Analysis of 40 studies of impact of HIV on suicide show conflicting results

There are many different opinions about whether HIV is related to suicide rates. But there's no unequivocal answer to this question. The Aidsmap information resource (an online magazine that works in the field of HIV and publishes and analyses research related to HIV/AIDS) presented an overview of 40 studies and asked mental health specialists to share their experience and comment on the results. https://www.aidsmap.com/news/aug-2021/hardest-outcome-all-hiv-and-suicide

The suicide rate is higher among people with HIV. But by how much?

In April, the medical journal General Psychiatry published an article prepared by the publisher of the British Medical Journal. This was the first attempt to systematically review and meta-analyse suicide rates, suicide attempts and suicidal thoughts in people with HIV. The paper, authored by Matt Payton and his colleagues at Penn State University in the United States, reviews 40 studies from all continents involving 185,199 people living with HIV.

But Aidsmap hesitated to report it, and there are two reasons for that. 

The main reason is that suicide is a sensitive topic, the team also wanted to be absolutely sure that the data in the publication would be accurate and not sensationalise the topic. Therefore, Aidsmap journalists asked three statisticians to analyse the article, and interviewed a psychiatrist as well as a clinical psychologist about their views on suicide among people with HIV.

The second reason was that what the journal published seemed shocking, and the team wanted to understand whether its conclusions were correct.

Suicide rates - in the world and among people living with HIV

The World Health Organization (WHO) reports that 700,000 people worldwide passed away of their own free will in 2019, and that 1.3% of deaths worldwide in 2019 were the result of suicide. In the general population, it is the third most frequent cause of death among young women aged 15-29 and the fourth most frequent cause of death among young men. Mortality rates for men of all ages are twice as high as for women, as are other deaths as a result of violence, such as attacks and road traffic accidents.

There is no apparent connection between suicide and income. Rates for men are the highest in high-income European countries and low-income Africa. For women, they are the highest in Southeast Asia.

In high-latitude, rather than tropical countries, there is a trend towards higher rates. The numbers in most Islamic countries, as well as in central and northern South America with strong Catholicism followings, are noticeably lower, so perhaps a united religious culture protects - or stigmatises suicide. 

Rates peak at 25 years of age in low-income countries and 55 years in higher-income countries. The good news is that over the past 20 years, rates have fallen in all but one region of the world. Rates have almost halved in Europe and East Asia, the exception is North America, where they have increased slightly.

According to WHO, the annual suicide rate worldwide in 2019 was 0.009%, or one suicide per just over 11,000 people per year.

The General Psychiatry article found 12 studies, all from North America and Europe, documenting data from "complete suicides" in people living with HIV. Matt Peyton found that the figure was 1.02% per year, or one for every 98 people. A hundred times more than among the general population.

Obviously, this figure attracted attention. But he also found a higher level of suicide attempts and suicidal thoughts.

Suicidal thoughts and attempts are much more common than “complete suicides”. Researchers have found that the lifetime rate of attempts in people with HIV is 15.8% compared to WHO's global estimate of 3% among the general population.

On the topic of suicidal thoughts, this could include anything from considering, to planning, to actively saving up pills, the level of ideas among people with HIV was 22.8%; WHO estimates for the general population is 9%.

Why? 

From the beginning, it was clear that there was something strange about the very high suicide rates. WHO estimates that only one in 286 suicide attempts actually ends in death. And yet in meta-analysis, the ratio of the annual frequency of attempts (in one group of studies) to the frequency of real suicides (in another group) was exactly 2:1. It seemed that there was no reason why people with HIV should 143 times more successful at following through on their plans.

Then there was the time period over which the data was collected. Of the 40 studies, ten collected data until 2000, and seven others were cohort studies that collected data for a long period of time, including years before 2000, when treatment was either unavailable or not entirely effective. Of the 12 articles reporting actual suicides, only one has collected all its data in the 21st century. 

Of the 16 articles that recorded life-long suicide attempts, 12 have collected all their data since 2000. Life-long suicides attempts fell 0.17% over the year of publication. Among those taking antiretroviral therapy, the number of attempts decreased by another 1.35%, which means that if this change rate persists, suicide attempts could almost halve in ten years.

