-infected IDUs, AIDS status had greatest impact, older age at HIV diagnosis also play some role. Whereas persons who ever received HAART had a significant better impact on survival. Our prior research has shown that 61.4% of the HIV-infected IDUs didn t seek for HIV- related medical care, which was significantly higher than that of the sexual transmission groups.

14 Discussion(3) In HIV-infected IDUs ever join methadone maintenance treatment clinics had a significant lower death rates as compared with those never joined MMT clinics. Efforts towards encouraging HIV-infected IDUs into medical care, includes HIV-related care and substance abuse treatment, is necessary to improve the prognosis of this population.

15 Conclusion HIV-infected IDUs had high mortality rate and poor prognosis. To further reduce mortality of this specific population, interventions i aimed at improving joined medical service such as HIV-related care and MMT clinics, health education about safe needle usage and psychiatric supports are warranted.

16 Ak Acknowledgement ld Shih-Yan Yang Yen-Fang Huang Hui-Rong Liu Sung-Yin Chen Ling-Ju Shih Su-Hwa Wang All colleagues of Third Division, Taiwan CDC