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Самые лучшие и честные брокеры бинарных опционов за 2020 год:

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Computer Science > Artificial Intelligence

Title: The Malicious Use of Artificial Intelligence: Forecasting, Prevention, and Mitigation

Abstract: This report surveys the landscape of potential security threats from malicious uses of AI, and proposes ways to better forecast, prevent, and mitigate these threats. After analyzing the ways in which AI may influence the threat landscape in the digital, physical, and political domains, we make four high-level recommendations for AI researchers and other stakeholders. We also suggest several promising areas for further research that could expand the portfolio of defenses, or make attacks less effective or harder to execute. Finally, we discuss, but do not conclusively resolve, the long-term equilibrium of attackers and defenders.

Latest from OSCE Special Monitoring Mission to Ukraine (SMM) based on information received as of 18:00 (Kyiv time), 5 January 2020

Newsroom

This report is for media and the general public

The SMM continued to monitor the implementation of the provisions of the Minsk Protocol and Memorandum and the work of the Joint Centre for Control and Co-ordination (JCCC). The JCCC noted that the situation in “Donetsk People’s Republic”-controlled areas had deteriorated considerably in the past 24 hours, with 69 ceasefire violations reported. Two explosions in Odesa caused damage.

At the headquarters of the JCCC in government-controlled Debaltseve (55 km north-east of Donetsk) officers from the Ukrainian Armed Forces and Russian Federation Armed Forces were present, along with members of the “Donetsk People’s Republic” (“DPR”) and “Lugansk People’s Republic” (“LPR”). The senior Ukrainian Armed Forces representative and the Russian Federation Army Chief of Staff both agreed the situation in “DPR”-controlled areas had deteriorated considerably in the previous 24 hours. During the 24-hour period from 08:00 on 4 January to 08:00 on 5 January, 69 ceasefire violations were noted: 32 from the Ukrainian Armed Forces; 37 from the “DPR” side. Forty incidents were recorded at Donetsk airport, the area around the Donetsk Volvo Centre located at the southern entrance to Pisky («DPR»-controlled), and Pisky (seven kilometres north-west of Donetsk, government-controlled). Other incidents were recorded at Nikishna (12 km south-east of Debaltseve, control contested by both “DPR” and Ukrainian Armed Forces), and Chornukhyne (six kilometres east of Debaltseve, “LPR”-controlled). There were also incidents recorded in the Debaltseve region, in the government-controlled villages of Redkdub (15 km south-east of Debaltseve), Kamenka (10 km south-south-east of Debaltseve) and Gorodeshe (15 km east of Debaltseve). The SMM were informed that these allegations of ceasefire violations were agreed by both sides:

— 2 January 2020: 21 in total – with “DPR” reported nine violations by the Ukrainian side; Ukrainian Armed Forces reported 10 violations by “DPR”, two unknown;

— 3 January 2020: 20 in total – “DPR” reported 12 violations by Ukrainian Armed Forces, Ukrainian Armed Forces reported eight violations by “DPR”;

— 4 January 2020: 49 in total – “DPR” reported 24 violations by Ukrainian Armed Forces; Ukrainian Armed Forces reported 25 violations by “DPR”.

The Russian Chief of Staff said that the Russian Major General, Representative of the Armed Forces of the Russian Federation to the JCCC, was in Donetsk to facilitate the next rotation of Ukrainian Armed Forces at Donetsk airport (planned for 6 January). Both Chiefs of Staff (Ukrainian Armed Forces and Russian Federation Army) from JCCC Debaltseve will be present at Donetsk airport to observe the rotation. Both sides invited the SMM to monitor the rotation.

On 5 January, the SMM visited Schastya (17 km north of Luhansk, government-controlled). Ukrainian Armed Forces personnel at the bus station informed the SMM that the situation was calm. The SMM spoke to a local resident who stated that during the last 2-3 weeks, the situation in Schastya has significantly improved from before with no shelling during this period. The SMM observed few people and light traffic in Schastya.

The situation in Kharkiv and Dnipropetrovsk remained calm.

