Predictors of mortality for patients with advanced disease in an HIV palliative care program

Background: Despite advances in treatment, AIDS and its associated comorbidities remain important causes of death. Traditional HIV prognostic markers may be less useful in predicting death in current late-stage patients than in the era before highly active antiretroviral therapy. Methods: We used standardized baseline and follow-up data to describe causes of death and predictors of mortality in a cohort of patients with advanced disease referred to a specialized HIV palliative care program at a large urban medical center. Results: Of 230 patients, 56% were male with a median age of 43 years; 54% were Hispanic and 39% were African American; 41% had a history of injection drug use; 89% had prior AIDS-defining illnesses; and median baseline values included a CD4⁺ count of 39 cells/mm³, HIV viral load of 65,202 copies/mL, Kamofsky score of 30, and 5 impaired activities of daily living (ADL). Over a median follow-up of 126 days (range: 1-823 days), 120 patients died; 54% of these died of late-stage HIV disease and/or bacterial pneumonia or sepsis, 19% of non-AIDS-defining cancers, 13% of liver failure and/or cirrhosis, and 12% of other progressive end-organ disease (eg, cardiac, pulmonary, renal). On multivariate analysis, death was predicted only by age (>65 years), baseline number of ADL impairments, and Karnofsky score (P < 0.0001 for all) and not by any AIDS-specific variables. Conclusions: For patients with late-stage disease referred to an HIV palliative care program, age and markers of functional status were more predictive of mortality than traditional HIV prognostic variables. Close to half of all deaths were attributable to non-AIDS-specific causes, including cancer and end-organ failure. These findings suggest the need for renewed study of predictors of mortality and prognostic markers in patients with advanced HIV disease and related comorbidities in the HAART era.