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  • Mortality rates have not declined for people with HIV in San Francisco since 2013
  • Researchers reviewed medical records for causes of death among people with HIV
  • A growing fraction of deaths result from cancers unrelated to HIV and overdose

For decades, San Francisco has been hard hit by the HIV pandemic. As a result, it has often been at the forefront of adapting models to deliver HIV-related care and treatment. What happens with the HIV pandemic in San Francisco usually happens in other cities of high-income countries, so it is worth paying attention to HIV-related trends in the city.

In 2013 a consortium of organizations and citizens called “Getting to Zero–San Francisco” formed. Its goals are to significantly reduce HIV-related deaths, new HIV infections and HIV-related stigma. The city has made much progress since 2013, with a 44% reduction in new HIV infections and a 25% reduction in deaths related to HIV. However, scientists at the University of California at San Francisco (UCSF) have found that “the overall age-adjusted mortality rate did not change among [HIV-positive people]” since 2013. They suspect that a large proportion of deaths in the current era arose from complications of cancers unrelated to HIV and substance use.

The study

To better understand the issues underlying deaths of HIV-positive people, the scientists at UCSF reviewed and compared health and socio-economic information between July 2016 and May 2017 among the following two groups of people:

  • 48 HIV-positive people who died
  • 108 HIV-positive people who did not die

On average, participants who died had been living with HIV for 20 years and their CD4+ count prior to death was 400 cells/mm3. In total, 90% of participants were men and 10% were women.

Results—Causes of death

Known causes of death were as follows:

  • HIV-related illness – 27%
  • cancers unrelated to AIDS – 15%
  • overdose/substance use – 15%
  • cardiovascular disease – 10%
  • trauma/accident – 4%
  • suicide – 4%
  • liver disease related to hepatitis B or C virus – 4%
  • other liver disease – 4%
  • infections unrelated to AIDS – 4%
  • chronic obstructive pulmonary disease – 2%
  • kidney disease – 2%

Compare and contrast

Scientists next compared many factors between the two groups of participants and found that the following factors were more likely among people who died:

  • homelessness
  • injecting street drugs in the past year
  • interrupting ART in the past year
  • not having a partner or being unmarried

A closer look

Scientists also conducted an in-depth review of the “circumstances that may have contributed to death” among participants. They found that the following factors were major contributors:

  • substance use
  • mental illness
  • homelessness

Interventions needed

Based upon their analysis, the scientists recommended interventions along the following themes to reduce deaths among vulnerable HIV-positive people in San Francisco:

Supportive housing

Although there is a program of supportive housing in the city, the scientists noted that the “housing supply remains far too limited.” They encouraged a future intervention that combined investment in supportive housing with case management.

Smoking tobacco

Smoking is associated with many harms, including an increased risk for a range of cancers. Surveys have found that rates of smoking among HIV-positive people are greater than those among HIV-negative people. The scientists mentioned the need for smoking cessation programs.

Heroin and other opioids

Injecting street drugs is associated with many harms. The scientists encourage the availability of treatment programs for people with opioid use disorder. Such treatment has been found in other studies to reduce deaths and improve HIV-related outcomes, such as engagement in care and achievement and maintenance of viral suppression.


According to the scientists, the use of stimulants (cocaine, crystal meth) “is increasing” among gay, bisexual and other men who have sex with men in San Francisco. They encouraged research to find effective interventions to treat stimulant use disorder.

Bipolar disorder and schizophrenia

The scientists found that mental illness contributed to the “circumstances of death for greater than one-third of [participants].” They said that schizophrenia and bipolar disorder may have made some participants more vulnerable to substance use, which in turn likely decreased their adherence to ART. They noted that among HIV-negative people with schizophrenia “death due to substance use outpaces suicide in its contribution to excess mortality.”

Social support

Studies among HIV-negative people have found an increased risk of death in unpartnered/unmarried people. The scientists stated that “provision of social support services may particularly benefit older [HIV-positive people] living alone, who may suffer the health consequences of geriatric conditions such as falls and neurocognitive issues without additional support.”

Falling out of care

The scientists stated that “retaining [HIV-positive people] on ART remains a challenge across the U.S., particularly in populations with serious mental illness, substance use challenges and housing instability, with new strategies needed. Continued investment in [ART] reengagement programs such as the Getting to Zero-San Francisco navigation program, particularly for individuals who miss or do not attend primary care visits, can potentially improve ART persistence in this population.”

Bear in mind

The present study is imperfect in design; it also had a relatively small sample of people. However, scientists took steps to minimize the potential of drawing biased conclusions when analysing the data. The findings from this study are very important, as issues similar to those in San Francisco are happening in other cities in high-income countries.

For the future

The scientists made the following solution-oriented statement:

“In addition to continued investment in medical interventions, implementation of comprehensive social services with known efficacy, such as supportive housing, substance use and mental health treatment, and investment in developing new strategies, will be needed to dramatically reduce preventable deaths.”

—Sean R. Hosein

As we go to press, the City’s Department of Public Health has announced funding for some of the issues mentioned in our news story.