On 4 January 2020, at approximately 22:35hrs an explosion at the location of the Maidan Coordination Council, (an umbrella group of several non-governmental organizations) in Odesa caused damage to the building. Police confirmed no one was injured. The building houses several non-governmental organizations (NGOs) and has been used in recent weeks as a collection point for donating aid to soldiers in the east. The SMM verified the damage to the building and to nearby property. A Ministry of Internal Affairs spokesperson at the location gave a press statement confirming the use of an explosive device. The police are investigating it as an act of terrorism (as defined in Article 258 of the Criminal Code of Ukraine).

Список брокеров на русском языке:

Following up on reports of an explosion at Odessa-Peresyp train station (see SMM Daily Report of 5 January 2020) the SMM spoke with the acting deputy chief of the Regional Transport Police, who confirmed a hole in a container wagon resulting in a large amount of “gas-oil” escaping. He confirmed that evidence collected during the investigation would be given to the Security Service of Ukraine (SBU) in the following days. The interlocutor claimed police experts had concluded that an explosive was used, possibly with the aim of trying to destabilise the situation.

On 5 January the SMM in Kherson met with the First Deputy Head of the Black Sea and Azov Regional Administration of the Border Guard Service of Ukraine who stated that the Chongar crossing point (180 km south-east of Kherson) was open.

The SMM gathered information on the situation concerning public transport across the administrative boundary line (ABL). The SMM spoke with the dispatcher at Novotroitske bus station on 5 January, who confirmed that most buses travelling to Crimea on 4 January (and one on 5 January) were delayed at the ABL before crossing. The dispatcher stated that a bus from Novotroitske to Crimea was prevented from crossing the ABL. He did not know the reason.

The situation in Chernivtsi, Ivano-Frankivsk, Lviv and Kyiv remained calm.

КРОУФ опубликовала отчет

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

Hasina Samji

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

Adriana Nophal

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

Erin Ding

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

Verena Strehlau

3 The University of British Columbia, Department of Psychiatry, Vancouver, BC

Julia Zhu

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

Julio S.G. Montaner

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

2 The University of British Columbia, Faculty of Medicine, Vancouver, BC

Robert S. Hogg

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

4 Simon Fraser University, Faculty of Health Sciences, Burnaby, BC

Silvia Guillemi

1 BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC

2 The University of British Columbia, Faculty of Medicine, Vancouver, BC

Associated Data

Abstract

Background

Suicide rates have been reported at elevated levels among people living with HIV/AIDS. We sought to characterize longitudinal suicide rates among people living with HIV/AIDS who are accessing free highly active antiretroviral treatment (HAART) in British Columbia and evaluate the sociodemographic, clinical and behavioural factors associated with suicide in this population.

Methods

Retrospective analysis of all patients in the HAART Observational Medical Evaluation and Research (HOMER) cohort who were 19 years of age and older who started treatment between August 1996 and June 2020. The primary outcome variable was death due to suicide. Data on deaths were obtained monthly through a linkage with the British Columbia Ministry of Health Vital Statistics Agency. Logistic regression and Cox proportional hazards models were used to identify factors independently associated with suicide mortality.

Results

A total of 993 deaths among 5229 patients accessing treatment were recorded, of which 82 (8.2%) were caused by suic >

Interpretation

Deaths from suicide declined substantially over time, and factors other than progression of HIV disease, such as injection drug use, may be important targets for intervention to reduce suicide risk.

In general, patients with chronic illnesses, and HIV in particular, are at an increased risk of suicide. 1 , 2 The sense of hopelessness that can accompany the life-long implications of being HIV positive can contribute to compromised quality of life and substantial mental distress. 3 – 8 The prevalence of mental health disorders, particularly depression, have been reported at elevated levels among people living with HIV/AIDS compared with the general population, and historical suicide rates within this population are also elevated. 2 , 3 , 9

However, the advent of highly active antiretroviral therapy (HAART) transformed HIV from a terminal illness to a manageable chronic condition. 3 HAART has effectively reduced the risk of developing AIDS-defining illnesses and opportunistic infections, providing the potential for enhanced quality and longevity of life for people living with HIV/AIDS. 3 , 5 , 9 – 14 In light of these widespread benefits, it was anticipated that rates of suicide among people living with HIV/AIDS could be reduced. 9 , 15 , 16

