Sun J, Mehta SH, Astemborski J, et al. - The widespread use of combination antiretroviral therapy seems to be linked with a decline in deaths attributable to HIV/infectious disease (HIV/ID) in Baltimore, Maryland, USA from 1988-2018. In Baltimore, raises in the drug-related death rates were identified prior to and continue in conjunction with national mortality rates linked with the opiate crisis.

• Data from the AIDS Linked to the Intravenous Experience (ALIVE) were used in this prospective cohort study of 5,506 participants with 84,011 person-years of follow-up.

• By 2018, 43.9% were deceased; 30.5% of the deaths were HIV/ID-deaths, 24.4% drug-related deaths, and 33.3% chronic-disease deaths.

• In 1996, HIV/ID-deaths reached the highest point coincident with the availability of cART, then a continuous decrease occurred.

• With the aging of the cohort, there was a continuous increase in chronic-disease deaths.

• There was a decline in drug-related deaths until 2011, but an increase occurred over 4-fold by 2018.

• Independent association of HIV/HCV infection and active injecting was observed with HIV/ID and drug-related deaths.

• Risk of dying from HIV/ID deaths was higher and risk of dying from drug-related deaths was lower for female and Black participants relative to male and non-Black participants.