  1. Spinelli MA, Hessol NA, Schwarcz S, et al. Homelessness at diagnosis is associated with death among people with HIV in a population-based study of a U.S. city. AIDS. 2019 Sep 1;33(11):1789-1794.
  2. Bornheimer LA, Zhang A, Tarrier N, et al. Depression moderates the relationships between hallucinations, delusions, and suicidal ideation: The cumulative effect of experiencing both hallucinations and delusions. Journal of Psychiatric Research. 2019 Sep;116:166-171.
  3. Heiberg IH, Jacobsen BK, Nesvåg R, et al. Total and cause-specific standardized mortality ratios in patients with schizophrenia and/or substance use disorder. PLoS One. 2018 Aug 23;13(8):e0202028.
  4. Aldridge RW, Story A, Hwang SW, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018 Jan 20;391(10117):241-250.
  5. Østergaard MLD, Nordentoft M, Hjorthøj C. Associations between substance use disorders and suicide or suicide attempts in people with mental illness: a Danish nation-wide, prospective, register-based study of patients diagnosed with schizophrenia, bipolar disorder, unipolar depression or personality disorder. Addiction. 2017 Jul;112(7):1250-1259.
  6. Icick R, Melle I, Etain B, et al. Tobacco smoking and other substance use disorders associated with recurrent suicide attempts in bipolar disorder. Journal of Affective Disorders. 2019 Jun 1;256:348-357.
  7. Onyeka IN, Collier Høegh M, et al. Comorbidity of physical disorders among patients with severe mental illness with and without substance use disorders: A systematic review and meta-analysis. Journal of Dual Diagnosis. 2019 Jun 4:1-15.
  8. Fortuna KL, Ferron J, Pratt SI, et al. Unmet needs of people with serious mental illness: Perspectives from certified peer specialists. Psychiatric Quarterly. 2019; in press.
  9. Iheanacho T, Stefanovics E, Rosenheck R. Opioid use disorder and homelessness in the Veterans Health Administration: The challenge of multimorbidity. Journal of Opioid Management. 2018 May/Jun;14(3):171-182.
  10. Navon L. Hospitalization trends and comorbidities among people with HIV/AIDS compared with the overall hospitalized population, Illinois, 2008-2014. Public Health Reports. 2018 Jul/Aug;133(4):442-451.
  11. Coviello DM, Lovato R, Apostol K, et al. Prevalence of HIV viral load suppression among psychiatric inpatients with comorbid substance use disorders. Community Mental Health Journal. 2018 Nov;54(8):1146-1153.
  12. Horwitz H, Dalhoff KP, Klemp M, et al. The prognosis following amphetamine poisoning. Scandinavian Journal of Public Health. 2017 Dec;45(8):773-781.
  13. Bauer-Staeb C, Jörgensen L, Lewis G, et al. Prevalence and risk factors for HIV, hepatitis B, and hepatitis C in people with severe mental illness: a total population study of Sweden. Lancet Psychiatry. 2017 Sep;4(9):685-693.
  14. Mandell LN, Rodriguez VJ, De La Rosa A, et al. Suicidal ideation among adults re-engaging in HIV care in Argentina. AIDS and Behavior. 2019; in press.
  15. Singh K, Chander G, Lau B, et al. Association of history of injection drug use with external cause-related mortality among persons linked to HIV care in an urban clinic, 2001-2015. AIDS and Behavior. 2019; in press.
  16. Loeliger KB, Altice FL, Ciarleglio MM, et al. All-cause mortality among people with HIV released from an integrated system of jails and prisons in Connecticut, USA, 2007-14: a retrospective observational cohort study. Lancet HIV. 2018 Nov;5(11):e617-e628.
  17. Olfson M, Crystal S, Wall M, et al. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827.
  18. Passaro RC, Ramsey K, Segura ER, et al. Speed kills: Associations between methamphetamine use, HIV infection, tobacco use, and accelerated mortality among gay and bisexual men in Los Angeles, CA 20 years after methamphetamine dependence treatment. Drug and Alcohol Dependence. 2019 Feb 1;195:164-169.
  19. Li MJ, Okafor CN, Gorbach PM, et al. Intersecting burdens: Homophobic victimization, unstable housing, and methamphetamine use in a cohort of men of color who have sex with men. Drug and Alcohol Dependence. 2018 Nov 1;192:179-185.
  20. Jin H, Ogunbajo A, Mimiaga MJ, et al. Over the influence: The HIV care continuum among methamphetamine-using men who have sex with men. Drug and Alcohol Dependence. 2018 Nov 1;192:125-128.
  21. Jones DL, Carrico AW, Babayigit S, et al. Methamphetamine-associated dysregulation of the hypothalamic-pituitary-thyroid axis. Journal of Behavioral Medicine. 2018 Dec;41(6):792-797.
  22. Fletcher JB, Swendeman D, Reback CJ. Mental health and substance use disorder comorbidity among methamphetamine-using men who have sex with men. Journal of Psychoactive Drugs. 2018 Jul-Aug;50(3):206-213.
  23. Riley ED, Vittinghoff E, Koss CA, et al. Housing First: Unsuppressed viral load among women living with HIV in San Francisco. AIDS and Behavior. 2019; in press.
  24. Clemenzi-Allen A, Neuhaus J, Geng E, et al. Housing instability results in increased acute care utilization in an urban HIV Clinic Cohort. Open Forum Infectious Diseases. 2019 Mar 27;6(5):ofz148.
  25. Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addiction Science & Clinical Practice. 2019 May 6;14(1):20.