Two recent studies have reported declines in suicide risk among people living with HIV/AIDS between the pre-HAART era (before 1996) and the HAART era (1996 onwards); however, the studies concluded that suicide risk 5 and suicide rates 16 remain substantially elevated among people living with HIV/AIDS at about 9 times and 2–3 times that of the general population, respectively. 5 , 16 This implies that despite effective HIV treatment, an elevated propensity toward suicide persists, perhaps indicating that there are factors, other than issues directly related to HIV infection, 7 , 16 that predispose people living with HIV/AIDS to suicidality. 16 – 18

Identifying these factors is essential to deriving meaningful targets for interventions that can effectively mitigate suicide risk in this population. 1 Therefore, we conducted this analysis to characterize longitudinal suicide rates and ascertain factors associated with suicide among people living with HIV/AIDS who have accessed free HAART in the province of British Columbia.

Methods

Setting

HAART has been provided free-of-charge to people living with HIV/AIDS in BC since its introduction in 1996 through the provincially funded drug treatment program at the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE). The BC-CfE is the centralized distributor of antiretroviral therapy for all patients accessing HIV treatment in BC.

Design

The HAART Observational Medical and Evaluation (HOMER) cohort includes all patients aged 19 years and older who were enrolled at the BC-CfE from 1996 onwards and who began HAART between August 1996 and June 2020. 19

The HOMER protocol was granted ethics approval by the University of British Columbia Research Ethics Board, which approved the retrospective use of anonymous administrative data without requiring consent; an information sheet for participants was provided in lieu of a consent form.

Sources of data

Sociodemographic and clinical data for these patients, including HAART history and immunologic and virologic markers, were available through the BC-CfE treatment registry. Cause and date of death were obtained through an ongoing monthly link between the BC-CfE registry and the British Columbia Ministry of Health Vital Statistics Agency up to June 2020. This link minimizes loss to follow-up to less than 4% and allows all deaths that occurred in the cohort to be included.

Variable selection

Our primary outcome variable was suicide, as listed as the underlying cause of death on the death record from the Vital Statistics Agency. The definition of suicide used in this study was adapted from the Manitoba Centre for Health Policy and includes several poisoning codes, such as “accidental poisoning” that account for International Classification of Disease (ICD)-10 codes suspected of capturing a significant proportion of suicides. 20 The ICD-10 codes from the Vital Statistics Agency used in this definition are listed in Appendix 1 (available at www.cmajopen.ca/content/3/2/E140/suppl/DC1).

The sociodemographic variables evaluated included sex, Aboriginal identity (extracted from several sources, e.g., surveys, physicians’ reports and death information), median income (the median income recorded in census data for each patient’s postal code was taken as the patient’s median income), whether patients were from urban or rural neighbourhoods (determined by postal code information held at the drug treatment program), age at death and year of death. Clinical variables evaluated included diagnosis of an AIDS-defining illness (a condition that, in the setting of an HIV infection, confirms the diagnosis of AIDS. This includes a list of serious and life-threatening diseases such as cancers and infections), a diagnosis of hepatitis C virus (HCV) infection, adherence to HAART treatment in the last year before death, calculated by the number of days undergoing treatment (based on the number of days of coverage provided by a given prescription) divided by the number of days the patient was alive in the last year, the last or most recent HAART regimen, efavirenz as part of the last or most recent regimen, number of years on HAART, most recent and nadir CD4 cell counts and latest viral load. History of injection drug use was the only sociobehavioural variable assessed.

Statistical analysis

Two main analyses were conducted in this study. The first analysis examined the predictors of suicide among all patients in the HOMER cohort who died from suicide or remained alive over the study period, whereas the second analysis was limited to all deaths (suicides and nonsuicides). Statistical comparisons were conducted using the Pearson χ 2 test or Fisher exact test for dichotomous variables and the Wilcoxon rank sum test for continuous variables.

A Cox proportional hazards regression model was used to identify the independent predictors of suicide among patients in the HOMER cohort who remained alive or died from suicide during the study period. Logistic regression was used to identify independent predictors of suicide among suicides and nonsuicides. Variables for inclusion in both models were selected using exploratory model selection process based on Akaike information criterion and type III p values.

