This study showed some notable findings on causes of death among a large and demographically diverse population of HIV patients. Mortality was higher among those patients aged 50 years old or older who had been infected by IDU or blood transfusion/donation and had not accepted HAART.
According to our study, the risk factor strongly related to death was age, especially for individuals aged 50 years old or older. There may be many reasons for this. First of all, a substantial proportion of elderly people who meet treatment criteria may give up treatment voluntarily. This is likely to be associated with the personal characteristics of this group, such as having low levels of education and desiring to reduce the burden on family. Furthermore, individuals in older age groups may be likely to refuse treatment as a result of the stigma associated with HIV/AIDS
, without the support of social and family members. Last but not least, elderly people may be underserved by the public health system, especially in some less developed areas.
The study noted a significant risk of mortality in individuals who were infected by IDU and blood transfusion/donation compared to heterosexual transmission. IDU was the primary mean of transmission at the beginning of China’s HIV epidemic
, which led to a long period of infection and late treatment initiation. Consequently, those infected by IDU had a higher mortality rate, which is consistent with other reports
[29, 30]. In addition, the high mortality in IDUs may be associated with personal characteristics; some foreign studies indicated that the majority of accidental deaths among IDUs are from drug overdoses
Similarly, blood transfusion was also one of the main routes in the early phase of China
, most former plasma donors (FPD) or blood receptors infected by HIV long time ago, which made the disease developed long enough to become a danger for bodies and thus a risk factor for higher mortality
Significantly, there is a protective influence in individuals infected by homosexual transmission, in contrast with individuals infected by heterosexual transmission. There may be a bias here due to the database’s small sample of men who have sex with men (MSM), although the population of MSM has begun to increase in recent years in China
[35, 36]. Another potential reason may be that the majority of MSM are relatively young.
The results of our study reveal a statistically significant difference between accepting HAART or not. The results provide evidence that increasing HAART coverage at the population level can decrease HIV-related mortality, which conforms with the results of overseas findings such as those from the mid-to-late 1990s in the USA
 and in other earlier studies
In the five provinces with the highest proportion of cumulative AIDS deaths, patients who died almost always had a history of paid blood donation. These regions excelled at early detection, management of cases and follow-ups, and reporting deaths. Conversely, in Beijing, Shanghai, Tianjin, and Zhejiang, the proportion of cumulative AIDS deaths was the lowest among all provinces. The reason for the low AIDS deaths in these areas may be due to their large migrant populations, whose high mobility complicates follow-up.
According to previous studies, end-stage patients with low CD4 counts achieve significantly fewer life-prolonging effects through HAART than those with high CD4 counts. However, according to the results of this study, most of those who died before initiating HAART never had a CD4 test. Efforts should be made to improve coverage of HIV diagnostic tests and the frequency of CD4 testing in order to offer timely HAART to prolong survival time. The median time between diagnosis and death was only 0.7 years, and nearly half of cases were discovered late. Though HAART can effectively reduce the fatality rate of HIV/AIDS, many at-risk individuals do not seek out standard HIV counseling and testing services. The stigmas associated with drug use and HIV/AIDS and the fear of arrest or of a positive result can be major barriers to accessing HIV voluntary counseling and testing (VCT) services
. It is critical to scale up early monitoring to provide prompt treatment and effectively reduce AIDS mortality.
The results of this survival analysis indicate the benefits of HAART in reducing overall mortality and AIDS-related morbidity, which is similar to results in other studies
[42, 43]. However, the cumulative number of HIV-positive adults using HAART in China was less than 20% by the end of 2010
. The results indicate that HIV-positive individuals need to be diagnosed much earlier, which would suggest that HIV testing programs should be expanded.
In our study, survival analysis in HIV patients received HAART also indicated that individuals were more likely to have a long interval of time between diagnosis and death compared to individuals who had high baseline CD4 cell counts. The differences were more visible between Group 1 and Group 4. Timely HAART should be provided to prolong survival time, as receiving HAART is the best way to reduce mortality. Mechanisms should be in place to prevent the development of drug resistance and to enhance clinical services, including implementing viral load testing, increasing adherence, and providing prompt second-line therapy for patients with first-line treatment failure.
This study had several limitations. First, data were used from sentinel detection databases and may not be representative of all deaths in China, may exclude those who were homeless or living alone when they died and may underestimate AIDS-related mortality. Second, many could have died of AIDS, but if they were never diagnosed the cause of death could have been listed as something else and they would not be included in the databases. Third, data may have been missing from the databases for other reasons. Missing data may influence the determination of receiving HAART or not, which likely underestimates the proportion of patients who had initiated HAART.