Experts have noticed other strangenesses in the meta-analysis. Professor Andrew Phillips, University College London, observed that the number of suicides “completed” was disproportionally increased by two articles: one was a review of death certificates in France in 2000 and the other by morgues from San Francisco in 1995-97. The two articles reported annual suicide rates of 10.7% and 19.3% respectively among people with HIV. One in five people with HIV did not die every year, even in the mid-1990s, let alone from suicide. These figures should be considered unreliable.

But as Phillips noted, they did not report suicide rates among all people with HIV, but the proportion of deaths among people with HIV that occurred as a result of suicide. If you want to calculate the incidence, you need to include a much larger group of people who did not die that year and therefore were not suicide by definition. So these studies should have been excluded.

Phillips' colleague, Professor Caroline Sabine, noted that it can be difficult to determine whether a death is really suicide. Death, which seems to be suicide, can be an accident; for example, an overdose of drugs or people who usually hurt themselves but accidentally went too far.

She also noted that several studies, that had very high rates of both completed and suicide attempts, concerned very vulnerable groups of people. One study that reported 22% of suicide attempts per year was a study from Puerto Rico, which involved a large number of drug users. Another suicide attempt study was conducted among children with perinatal infection in the United States. A third report, which reported a high rate of completed suicides in the Netherlands, was conducted in the early years of the fight against AIDS (1984-92), and its name speaks for itself: ‘Deaths by suicide and overdose among injecting drug users after disclosure of the first result HIV test’.

The two above-mentioned U.S. studies were the only ones in the country that reported annual suicide attempts. All three studies conducted in Europe found a much lower annual frequency of attempts. As a result, the survey figure of the annual suicide attempts in the U.S. is 51 times higher than in Europe.

If we exclude the results from these unreliable or unrepresentative studies and articles, it turns out that the suicide rate for people living with HIV is around 0.7% per year. This is almost eight times higher than the world figure and 5.5 times higher than the world figure for men, but now it is within the same order of magnitude. Similarly, for life-long suicide attempts, this figure is five times higher than the average, and for suicidal thoughts it is 2.5 times higher.

This is much closer to the figures presented in a study by Dr. Sarah Crocksford of the Public Health England, at the British HIV Association's 2017 conference. This study found that suicide rates among people with HIV are more than twice as high as among the general population (0.021% per year, representing 2% of all deaths among people with HIV). The figure for men was 0.032 percent.

Sarah Croxford highlighted to Aidsmap that the suicide rate was five times higher than the global population in the first year after diagnosis (0.052%) and that it accounted for 40% of all suicides in the cohort.

So, even if the true suicide rate among people with HIV is not as high as it may seem at first glance when General Psychiatry’s analysis, the rates are still higher than among the general population.

Interviews with mental health specialists

Aidsmap interviewed two mental health experts for people living with HIV, clinical psychologist Professor Lorraine Sherr of University College London, and Dr. Pepe Catalan, a former psychiatrist consultant from Chelsea and Westminster Hospital.

How to deal with suicide?

“It's hard to analyse suicidal thoughts, attempts and suicide rates,” says Sherr. - Completed suicides are a mixture of "successes" and "failures" - people who intended to die and died, and people who didn't really want to kill themselves, but did it by accident when they hurt themselves or due to accidental overdose. Likewise, those who “try” to commit suicide are a mixture of people who wanted to die but “couldn't” - there weren't enough pills, they were found in time, the train didn't hit them. Then there are those who use it an attempt as a cry for help - they are very different people. The first group wants to die, the second group just doesn't know how to live.

This also complicates the analysis of suicide because the demographics of the two groups are very different. Suicides are more often younger and females, but planned suicides are more often older and males. People planning suicide are more often people, especially men, who have experienced great failure, humiliation, or shame.

The diagnosis of HIV, of course, can be perceived as such a change. Back in the days when HIV often meant job loss, it often seemed like a provoking factor. The stigma of suicide can also affect record collecting - coroners may record “accidental death” under pressure from families.

