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HIV+ People on ART May Match General Population Life Expectancy

Young adults with HIV in high-income countries who take effective antiretroviral therapy (ART) may live nearly as long as HIV negative people in the general population, according to findings from the NA-ACCORD collaboration published in the December 18, 2013, edition of PLoS ONE.

The advent of effective combination ART has led to a dramatic decline in AIDS-related mortality and increased survival. People with HIV remain at greater risk for a variety of chronic non-AIDS conditions, but this may be reduced among those who start optimal treatment early and maintain long-term viral suppression.

Hasina Samji from the British Columbia Centre for Excellence in HIV/AIDSand fellow investigators with the North American AIDS Cohort Collaboration on Research and Design estimated temporal changes in life expectancy among HIV positive adults on ART from 2000 to 2007 in the U.S. and Canada.

The analysis included 22,937 participants who were at least 20 years of age and taking combination ART consisting of at least 3 drugs. They were treatment-naive at ART initiation and had not previously used suboptimal therapy such as nucleoside analog monotherapy. About three-quarters were men, 38% were white, 39% were men who have sex with men, 20% had a history of injection drug use, and about 70% had a pre-treatment CD4 T-cell count below 350 cells/mm³. At ART initiation 25% were age 20-34, 42% were 35-44, 25% were 45-54, and 8% were older than 55.

Participants were followed from January 1, 2000 or ART initiation until death, loss to follow-up, or December 31, 2007. Life expectancy at age 20 -- defined as the average number of additional years a person would be expected to live -- was estimated using abridged life tables assuming age-specific mortality rates in effect during the study period remained constant.

Results

• Overall, 1622 deaths occurred during 82,022 person-years of follow-up.
• The crude mortality rate was 19.8 per 1000 person-years.
• Mortality rates were 12.5 per 1000 person-years for gay/bisexual men, 34.5 for injection drug users, 16.0 for whites, 22.4 for non-whites, 23.3 for those with <350 cells/mm³ and 11.3 for those with higher CD4 counts.
• Overall unweighted life expectancy at age 20 increased from 36.1 additional years during 2000-2002 to 45.2 years during 2003-2004 to 51.4 years during 2006-2007.
• Comparable life expectancy estimates for the general population at age 20 were 59.7 and 57.0 years for men and 63.9 and 61.7 years for women in Canada and the U.S., respectively.
• Men and women with HIV had comparable life expectancies during all periods except 2006-2007 (53.4 vs 47.3 additional years, respectively).
• Life expectancy was lower for non-white study participants, people with a history of injection drug use, and those with a baseline CD4 count <350 cells/mm³.
• Predicted life expectancy during 2006-2007 for these groups were 48.4, 28.8, and 46.9 additional years, respectively.

"A 20-year-old HIV-positive adult on ART in the U.S. or Canada is expected to live into their early 70s, a life expectancy approaching that of the general population," the study authors concluded. "Differences by sex, race, HIV transmission risk group, and CD4 count remain."

"[G]iven that many individuals living with HIV have demographic, clinical, and behavioral characteristics associated with greater morbidity and mortality than the general population, the gap in life expectancy may be attributable to other lifestyle factors and not just HIV infection," they added in their discussion.

"The absence of significant differences in life expectancy by sex, and the higher life expectancy of men in the latest period suggests that there is in fact a sex differential in life expectancy in our study," the researchers continued, as women in high-income countries generally live longer than men. This may be due to women accessing HIV care later or a higher proportion of women having a history of injection drug use, they suggested.

Differences in life expectancy by race and those related to injection drug use "may be reflective of underlying differences in socioeconomic conditions, access to care, and health insurance coverage, suggesting an urgent need for strategies and programs to combat these inequities," they wrote. However, they noted that the gap in life expectancy between white and non-white participants decreased substantially, from 23.0 years in 2000-2002 to 8.5 years in 2006-2007.

They also noted that the longer life expectancy for people with higher CD4 counts "may lend additional support to the earlier initiation of ART."

The authors cautioned that these findings only apply to people starting with effective combination ART, not older suboptimal regimens, and may under-represent individuals at greatest risk of death who may be less likely to seek care.

Finally, they acknowledged that "due to the increased risk of age-related co-morbidities among HIV positive adults, it is possible life expectancy may plateau or decrease in the future" and "it will be important to monitor life expectancy estimates as more adults age with HIV."

12/23/13

Reference

H Samji, A Cescon, RS Hogg, et al (NA-ACCORD). Closing the Gap: Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada. PLoS ONE 8(12): e81355. December 18, 2013.

Other Source

Public Library of Science. Life expectancy increases among treated HIV-positive individuals in US and Canada. Press release. December 18, 2013.