Background
Over 1,200 government and private healthcare facilities provide free HIV services under Universal Health Coverage (UHC) for >90% of persons living with HIV (PLHIV) in Thailand. The National AIDS Program (NAP) extracted death information from the National Death Registration System for all PLHIV since 2005. We analyzed mortality trends and causes among reported PLHIV from 2007 to 2022.
Methods
We conducted a retrospective analysis of PLHIV ≥15 years registered in NAP as of January 31, 2023. Causes of death were categorized using an algorithm designed by clinicians, following Thai HIV case surveillance definitions and WHO HIV clinical staging guidelines. A text clustering model was used to automatically classify causes of death from 2007 to 2022. We applied a Cox proportional hazards regression model to calculated cause-specific mortality rate ratios (MRR) across two-year intervals adjusting for the last reported CD4 category, age group at death, and time-period.
Results
Among 673,635 registered PLHIV ≥15 years, 162,051 (24%) died from various causes. The median age at HIV diagnosis was 35 years (IQR: 28-42 years), while it was slightly higher at 38 years (IQR: 31-46 years) for those who died. Mortality rates varied, from 9.5% (15,390) in 2007-2008 to 14% (22,736) in 2021-2022. Half of the deceased had a baseline CD4 count < 100 cells/µL and 30% (49,157) died before initiating treatment. The most common causes of death were AIDS (59,573 deaths; 36%), unspecified AIDS-related causes (44,369 deaths; 27%), and non-AIDS infections (11,918 deaths; 7%). The proportion of AIDS-related deaths increased slightly from 32% (4,870) in 2007-2008 to 35% (7,962) in 2021-2022.
Using a Cox model, we found that AIDS-related mortality (adjusted MRR [aMRR]: 1.03, 95% CI: 1.02-1.04), unspecified AIDS-related mortality (aMRR: 1.05, 95% CI: 1.04-1.07) and deaths from suicide or accidents (aMRR: 1.07, 95% CI: 1.04-1.10) were associated with higher mortality risk compared to death from non-AIDS infections, after adjusting for factors such as CD4 count and age. Conversely, deaths from non-AIDS non-hepatitis malignancies (aMRR: 0.97, 95% CI: 0.95-0.99) and CNS-related causes (aMRR: 0.90, 95% CI: 0.86-0.94) were associated with a lower mortality risk.
Conclusions
AIDS-related causes accounted for the majority of deaths among PLHIV >15 years. Targeted interventions to strengthen early case detection and improve treatment initiation could help reduce AIDS-related deaths.
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