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Life Expectancy for People with HIV Increases, But Does Not Match HIV-Negatives

People with HIV are living longer thanks to improvements in treatment, but life expectancy varies substantially across countries and even people who start antiretroviral therapy early have about an 8-year shorter life expectancy, on average, than the HIV-negative general population, according to recently published reports.

The advent of effective antiretroviral therapy (ART) in the mid-1990s dramatically reduced HIV-related mortality and increased survival for people living with HIV worldwide. Some studies have suggested that HIV-positive people who receive prompt treatment in countries with good access to care can have a life expectancy similar to that of HIV-negative individuals. But many people -- especially those who contracted HIV earlier in the epidemic and those in resource-limited countries -- may have reached very low CD4 T-cell counts before starting treatment and may have use poorly tolerated older antiretrovirals, leading to long-term detrimental health consequences.

Life Expectancy Among People in Care

As described in the September 1 Journal of Acquired Immune Deficiency Syndromes, Julia Marcus from Kaiser Permanente Northern California and colleagues aimed to determine whether a survival gap remains between HIV-positive and HIV-negative individuals with similar access to care.

The researchers conducted a cohort study of members of Kaiser Permanente California -- a non-profit integrated managed care organization -- using abridged life tables to estimate the expected number of years of life remaining at age 20.

The analysis included 24,768 HIV-positive and 257,600 HIV-negative Kaiser participants in care during 1996-2011.

There were a total of 2229 deaths among HIV-positive people, yielding a mortality rate of 1827 per 100,000 person-years (PY). Among HIV-negative people there were 4970 deaths, for a death rate of 326 per 100,000 PY.

Life expectancy among people with HIV increased over time. During 1996-1997, HIV-positive people at age 20 could expect to live 19.1 more years -- much less than the 63.4 years for HIV-negative individuals.

Life expectancy for HIV-positive people at age 20 increased to 47.1 years in 2008 and to 53.1 years in 2011, while it stayed about the same for HIV-negative people (64.9 years in 2011), narrowing the survival gap from 44.3 years in 1996-1997 to 11.8 years in 2011.

However, some groups had a shorter life expectancy, including African Americans and people with a history of injection drug use (45.8 and 46.0 more years at age 20, respectively, during 2008-2011). In contrast, white people, Hispanics, gay men, and heterosexuals had longer life expectancies (50.4, 52.2, 51.1, and 51.3 more years, respectively). Life expectancy at age 20 was similar for women (50.5 years) and men (49.2 years) -- notable because women in the HIV-negative population live longer than men, on average.

Among people who started ART early, with a CD4 count of 500 cells/mm³ or higher, life expectancy at age 20 was 54.5 years during 2008-2011 (vs 49.3 for all people with HIV), narrowing the gap to 7.9 years less than the HIV-negative population. Within this group, life expectancy increased further among people who did not smoke (56.9 years), did not have drug or alcohol abuse problems (55.7 years), and were not coinfected with hepatitis B or C (55.1 years).

"Even with early treatment and access to care, an 8-year gap in life expectancy remains for HIV-infected compared with HIV-uninfected individuals," the study authors concluded.

"These findings confirm that ART has had a substantial impact on the survival of HIV patients, and suggest that early ART initiation and risk reduction strategies, such as smoking cessation, may further reduce the remaining gap in survival relative to HIV-uninfected individuals," they added. "As lifespan lengthens and AIDS-related deaths decline among HIV patients, the impact on survival of smoking and other risk factors is likely to increase."

Life Expectancy Across Countries

In a related study, published in the August 31 advance edition of HIV Medicine, Sirinya Teeraananchai from the Kirby Institute at the University of New South Wales and colleagues did a meta-analysis of life expectancy after starting HIV treatment in countries with different income levels.

The authors identified 8 cohort studies, with a total of 154,670 participants, from the U.S., Canada, Europe, the U.K., Rwanda, South Africa and Uganda. Studies in high-income countries included mostly gay men, while those in low-income countries had a more even mix of men and women. Participants started ART with relatively low CD4 counts overall, between 100 and 300 cells/mm³.

The studies estimated life expectancy among HIV-positive people initiating combination ART at age 14 or older, again using abridged life tables. The researchers calculated pooled estimates of life expectancy overall and by country income level.

HIV-positive people in high-income countries had a life expectancy of 43.3 more years if they started ART at age 20 and 32.2 more years if they started at age 35. In low- and middle-income countries, however, life expectancy fell to 28.3 years at age 20 and 25.6 years at age 35.

Life expectancy was similar for men and women in high-income countries -- as seen in the Kaiser Permanente study -- but in low- and middle-income countries men starting ART at age 20 had a shorter life expectancy than women (22.9 vs 33.0 more years).

At all income levels life expectancy increased over time, likely reflecting improvements in ART, guidelines recommending earlier treatment, better adherence and support programs, and scale-up of treatment access.

10/18/16

Sources

JL Marcus, CR Chao, WA Leyden, et al. Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. Journal of Acquired Immune Deficiency Syndromes 73(1):39-46. September 1, 2016.

S Teeraananchai, SJ Kerr, J Amin, et al. Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis. HIV Medicine. August 31, 2016 (online ahead of print).