Other issues that may provoke suicidal thoughts and attempts are linked to the method in which they acquired HIV. We know that gay men are more likely to commit suicide than other men, and they’re more likely to get HIV.

Socio-political factors matter. The closure of the coal mines did not immediately lead to an increase in suicide rates, perhaps because shared experience and community support helped with the consequences of losing a job. In contrast, when people become unemployed alone, the impact is stronger. Suicide rates generally increased during the deindustrialisation of the 1980s, but have slowly declined since then. It will be interested to know what COVID has done - will it be experienced as a time of exchange of experience and support or as a time of anxiety and isolation?

Can suicide be predicted and prevented?

“Listen to them very carefully and allow them to speak,” Sherr says. One of the most common myths about suicide is that those who talk about suicide do not commit suicide. In my experience, this is not true. In fact, if a person who usually finds it difficult to speak suddenly announces that they have suicidal feelings, they should be taken very seriously.”

“Yes, hold on to the chair, shut up and listen,” Catalan agrees. “And don't rush to decisions, don't play down their feelings, don't tell them they'll feel better soon, and above all, don't tell them to “get it together”. Depression is not necessarily a sign of suicidality. In fact, people often cheer up a few days before suicide. They're all throwing it away. When a person talks about plans, you really pay attention.

“One of the warning signs and triggers is the complete loss of normal sleep patterns,” he adds. - This is a sign of a state of unhindered anxiety and loss of role, and of course, if you were not suicidal before, you could be after a few sleepless nights”.

“The best prevention is the support you give anyone,” Sherr says. - Do they have good social services and housing support? Do they have a therapist and is there a rapport with them? Medication can go a long way, and I don't necessarily mean antidepressants, I mean treating chronic illness or pain.

(Sarah Croxford's article shows that in the days when antiretroviral therapy was not given immediately after HIV diagnosis, the suicide rate among people with HIV dropped dramatically as soon as they started ART - both because they felt better physically and and because they felt in control of their health.)

“But it's important not only to meet external needs,” adds Cher. - Suicide is, ultimately, a psychological problem, consisting of the loss of hope. Suicidal people have often lost their way, there is no structure in their life, and I try to change the situation a little, even by simply saying, “Call me tomorrow! At ten!"

“A failed suicide attempt can even be interpreted as a signal for a better future,” says Catalan. - One of my first psychiatric jobs was working with people who jumped in front of a subway train. Most often they survive - they fall into the well between the rails. One of my HIV positive clients saw it as a miracle, a sign that he was destined to live, and he never did it again.”

Suicide and its consequences

What about the idea that suicide "catches"? Is this learned behaviour? People often get nervous when discussing the topic.

“There is some truth in the idea of ​​copycat suicide,” says Catalan. - In the days of AIDS, we had suicide groups. It somehow gave people social permission.

"I am really worried about social media, but not because they directly encourage suicidal behavior or self-harm. Quite the opposite: everyone portrays themselves to be successful, beautiful, loved and, above all, happy. And if you don't feel it, you may feel excluded from everything. It worries me that young people are ashamed if they are not happy."

What advice would you give to families and loved ones of people who kill themselves? Or who is suicidal?

If someone is suicidal, try to listen, try not to get angry and not give directions, do not offer solutions too quickly, but offer options. If someone committed suicide, try to reassure your family that it wasn’t because of something they did or didn’t do. In fact, without their support, a person could have done it ten years earlier. They loved them for ten years, and it kept them alive, says Sherr.

Thoughts 

For all, suicide evokes a mixture of simultaneous alienation and sympathy. On the one hand, as long as there is life, there is hope, it is difficult to imagine the degree of despair that can cause someone to commit suicide, and this can make us angry because they left us.

On the other hand, there is a sense of camaraderie. Probably, there are few people who, on one dark night, did not think to themselves: "What is the point in this?" Even though suicide is not contagious, it can be felt.

Suicide can hurt friends and family in much the same way as someone who kills himself, often out of guilt. “If I could only see that they were desperate, if I could only talk to them, if I said a magic thing that would stop them,” we think. When a parent, child, or loved one leaves, the effect can be devastating and permanent.