Self-injurious unnatural death among Veterans with HIV: A nested case-control study
Abstract: Objective: People living with HIV (PWH) are at increased risk of suicide and death from unintentional causes compared with people living without HIV. Broadening the categorization of death from suicide to self-injurious unnatural death (SIUD) may better identify a more complete set of modifiable risk factors that could be targeted for prevention efforts among PWH. Design: We conducted a nested case-control study using data from the Veterans Aging Cohort Study (VACS), a longitudinal, observational cohort of Veterans from 2006-2015. A total of 5,036 Veterans with HIV, of whom 461 died by SIUD, were included in the sample. Methods: SIUD was defined using the International Classification of Disease 10th revision cause of death codes. Cases (n = 461) included individuals who died by SIUD (intentional, unintentional, and undetermined causes of death). Controls (n = 4,575) were selected using incidence density sampling, matching on date of birth ± one year, race, sex, and HIV status. SIUD and suicide was estimated using conditional logistic regression. Results: A previous suicide attempt, a diagnosis of an affective disorder, recent use of benzodiazepines, psychiatric hospitalization, and living in the western US significantly increased the risk of suicide and SIUD. Risk factors that appear more important for SIUD than for suicide included a drug use disorder, alcohol use disorder, Hepatitis C, VACS Index 2.0, current smoking, and high pain levels (7-10). Conclusion: Limiting studies to known suicides obscures the larger public health burden of excess deaths from self-injurious behavior. Our findings demonstrate the benefit of expanding the focus to SIUD for the identification of modifiable risk factors that could be targeted for treatment.