Improvements in and long-term effectiveness of combination antiretroviral therapy (cART) for HIV-infected patients in high income countries have seen life expectancy increase by some 13 years from 1996-99 to 2003-05, and an accompanying drop in mortality of nearly 40% in the same period. But life expectancy in these patients remains well short of the general population, and patients treated late in the course of their infection have worse life expectancy. These are among the conclusions of authors of an Article in this week's HIV Special Issue of The Lancet.
Since cART was introduced in 1996, combination therapy regimens have become more effective, better tolerated, and have been simplified in terms of dosing. However, the effect of HIV on life expectancy in the era of combination therapy is not well understood due to the relative novelty of this treatment. Professor Robert Hogg (British Colombia Centre for Excellence in HIV/AIDS, Vancouver, British Colombia, Canada, and Simon Fraser University, Burnaby, Canada) and Professor Jonathan Sterne (University of Bristol, UK) and colleagues from The Antiretroviral Therapy Cohort Collaboration* (ART-CC) compared changes in mortality and life expectancy among HIV-positive individuals on cART.
This collaboration of 14 studies in Europe and North America analysed 18587, 13914, and 10584 patients who started cART in 1996-99, 2000-02, and 2003-05 respectively. A total of 2056 patients died during the study period, with mortality decreasing from 16.3 deaths per 1000 person-years in 1996-99 to 10.0 in 2003-05 – a drop of around 40%. Potential life years lost per 1000 person-years also decreased over the same time, from 366 to 189 — a fall of 48%. TOTAL life expectancy for a person aged exactly 20 years on cART increased from 56.1 years in 1996-99 to 69.4 years in 2003-05, an increase of more than 13 years. Patients treated later in the course of their infection, with lower CD4+ cell counts (below 100 cells per μl blood at initiation of cART), had shorter TOTAL life expectancy, at 52.4 years, compared with 70.4 years in patients treated at earlier stages with higher CD4 loads (above 200 cells per μl). Patients with presumed transmission via injecting drug use had a shorter TOTAL life expectancy (52.6 years) than those from other transmission groups (64.7 years). Finally, women had a slightly longer life expectancy than men (64.2 v 62.8 years), which may be due to women on average starting their treatment earlier in the course of HIV-infection.
Despite these positive results, an HIV-positive person starting cART at age 20 will only, on average, live another 43 years (to age 63), while a 20- year-old HIV-negative person in a high-income country can expect to live to around 80 years, a difference of nearly 20 years. This last finding leads the authors to call on health planners to improve health services and living conditions for HIV-infected patients to reduce this gap.
The authors say: "The progressive reductions in mortality and gains in life expectancy over the three periods studied here are probably the result of both improvements in therapy during the first decade of cART and continuing declines in mortality rates among individuals on such treatment for long periods…These advances have transformed HIV from being a fatal disease, which was the reality for patients before the advent of combination treatment, into a long-term chronic condition.
They conclude: "In summary, the results of this study indicate that people living with HIV in high-income countries can expect increasing positive health outcomes on cART. The marked increase in life expectancy since 1996 is a testament to the gradual improvement and overall success of such treatment."
In an accompanying Comment, Dr David Cooper, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia, focuses on the discrepancy in survival related to CD4 cell counts at the start of treatment. He looks forward to the results of the upcoming START study, which compares patients with a starting CD4 cell count of above 500/μl with those of 350/μl or less, and says that looking at the prevention of serious non-AIDS illness and CD4 loss, and possible early immune activation in HIV-infected people with CD4 cell counts above 500/μl "is perhaps the most important clinical trial that should be done in the post-cART era."
http://multimedia.thelancet.com/pdf/press/lifeexpectancy.pdf
Professor Robert Hogg, British Colombia Centre for Excellence in HIV/AIDS/Simon Fraser University, Vancouver, British Colombia, Canada T) +1 604-377-8606 E) bobhogg@cfenet.ubc.ca / rhogg@sfu.ca
Professor Jonathan Sterne, University of Bristol, UK T) +44 (0) 117 928 7396 E) jonathan.sterne@bristol.ac.uk
Dr David Cooper, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia T) +61 2 9385 0900 E) dcooper@nchecr.unsw.edu.au
Notes to editors: *below are additional in country contacts for this paper from ARTCC:
Dominique Costagliola, Directeure De L'u720 INSERM Et UPMC Paris Univ 06 Epidemiologie Clinique Et Therapeutique De L'infection A VIH, Paris, France T) +33609261287 E) dcostagliola@ccde.chups.jussieu.fr
Jordi Casabona, MD, MPH, PhD Scientific Director of the Center for HIV/STI Epidemiological Studies in Catalonia (CEEISCAT). ICO/Health Department Badalona, Catalonia (Spain) T) +34 639373540 / +34 4978890 E) jordicb@attglobal.net / jcb.ceescat.germanstrias@gencat.net
Amy C. Justice, MD, PhD Veterans Aging Cohort Study Yale University/VA Connecticut HealthCare System West Haven T) +1 203-932-5711 x3541 E) amy.justice2@va.gov
Pr Francois DABIS, MD, PhD Université Victor Segalen Bordeaux 2. INSERM U.897 - ISPED (Case 11) Bordeaux, France T) +33 (0) 5. 57.57.14.36 (Direct) or 17.67 (Sec) / + 33 (0) 6.87.80.17.40 E) Francois.dabis@isped.u-bordeaux2.fr
Michael J. Mugavero, MD, MHSc University of Alabama at Birmingham T) +1 (205) 996-5822 E) mmugavero@uab.edu
Priv.-Doz. Dr. med. Jan-Christian Wasmuth Universitätsklinikum Bonn, Germany T: +49-228-287-16558 E) j-c.wasmuth@uni-bonn.de
Journal
The Lancet