HIV This Week

Suicide in HIV-Infected Individuals and the General Population in Switzerland, 1988-2008.

Keiser O, Spoerri A, Brinkhof MW, Hasse B, Gayet-Ageron A, Tissot F, Christen A, Battegay M, Schmid P, Bernasconi E, Egger M; for the Swiss HIV Cohort Study and the Swiss National Cohort. Am J Psychiatry. 2010. 167:143-150.

High rates of suicide have been described in HIV-infected patients, but it is unclear to what extent the introduction of antiretroviral therapy has affected suicide rates. The authors examined time trends and predictors of suicide in the pre-antiretroviral treatment (1988-1995) and antiretroviral treatment (1996-2008) eras in HIV-infected patients and the general population in Switzerland. The authors analyzed data from the Swiss HIV Cohort Study and the Swiss National Cohort, a longitudinal study of mortality in the Swiss general population. They calculated standardized mortality ratios comparing HIV-infected patients with the general population and used Poisson regression to identify risk factors for suicide. From 1988 to 2008, 15,275 patients were followed in the Swiss HIV Cohort Study for a median duration of 4.7 years. Of these, 150 died by suicide (rate 158.4 per 100,000 person-years). In men, standardized mortality ratios declined from 13.7 (95% CI=11.0-17.0) in the pre-antiretroviral treatment era to 3.5 (95% CI=2.5-4.8) in the late antiretroviral treatment era. In women, ratios declined from 11.6 (95% CI=6.4-20.9) to 5.7 (95% CI=3.2-10.3). In both periods, suicide rates tended to be higher in older patients, in men, in injection drug users, and in patients with advanced clinical stage of HIV illness. An increase in CD4 cell counts was associated with a reduced risk of suicide. Suicide rates decreased significantly with the introduction of antiretroviral treatment, but they remain above the rate observed in the general population, and risk factors for suicide remain similar.

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Editors’ note: The results of this study, revealing encouraging declines in the suicide rate among people living with HIV in Switzerland since the advent of antiretroviral treatment, need to be seen in context. Swiss suicide rates are in the top-third in Europe and the top quintile, i.e the top 20%, in the world. Declines in the suicide rate have occurred in the general population too but not to the extent seen in surrounding countries. Switzerland has no national suicide prevention programme to address this important public health problem and the suicide rate among people living with HIV, despite the important declines documented here, may be higher than in other European countries. They are certainly higher than in the general Swiss population and are higher than those in other patients with life-threatening conditions. Although 75% of people with HIV who committed suicide had a diagnosis of mental illness, it is unclear to what extent stigma, discrimination, social isolation, drug toxicity, and other factors are playing roles. Understanding what is influencing decisions to commit suicide is the first step to preventing such unnecessary deaths among people living with HIV.