A review of the autopsy reports of 252 men and women who died of acquired immunodeficiency syndrome (AIDS) in New York City between 1984 and 2016 reveals several long-term trends in combatting the epidemic. The infectious disease is known for drastically lowering the body’s immune defenses and is spread by the human immunodeficiency virus, or HIV.
The researchers at NYU School of Medicine and NYU Long Island School of Medicine who led the study say their analysis is the largest review of autopsy-verified causes of death since a similar California report in 2000, and almost 40 years since the epidemic was recognized by health officials in 1981.
“Our study accurately reflects the history of the epidemic in New York City, which still has the highest number of new HIV infections per year in the United States,” says senior study investigator Amy Rapkiewicz, MD.
“Autopsy reports reliably tell the whole disease story and why people are still dying from it,” says Rapkiewicz, an associate professor in the Department of Pathology at NYU Langone Health and vice chair of pathology at NYU Winthrop Hospital on Long Island. “That is because there is often a difference between the immediately reported cause of death, such as a heart attack, and the actual cause of death, whether from obesity, drug use, or HIV/AIDS.”
Among the key findings in the report, publishing in the Archives of Pathology and Laboratory Medicine online Aug. 28, is that early in the HIV epidemic in 1984, the average age of death in the city from AIDS was 36. By 2010, the average age had risen to 54.
Rapkiewicz credits this increase in lifespan to the development of combination antiviral drug therapies in the 1990s that prevent HIV from reproducing and infecting other cells, but, she says, “people are still dying predominantly from the underlying disease and not just factors related to old age.”
According to researchers, infections such as pneumocystis pneumonia in the lungs are still the leading cause of death (accounting for 100 percent of deaths between 1984 and 1987, 52 percent between 1996 and 1999, and 86 percent from 2012 to 2016). “Even a treated HIV-positive patient is immunocompromised and at increased risk of dying from pneumonia,” says Rapkiewicz.
And now that people are living longer with HIV, she says, other common co-infections, such as viral hepatitis C, which takes years to damage the liver, are starting to emerge as causes and contributors of death. Three-quarters of those autopsied between 2014 and 2016 had hepatitis C and cirrhosis, a severe and potentially deadly scarring of the liver.
However, researchers expect that recent advances in drug therapies for hepatitis C will drive down these numbers in the near future.
One study finding that remains to be explained by future autopsy reports, they say, is the sharp increase in hardened and fat-narrowed arteries from atherosclerosis among those dying with HIV. Between 1988 and 1991, atherosclerosis was found in 21 percent of those autopsied, but for the years 2008 to 2011, the condition was found in 54 percent.
Lead study investigator Sobia Nizami, MD, a clinical fellow in infectious diseases at NYU Langone, says it is difficult to assess if this trend is due to HIV-positive people simply living longer, overeating, and adopting the sedentary lifestyles widely seen among non-infected Americans, or if something more worrisome, such as long-term side effects of antiviral medications, are at the root of the problem. Body fat deposits seen with earlier anti-HIV drugs were, she says, mostly eliminated with later versions of the drugs.
The investigators say their study was designed in part to educate more clinicians, not just physicians, but also physician assistants and nurse practitioners, about the importance of accurately documenting death certificates to properly reflect people’s HIV status and the main cause of death. The researchers caution that their analysis only reflects the disease’s trends in New York City, not nationally.
For the study, self-funded by NYU Langone, researchers reviewed all the autopsy records at NYC Health + Hospitals/Bellevue of people who died with HIV. The hospitals’ HIV clinic is the city’s largest and serves a predominantly poor community with higher than average rates of drug use, a risk factor for HIV infection.
Experts estimate that more than 100,000 New Yorkers have died of AIDS-related causes since the epidemic began, and 125,000 are currently living with HIV. In 2017, the city recorded more than 2,100 new cases of HIV infection.
NYU Langone study co-investigators included Robert Holzman, MD, who has treated people living with HIV in New York since the beginning of the epidemic. Additional research support was provided by students Kelly Hu and Cameron Morales.