BETA March 1997.
by Liz Highleyman
Recent media reports and anecdotal data suggesting positive results among those using new antiretroviral drugs and combination regimens are borne out by statistical data from several U.S. cities. (Note: due to a delay in reporting of deaths, many health departments are able to report reliable figures only for the first 6 months of 1996.)
In the February 28, 1997 issue of Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention (CDC) reported a "marked decline" in the number of AIDS-related deaths in 1996, the first decrease in the history of the epidemic. The number of deaths declined 12% from 24,900 in the first 6 months of 1995 to 22,000 in the first half of 1996.
Death rates decreased for all racial/ethnic groups, but by considerably different amounts; the death rate decreased by 21% for whites, 10% for Latinos, 2% for African Americans, 6% for Asians/Pacific Islanders and 32% for Native Americans. Among women, however, the AIDS-related death rate increased by 3% (compared to a 15% decrease for men as a whole). By transmission category, death rates declined by 18% for gay/bisexual men and by 6% for injection drug users, but increased by 3% for those infected through heterosexual transmission. By geographic region, AIDS-related deaths decreased by 16% in the west, 15% in the northeast, 11% in the midwest and 8% in the south.
CDC attributed the decline to "improvements in recent years in treatments that delay the progression of HIV disease and prevent opportunistic infections, coupled with the success of prevention efforts in slowing the growth of the epidemic overall"; the CDC noted that it is "too soon to determine the impact" of the use of protease inhibitor drugs.
Ling Hsu, an epidemiologist with San Francisco's Department of Public Health AIDS Office, reports that the city's AIDS-related death rate has fallen from 734 deaths in the first half of 1995 to 573 deaths for the first half of 1996, a decrease of over 20%.
John Stansell, MD, Medical Director of the UCSF PositiveHealth Program at San Francisco General Hospital, reports that the AIDS clinic has seen a "dramatic slowing" of the death rate over the past 12-18 months; he estimates that the decrease has been at least 50%. Stansell noted that over the same period of time, the number of patients using the clinic's services has not changed, but that patients were less sick. Stansell maintains that the changes are traceable to the beginning of widespread use of combination antiretroviral therapy. Protease inhibtors have been helpful but have "only accelerated an already existing trend."
David Senechek, MD, who has one-third of his AIDS patients taking triple combination therapy, has seen a reduction in deaths in his practice from 20 in 1994 to 4 in 1996. Los Angeles
Jane Rollins, an epidemiologist with the HIV Epidemiology Program of the Department of Health Services of Los Angeles County, reports that, according to provisional figures, AIDS deaths decreased from 1,206 in the first 6 months of 1995 to 958 in the first half of 1996, a 20% decline.
In California as a whole, AIDS-related deaths declined 40% from 1995 to 1996, according to the state's Division of Health Services.
In a report from the Fourth Conference on Retroviruses and Opportunistic Infections held in January, Peter Ruane, MD, reported a decrease in utilization of hospital and home care resources at Tower Infectious Disease Medical Associates, a private group practice of AIDS specialists in West Los Angeles, between July 1994 and June 1996. Length of average hospital stay fell from 3.36 days/month to 1.28 days/month. Ruane also reported an 87% decrease in AIDS-related deaths among patients of the practice, which was especially evident during the final quarter of 1996.
At the same time, the practice has seen an increase in outpatient visits and a 3-fold increase in HIV-related drug costs, suggesting that healthier patients are taking advantage of ambulatory rather than in-hospital care. Ruane and colleagues concluded that "utilization of newer antiretroviral agents...is associated with significant reductions in utilization of other healthcare resources."
Two reports from the January conference concerned trends in New York City, the city with the highest number of AIDS cases and deaths in the country.
Mary Ann Chaisson and colleagues from the New York City Department of Health reported that the average daily number of AIDS-related deaths decreased by half, from 21 in November 1995 to 10 in November 1996. Overall death rates fell 30% from 7,000 in 1994-1995 to 5,000 in 1996. The decrease was seen in both men and women, and across ethnicities. The researchers suggested that the decline was likely attributable to early diagnosis, prophylaxis for opportunistic infections, new antiretroviral therapies and increased AIDS care services due to a doubling of the city's Ryan White CARE funding in 1994.
At St. Vincent's Hospital and Medical Center, Ramon Torres, MD, and colleagues reported a 27% reduction in HIV/AIDS-related hospitalizations between 1994 and 1996. There was a 16% reduction in the average length of hospital stay from 15.2 days in May 1995 to 12.8 days in March 1996, and a 24% decrease in the hospital's average monthly AIDS patient census. At the same time, there was a 33% increase in outpatient visits and a large increase in inpatient pharmacy costs, as patients made more extensive use of new combination drug regimens for HIV.
The number of AIDS-related deaths in Philadelphia decreased from 750 in 1995 to 574 in 1996, a decline of 23%. James McAnaney, of the Philadelphia health department, emphasized that the decline indicates that people with AIDS are living longer, not that fewer people have the disease.
Erica Seigfried, a research analyst with the health department in Boston, provided provisional data indicating that death rates in that city fell from 539 for the first half of 1995 to 298 for the first half of 1996, a 45% decline.
Kathleen Moore, Communications Director of Boston's AIDS Action Committee, reports that deaths among the agency's clients have fallen from several each week to 1-2 per week; however, the agency's caseload is the highest it has ever been.
Trends are not as positive in Chicago. According to James Murphy, an epidemiologist with the Chicago health department, death rates in that city fell from 478 in the first half of 1995 to 442 in the first half of 1996. Murphy emphasized that this small decrease cannot be considered significant because data is provisional and that 1996 death rates may be adjusted upward as additional reports are received.
Officials from the Dade County Health Department's AIDS Surveillance Unit provided data indicating that AIDS-related deaths have also declined in the city with the third highest number of AIDS cases in the U.S. In the first half of 1995, 737 deaths were reported compared to 593 deaths in the first 6 months of 1996, a decline of 20%. For the state of Florida as a whole, based on preliminary figures, there was a 25% decline from 4,400 deaths in 1995 to 3,300 in 1996. Florida health chief Annie Neasman noted that many AIDS patients in the state are not yet receiving protease inhibitor therapy, and that the decline in deaths is therefore likely due to older antiviral drugs.
Interestingly, major U.S. cities are typically reporting decreases in AIDS-related deaths of 20-25%, about twice the nationwide decline reported by the CDC.
Liz Highleyman is on the editorial staff of BETA.
Center for Disease Control and Prevention. Update: Trends in AIDS incidence, deaths and prevalence Ð United States, 1996. Morbidity and Mortality Weekly Report 46(8). February 28, 1997.
Chaisson M and others. Declining AIDS Mortality in New York City. Fourth Conference on Retroviruses and Opportunistic Infections. January 22-26, 1997. Abstract #376.
Ruane P and others. Impact of newer antiretroviral therapies on inpatient and outpatient utilization of healthcare resources in patients with HIV. Fourth Conference on Retroviruses and Opportunistic Infections. January 22-26, 1997. Abstract #262.
Torres R and Barr M. Impact of potent new antiretroviral therapies on in-patient and out-patient hospital utilization by HIV-infected persons. Fourth Conference on Retroviruses and Opportunistic Infections. January 22-26, 1997. Abstract #264.
This information is designed to support, not replace, the relationship that exists between you and your doctor.