Suicide rates and general mortality data in the HOMER cohort were compared with suicide rates and general mortality data in the general population of BC to contextualize findings. These calculations were restricted to 1997–2020 to ensure full-year comparisons. Person-years of risk in the HOMER cohort were based on time under observation of the patient and on annual population estimates in the general population of BC. 21 , 22 The number of deaths from suicide in the general population, by year, were obtained from reports of the Vital Statistics Agency. 15 Crude rates were expressed as deaths per 100 000 person-years. The Somers D asymptotic test of trend was used to analyze the change in suicide rates over time because of the small number of deaths due to suicide.

Results

Table 1:

Method
ICD-10 code No. of deaths
Accidental poisoning by and exposure to antiepileptic, sedative–hypnotic, antiparkinsonism and psychotropic drugs X41 1
Accidental poisoning by and exposure to narcotic and psychodysleptic drugs X42 60
Accidental poisoning by and exposure to other gases and vapours X47 1
Suicide by antiepileptic, sedative–hypnotic, antiparkinsonism and psychotropic drugs X61 4
Suicide by drowning and submersion X71 1
Suicide by hanging, strangulation and suffocation X70 6
Suicide by jumping from a high place X80 4
Suicide by nonopioid analgesic, antipyretic and antirheumatic drugs X60 1
Suicide by other and unspecified drugs, medicaments and biological substances X64 2
Suicide by other and unspecified firearm discharge X74 1
Suicide by other specified means X83 1

Note: ICD = International Classification of Disease.

Comparison of suic >

The bivariate analysis in Table 2 describes the characteristics of all study participants who died from suic >

Table 2:

Variable
No. of patients (%)* p value
Died by suicide
n = 82
Alive
n = 4 236
Sex
Female 18 (22) 773 (18) 0.4
Male 64 (78) 3 463 (82)
Ethnicity
Aboriginal 16 (20) 473 (11) 0.01
Non-Aboriginal 24 (29) 1 805 (43)
Unknown 42 (51) 1 958 (46)
Geographic region
Rural 2 (2) 162 (4) 0.8
Urban 64 (78) 3 327 (79)
Unknown 16 (20) 747 (18)
History of injection drug use
Yes 47 (57) 1 535 (36)
No 10 (12) 1 973 (47)
Unknown 25 (30) 728 (17)
AIDS-defining illness
Yes 4 (5) 758 (18) 0.001
No 78 (95) 3 478 (82)
Hepatitis C
Yes 63 (77) 1 582 (37)
No 13 (16) 2 355 (56)
Unknown 6 (7) 299 (7)
Most recent HAART regimen
Single PI 47 (57) 2 131 (50) 0.002
Single NNRTI 30 (37) 1 717 (41)
Any IIN 299 (7)
Other 5 (6) 89 (2)
Efavirenz included in last or most recent regimen
Yes 7 (9) 1 086 (26)
No 75 (91) 3 150 (74)
Adherence
≥ 95% 19 (23) 2 685 (63)
63 (77) 1 551 (37)
Age at the end of follow-up,† yr; median (IQR) 42 (38–49) 47 (41–54)
Year of death, median (IQR) 2003 (2000–2006)
Median income, CAD (IQR) 21 015 (14 750–27 799)‡ 23 406 (18 258.5–29 901)§ 0.01
Baseline CD4+ cell count, × 10 9 /L; median (IQR) 0.29 (0.17–0.4) 0.22 (0.325–0.67) 0.001
Most recent CD4+ cell count before the end of follow-up,* × 10 9 /L; median (IQR) 0.355 (0.2–0.5) 0.49 (0.325–0.67)
Nadir CD4+ cell count, × 10 9 /L; median (IQR) 0.17 (0.07–0.29) 0.16 (0.06–0.25) 0.2
Most recent viral load before the end of follow-up,† log10 copies/mL; median (IQR) 5.0 (2.69–5.0) 2.69 (2.69–2.69)
No. of years of treatment with HAART, yr; median (IQR) 3 (2–6) 6 (3–10) *Unless otherwise specified.
†End of follow-up can be the date of death, the date of last contact, date of last contact before moving out of British Columbia or to participation in antiretroviral blinded trials.
‡Some values for income were missing. Median income was calculated using n = 65.
§Some values for income were missing. Median income was calculated using n = 3308.

A second bivariate analysis ( Table 3 ) was performed to compare suic >

Table 3:

Variable
No. of patients (%) p value
Suicide death
n = 82
Nonsuicide death
n = 911
Sex
Female 18 (22) 194 (21) 0.9
Male 64 (78) 717 (79)
Ethnicity
Aboriginal 16 (20) 195 (21) 0.9
Non-Aboriginal 24 (29) 267 (29)
Unknown 42 (51) 449 (49)
Geographic region
Rural 2 (2) 42 (5) 0.75
Urban 64 (78) 699 (77)
Unknown 16 (20) 170 (19)
History of injection drug use
Yes 47 (57) 449 (49) 0.1
No 10 (12) 196 (22)
Unknown 25 (30) 266 (29)
AIDS-defining illness
Yes 4 (5) 296 (32)
No 78 (95) 615 (68)
Hepatitis C
Yes 63 (77) 548 (60) 0.01
No 13 (16) 250 (27)
Unknown 6 (7) 113 (12)
Last or most recent HAART regimen
Single PI 47 (57) 537 (59) 0.4
Single NNRTI 30 (37) 281 (31)
Any IIN 0 (0) 25 (3)
Other 5 (6) 68 (7)
Efavirenz included in last or latest regimen
Yes 7 (9) 142 (16) 0.1
No 75 (91) 769 (84)
Adherence
≥ 95% 19 (23) 197 (22) 0.8
63 (77) 714 (78)
Age at death, yr; median (IQR) 42 (38–49) 46 (39–54)
Year of death, median (IQR) 2003 (2000–2006) 2006 (2002–2009)
Median income, CAD (IQR) 21 015 (14 750–27 799)† 19 346.5 (14 518–26 073)‡ 0.7
Baseline CD4+ cell count, × 10 9 /L; median (IQR) 0.29 (0.17–0.4) 0.15 (0.05–0.27)
Last or most recent CD4+ cell count before the end of follow-up, × 10 9 /L; median (IQR) 0.355 (0.2–0.5) 0.14 (0.03–0.31)
Nadir CD4+ cell count, × 10 9 /L; median (IQR) 0.17 (0.07–0.29) 0.05 (0.01–0.14)
Last or most recent viral load before the end of follow-up,* log10 copies/mL; median (IQR) 5.0 (2.69–5.0) 5 (2.69–5.0) 0.5
No. of years of treatment with HAART, yr; median (IQR) 3 (2–6) 3 (1–6) 0.5

Note: HAART = highly active antiretroviral therapy, IIN = integrase inhibitor, IQR = interquartile range, NNRTI = non-nucleos >*End of follow-up can be the date of death, the last date of contact, last date of contact date before moving out of British Columbia or to participation in antiretroviral blinded trials.
†Some values for income were missing. Median income was calculated using n = 65.
‡Some values for income were missing. Median income was calculated using n = 700.

Table 4 highlights the results of the Cox proportional hazards model. In this analysis, those patients who died from nonsuicide deaths were censored, and never having had an AIDS-defining illness (adjusted hazard ratio [AHR] 4.45, 95% confidence interval [CI] 1.62–12.25) or having a history of injection drug use (AHR 3.95, 95% CI 1.99–7.86) were independently associated with an increased rate of suicide mortality. Each additional calendar year was associated with a 51% decrease in suicide rate (AHR 0.49, 95% CI 0.45–0.54).

Table 4:

Variable
Unadjusted HR (95% CI) p value AHR
(95% CI)
p value
AIDS-defining illness 0.002 0.004
Yes 1.00 (ref) 1.00 (ref)
No 4.90 (1.79–13.39) 4.45 (1.62–12.25)
History of injection drug use
No 1.00 (ref) 1.00 (ref)
Yes 5.86 (2.96–11.60) 3.95 (1.99–7.86)
Unknown 9.13 (4.38–19.03) 2.59 (1.21–5.56)
Adherence in the last year before death
1.00 (ref)
≥ 95% 0.16 (0.10–0.27)
Age at the end of follow-up* 0.93 (0.90–0.95) Not selected
Year of the end of follow-up* 0.49 (0.44–0.53) 0.49 (0.45–0.54)
Last CD4+ cell count before the end of follow-up* 0.77 (0.70–0.85) Not selected
Last viral load before the end of follow-up* 3.14 (2.54–3.87) Not selected
Efavirenz included in last drug regimen Not selected
No 1.00 (ref)
Yes 3.01 (1.37–6.54) 0.005

Note: AHR = adjusted hazards ratio, CI = conf >*End of follow-up can be the date of death, the last date of contact, the last date of contact before leaving British Columbia or to participation in antiretroviral blinded trials.

Table 5 highlights results from the logistic regression model comparing suicide with nonsuicide deaths. Never having an AIDS-defining illness was associated with nearly a 7-fold increase in the odds of suicide v. nonsuicide death (adjusted odds ratio [AOR] 6.63, 95% CI 2.34–18.83), whereas having a history of injection drug use was associated with a 2-fold increase in the odds of suicide v. non-suicide death (AOR 1.92, 95% CI 0.87–4.28). Death at an older age (AOR 0.96, 95% CI 0.94–0.99) or in a later calendar year (AOR 0.85, 95% CI 0.79–0.91) was associated with decreased odds of suicide. A higher last CD4 cell count was associated with an increased likelihood of suicide v. nonsuicide death (AOR 1.21, 95% CI 1.06–1.38)

Table 5:

Variable
Unadjusted OR (95% CI) p-value AOR
(95% CI)
p-value
AIDS-defining illness
Yes 1.00 (ref) 1.00 (ref)
No 9.39 (3.40–25.88) 6.63 (2.34–18.83)
History of injection drug use 0.1 0.02
No 1.00 (ref) 1.00 (ref)
Yes 2.02 (1.02–4.14) 1.92 (0.87–4.28)
Unknown 1.84 (0.86–3.92) 0.89 (0.37–2.14)
Age at the end of follow-up* 0.96 (0.93–0.98) 0.96 (0.94–0.99) 0.006
Year of death* 0.87 (0.82–0.92) 0.85 (0.79–0.91)
Nadir CD4+ cell count (per 0.1 × 10 9 /L) 1.71 (1.47–1.99) 1.23 (0.97–1.56) 0.09
Last CD4+ cell count before death
(per 0.1 × 10 9 /L)
1.24 (1.15–1.34) *End of follow-up can be the date of death, the last date of contact, the last date of contact before leaving British Columbia or to participation in antiretroviral blinded trials.

Interpretation

Our results show that suicide rates among patients using HAART have declined substantially since the start of the HAART era. However, suicide rates remained elevated compared with the general population. Suicide mortality decreased with each calendar year during the HAART era and was greater among those patients who never experienced advanced HIV disease in the form of an AIDS-defining illness.

Several factors may have contributed to such a dramatic decline within this cohort. First, as the HAART era progressed, treatment regimens became simpler, more effective, less toxic and better tolerated, 18 , 23 thereby reducing treatment burden and impact on quality of life. Second, HIV was initially characterized as a terminal illness, and therefore inherently associated with an elevated risk of suicide, 18 , 24 but HAART transformed HIV into a chronic manageable condition. 9 , 23 Third, public perception of HIV has evolved over time, leading to greater social acceptance of people living with HIV/AIDS and potentially contributing to reduced suicide rates in this population. People living with HIV/AIDS in BC may now be less exposed to established correlates of suicidality, such as stigma, marginalization and social exclusion, 9 , 15 , 17 – 21 than at the start of the epidemic. Finally, improved access to facilities (e.g., the supervised injection site) may have reduced the number of accidental poisonings and improved access to psychiatric care may have helped to mitigate suicide behaviour, including suicidal thoughts, ideation and attempts, and prevent escalation to the most severe end of the spectrum, death by suicide.

