title: Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment.
abstract: OBJECTIVE
  Understanding mortality differences among HIV-infected patients can focus efforts to improve survival.
  
  
  METHODS
  We evaluated death rates, causes, and associated factors among treated patients in the HIV Outpatient Study (HOPS), a large, prospective, multicenter observational cohort of HIV-infected persons seen at a diverse set of US sites of care.
  
  
  METHODS
  Among 3754 HOPS participants seen during 1996-2007 with at least 6 months of follow-up after initiating HAART and receiving HAART at least 75% of time under observation ('substantially treated'), we calculated hazard ratios for death using proportional hazards regression models. We also examined death causes and comorbidities among decedents.
  
  
  RESULTS
  Substantially treated participants, followed a median 4.7 years (interquartile range, 2.2-8.5), experienced 331 deaths. In multivariable analyses, higher mortality was associated with an index CD4 cell count less than 200 cells/μl [adjusted hazard ratio (aHR), 2.86; 95% confidence interval (CI) 1.95-4.21], older age (aHR, 1.50 per 10 years; 95% CI 1.33-1.70), log(10)HIV RNA (aHR, 1.67 per log(10); 95% CI 1.51-1.85), but not race/ethnicity (aHR, 0.99 for blacks vs. whites, P = 0.92). Mortality was increased among publicly insured (PUB) vs. privately insured participants (PRV) when index CD4 cell count was at least 200 cells/μl (aHR, 2.03; 95% CI 1.32-3.14) but not when index CD4 cell count was less than 200 cells/μl (aHR, 1.3, P = 0.13). By death cause, PUB had significantly more cardiovascular events and hepatic disorders than PRV. Comorbidities more frequent among PUB vs. PRV decedents included cardiovascular disease, renal impairment, and chronic hepatitis.
  
  
  CONCLUSIONS
  Among HAART-treated participants with CD4 cell counts at least 200 cells/μl, PUB experienced higher death rates than PRV. Non-AIDS death and disease causes predominated among publicly insured decedents, suggesting that treatable comorbidities contributed to survival disparities.
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA. f-palella@northwestern.edu
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Palella
authors.forename: Rose K
authors.initials: RK
authors.lastname: Baker
authors.forename: Kate
authors.initials: K
authors.lastname: Buchacz
authors.forename: Joan S
authors.initials: JS
authors.lastname: Chmiel
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Tedaldi
authors.forename: Richard M
authors.initials: RM
authors.lastname: Novak
authors.forename: Marcus D
authors.initials: MD
authors.lastname: Durham
authors.forename: John T
authors.initials: JT
authors.lastname: Brooks
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015897:Comorbidity; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010045:Outpatients / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D011446:Prospective Studies; D017150:Public Sector; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology