Dynamics of overdose and non-overdose mortality among people living with HIV amidst the illicit drug toxicity crisis in British Columbia

Figures & data

Table 1. Mortality due to overdose and non-overdose causes among PLWH in BC (n = 9180) from 2009/2010 to 2016/2017.

Deaths (n = 962)	n (%)
Death Events due to Overdose	142 (14.7)
Unintentional (X40–X44)*^1	137 (14.2)
X40	0 (0)
X41	13 (9.4)
X42	72 (52.5)
X43	0 (0)
X44	52 (37.9)
Intentional/Self-Harm (X60–X64)*^2	5 (0.5)
Death Events due to Other Causes	820 (85.2)
HIV-related causes	184 (22.4)
Non-AIDS cancer	175 (21.3)
Cardiovascular diseases	93 (11.3)
Infection	61 (7.4)
– Chronic Viral Hepatitis C	36 (4.3)
– Other Viral Hepatitis	7 (0.8)
– Influenza and Pneumonia	18 (2.2)
Mental Health Disorders	38 (4.6)
Chronic Lower Respiratory Diseases	34 (4.1)
Chronic Liver Diseases	26 (3.1)
Accidents	14 (1.7)
Nephritis, nephrotic syndrome and Nephrosis	8 (0.9)
Others	111 (13.5)
Unknown causes/R99	76 (9.2)

Note: Death represent underlying cause of death, identified via Vital Statistics Deaths, using ICD-10 codes.

*1 X40–X44:

X40: Accidental poisoning by and exposure to nonopioid analgesics, antipyretics, and antirheumatics

X41: Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs

X42: Accidental poisoning by and exposure to narcotics and psychodysleptics

X43: Accidental poisoning by and exposure to other drugs acting on the autonomic nervous system

X44: Accidental poisoning by and exposure to other and unspecified drugs, medicaments, and biological substances

*2 X60–X64 have similar definitions as the above codes for intentional poisoning (suicide).

Abbreviations: PLWH: people living with HIV; BC: British Columbia; AIDS: acquired immune deficiency syndrome.

Table 2. Mortality rates among PLWH in BC from 2009/2010 to 2016/2017.

	Frequency	Person-years	Rates (95% CI)*^1
Crude Rates
Overdose	142	56,430.44	2.52 (2.13, 2.97)
Non-overdose	820	56,430.44	14.53 (13.57, 15.56)
Sex-specific Crude Rates
Overdose
Males	99	44,920.36	2.20 (1.81, 2.68)
Females	43	11,510.08	3.74 (2.77, 5.04)
Non-overdose
Males	634	44,920.36	14.11 (13.06, 15.26)
Females	186	11,510.08	16.16 (14.0, 18.66)
Age-specific Crude Rates
Overdose
<30	<5	3072.98	1.30 (0.49, 3.47)
30–49	86	30,255.11	2.84 (2.30, 3.51)
50–64	50	19,339.32	2.59 (1.96, 3.41)
65+	<5	3763.03	0.53 (0.13, 2.13)
Non-overdose
<30	10	3072.98	3.25 (1.75, 6.05)
30–49	243	30,255.11	8.03 (7.08, 9.11)
50–64	386	19,339.32	19.96 (18.06, 22.05)
65+	181	3763.03	48.10 (41.58, 55.64)
Age-and-Sex Standardized Rates *^2,*3
Overdose			2.91 (2.28, 3.53)
Non-overdose			17.20 (15.59, 18.82)

*¹ All units of mortality rates are per 1000 person-years.

*² Standardization was performed using direct method and based on the 2016 Canadian population as a reference.

*³ Counts of overdose deaths for age categories <30 and >65 were sparse. Therefore, age categories <30 and “30–49”, and “50–64” and >65 were combined, i.e., age-adjusted categories for the purpose of standardization were defined as <50 and >50.

Abbreviations: PLWH: people living with HIV; BC: British Columbia; CI: confidence interval.

Figure 1. Age-standardized annual mortality trends from 2009/2010 to 2016/2017, divided by overdose versus non-overdose deaths. Note: Fiscal year is the period between 01 April of the previous year and March 31 of the year indicated in the y-axis, e.g., year 2017 indicates the period from 01 April 2016 to 31 March 2017. Note: Standardization was performed using direct method and based on the 2016 Canadian population as a reference. Note: Counts of overdose deaths for age categories <30 and 65+ were sparse. Therefore, age categories <30 and 30–49, and, separately, 50–64 and 65+ were combined, i.e., age-adjusted categories for the purpose of annual trend were defined as <50 and 50+. Abbreviations: PYs: person-years.

Table 3. Comparison of health-related characteristics among people who died of overdose versus non-overdose causes from 2009/2010 to 2016/2017.

	Overdose deaths (n = 142)	Non-overdose deaths (n = 820)	p-value
Categorical Variables, n (%)
Sex (at birth)
Male	99 (69.7)	634 (77.3)	0.04
Female	43 (30.2)	186 (22.6)
CD4 Cell Count *^1
≥350 cells/mm^3	62 (43.6)	237 (28.9)	0.0003
200–349	23 (16.2)	139 (16.9)
<200	20 (14.0)	221 (26.9)
Depression *^2			0.13
No	104 (73.2)	647 (78.9)
Yes	38 (26.7)	173 (21.1)
Substance Use *^2			0.06
No	59 (41.5)	409 (49.8)
Yes	83 (58.4)	411 (50.1)
Chronic Pain *^2			0.03
No	91 (64.1)	598 (72.9)
Yes	51 (35.9)	222 (27.1)
Hepatitis C *^3			0.0001
No	20 (14.1)	239 (29.1)
Yes	92 (64.7)	413 (50.3)
Hospitalization Episodes (yes)			<.0001
≤4 weeks before death	28 (19.7)	522 (63.6)
5–12 weeks before death	26 (18.3)	327 (39.8)
13–48 weeks before death	49 (34.5)	431 (52.5)
Continuous Variables, median (Q1, Q3)
Age *^1	46 (42, 52)	54 (48, 63)	<.0001
Viral Load (log 10) *^1	1.69 (1.69, 3.73)	1.69 (1.69, 2.99)	0.32

Note: Unknown values for hepatitis C and CD4 cell count were not included in the analysis.

*¹ Variables were assessed at death. For Viral load, the last result available in the year prior to death was used.

*² Variables were assessed in the one-year period prior to death.

Table 4. Comparison of prescription history between PLWH who died of overdose versus non-overdose from 2009/2010 to 2016/2017, stratified by sex.

	Males		p-value	Females		p-value
	Overdose (n = 99)	Non-overdose (n = 643)		Overdose (n = 43)	Non-overdose (n = 186)
OAT
No	87 (87.8)	594 (93.6)	0.03	35 (81.4)	161 (86.5)	0.38
Yes	12 (12.1)	40 (6.31)		8 (18.6)	25 (13.4)
Opioids
No	47 (47.4)	293 (46.2)	0.8	19 (44.1)	81 (43.5)	0.93
Yes	52 (52.5)	341 (53.7)		24 (55.8)	105 (56.4)
NPR
No	71 (71.7)	459 (72.4)	0.8	20 (46.5)	123 (66.1)	0.01
Yes	28 (28.8)	175 (27.6)		23 (53.4)	63 (33.8)
SSRI/SNRI
No	77 (77.8)	492 (77.6)	0.9	23 (53.4)	122 (65.5)	0.13
Yes	22 (22.2)	142 (22.4)		20 (46.5)	64 (34.4)
Sedatives
No	78 (78.7)	433 (68.3)	0.03	30 (69.7)	123 (66.1)	0.64
Yes	21 (21.2)	201 (31.7)		13 (30.2)	63 (33.8)

Note: Variables were assessed within one year before death as binary categorical variables (yes, no) and expressed in proportions, n (%).

Abbreviations: OAT: opioid agonist therapy; NPR: neuropathic pain relievers; SSRI: selective serotonin reuptake inhibitors; SNRI: serotonin-norepinephrine reuptake inhibitor