In sub-Saharan Africa more than 2 million people with HIV now receive antiretroviral treatment (ART), and mortality in HIV-infected patients who have access to ART is declining. In the new study, Matthias Egger of the University of Berne and colleagues investigated how mortality among HIV-infected people starting ART compares with non-HIV related mortality in Cote d'Ivoire, Malawi, South Africa, and Zimbabwe. The researchers analyzed information about people during their first two years on ART in five treatment programs participating in the International epidemiological Databases to Evaluate AIDS (IeDEA) initiative, and obtained estimates of HIV-unrelated deaths in these countries from the World Health Organization Global Burden of Disease (GBD) project.

Their findings indicate that mortality among HIV-infected people during the first two years of ART is higher than in the general population in these four sub-Saharan countries. However, for patients who start ART when they have a high CD4 lymphocyte count and no signs of advanced HIV disease, the excess mortality is moderate and similar to that associated with diabetes.

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While earlier studies had quantified deaths linked to a few factors, like smoking and alcohol, this is the first to look at a wide range of risk factors, including those linked to diet, lifestyle and metabolic factors, and the first to do so for the whole U.S. population. This is also the first to use methods that allowed a true comparison of a diverse set of risks in terms of how many deaths each of the risk factors is responsible for. The researchers analyzed data from a number of public sources, including from the National Center for Health Statistics and numerous published epidemiological studies and clinical trials.

The researchers also found differences between the preventable causes of death among men and women. High blood pressure was the leading cause of death in adult women, killing nearly 230,000 American women each year, 19 percent of all female deaths. By comparison, that is more than five times the 42,000 number of annual deaths in women from breast cancer.

Smoking was the leading cause of death in men, killing an estimated 248,000 annually, or 21 percent of all adult male deaths.

The mortality effects of many other risk factors were about equal in men and women, with alcohol use being a major exception. Seventy percent of all deaths caused by alcohol were among men and represented 45,000 deaths, a result the researchers said was because men consumed more alcohol and engaged in more binge drinking.

"The findings should be a reminder that although we have been effective in partially reducing smoking and high blood pressure, we have not yet completed the task and have a great deal more to do on these major preventable factors," said senior author Ezzati. "The government should also use regulatory, pricing, and health information mechanisms to substantially reduce salt and trans fats in prepared and packaged foods and to support research that can find effective strategies for modifying the other dietary, lifestyle, and metabolic risk factors that cause large numbers of premature deaths in the U.S."

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