Consistent with previous research, injection drug use was independently associated with higher rates of suicide mortality. 17 , 25 , 26 Within the HOMER cohort, over a third of participants had a history of injection drug use, a behaviour known to often occur in the presence of concomitant mental illness, 27 , 28 and psychosocial and socioeconomic disparities. 25 , 29 It may be that compromised mental health becomes neglected in the face of injection drug use, HIV infection and more visibly apparent health concerns, therefore contributing to the exacerbation of suicide risk or suicidality. 16 , 18 , 30

Moreover, even though mental health services have always been offered free of charge in BC as part of the public health care system, the need for specialized services for patients with HIV infection was recognized early on in the epidemic. Designated psychiatrists have provided care at the John Ruedy Immunodeficiency Clinic at St. Paul’s Hospital, Vancouver, since 2003. This clinic provides outpatient care for patients with HIV infection who have significant comorbidities; subsequently, the mental health services team expanded to include psychiatric nurses, social workers, counsellors and psychologists. There are other outpatient psychiatric services throughout the province that are free-of-charge for BC residents, but they are not exclusively for patients with HIV infection. These services may help mitigate suicide behaviour, including suicidal thoughts, ideation and attempts, and prevent escalation to the most severe end of the spectrum, death by suicide. Recent research reported an association between regimens containing efavirenz and an increased risk of suicidality. 31 Our analysis only detected an association between suicide and efavirenz in univariate results comparing those patients who died of suicide to those who remained alive. However, the small number of suicides in our sample and the small number of these patients who were prescribed efavirenz in their most recent regimen limited our statistical power. Moreover, most of the suicides in the HOMER cohort occurred earlier in the HAART era (between 1996 and 2004), a time when nevirapine was the primary non-nucleoside reverse-transcriptase inhibitor prescribed.

Conflicting results have been reported with respect to the relationship between disease stage and suicide. 5 , 16 , 17 , 24 , 32 , 33 Several studies reported that advanced HIV disease is associated with a greater likelihood of suicide, 6 , 18 , 34 whereas others reported that disease progression or symptomatic disease is not associated with an increased risk of suicide. 17 , 18 , 35 – 37 Our results showed that those patients who never had an AIDS-defining illness were more likely to die by suicide, which is consistent with a previous finding that 70% of the autopsies in patients with HIV infection who died by suicide showed no signs of AIDS-related disease. 17 This suggests that people living with HIV/AIDS with less graduated disease are at greater risk of suicide. Within our cohort, 76.8% of individuals who died of suicide did not adhere to treatment in the year preceding their death. Compromised mental health is a widely recognized mediator of nonadherence to treatment among people living with HIV/AIDS; 38 – 40 therefore, this trend toward nonadherence could be indicative of underlying, and possibly undiagnosed and untreated, mental illness.

Readers should be cautious when interpreting our results. First, in the cross-sectional analysis, we were able to highlight associations, but unable to show or infer causality or direction of the associations. Second, our data pertained to a very specific population of people living with HIV/AIDS who have started HAART in BC, which is a universal health care setting with free access to treatment and HIV-related care. Third, the lack of accepted methodology within this field of research, suicidality in HIV-positive populations, limits the comparability and generalizability of results across studies. 1 , 9 , 11 , 41 , 42 Fourth, suicides may be underestimated as those that occur as a result of self-administered withdrawal of care or similar indirect ways often cannot be distinguished as such; however, given the definition of suicide used in this study includes accidental poisoning it may also be possible that the number of suicides was overestimated and that some instances of overdose death are, in fact, not suicides. Fifth, our sample size, information on certain variables such as intravenous drug use and sex distribution is limited; in addition, we had no access to clinical information regarding previous psychiatric history, particularly depression, or any mental health–related treatments. Lastly, suicide itself can be seen as the severest outcome of a spectrum. We did not collect data for other suicidal or self-harming behaviours, but we acknowledge that they are closely related because they represent the array of suicidal behaviours that exist.

Conclusion

Suicide rates among patients with HIV infection who access antiretroviral therapy have declined substantially since 1996. Our results reflect a large decline in the number of suicides compared with other recent studies, such as those reported by the national registries of Switzerland and Denmark. This difference is likely partially due to differences in methodological design — HOMER is a distinct cohort of patients living with HIV who are receiving treatment — and we have a centralized distribution site in which all patients who are receiving treatment in BC are enrolled. However, despite substantial declines, suicide rates in our cohort remained at nearly 3 times the rate of the general population in the most recent comparison. Thus, our results reinforce the need for further integration of care, and proactive mental health screening and treatment in patients with HIV infection, particularly for those with histories of injection drug use, to identify suicidal risk.

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