Explaining the life expectancy deficit of HIV positives in the era of ART

Do people with HIV infection have a normal life expectancy in the era of combination antiretroviral therapy?

Sabin CA. BMC Med. 2013 Nov 27;11(1):251.

There is evidence that the life expectancy (LE) of individuals infected with the human immunodeficiency virus (HIV) has increased since the introduction of combination antiretroviral therapy (cART). However, mortality rates in recent years in HIV-positive individuals appear to have remained higher than would be expected based on rates seen in the general population. A low CD4 count, whether due to late HIV diagnosis, late initiation of cART, or incomplete adherence to cART, remains the dominant predictor of LE, and thus the individual's disease stage at initiation of cART (or thereafter) certainly contributes to these higher mortality rates. However, individuals with HIV also tend to exhibit lifestyles and behaviors that place them at increased risk of mortality, particularly from non-AIDS causes. Thus, although mortality rates among the HIV population may indeed remain slightly higher than those seen in the general population, they may be no higher than those seen in a more appropriately matched control group. Thus, further improvements in LE may now only be possible if some of the other underlying issues (for example, modification of lifestyle or behavioral factors) are tackled.

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Editor’s notes: The uptake of antiretroviral therapy (ART) has increased dramatically in recent years, and current ART regimens are more efficacious and more forgiving of minor lapses in adherence. As a result the life expectancy of people living with HIV is approaching that of the general population in both resource-rich and resource-poor settings. However, despite the dramatic improvements, life expectancy for people living with HIV is still lower than the general population. This review shows that late HIV diagnosis and ART initiation, and imperfect retention in care are repeatedly identified as barriers to the normalization of life expectancy in HIV positive individuals. In addition, the review highlights non-HIV related factors that put people living with HIV at a higher mortality risk than the general population. This includes behavioural and lifestyle factors such as smoking, alcohol and recreational drug use, and other sexually transmitted co-infections. This review underscores the importance of early diagnosis and linkage to care for improving programme effectiveness. It also has implications for the design of future studies aiming to quantify the life expectancy deficit in HIV positive individuals such as identifying appropriately matched HIV-negative control populations for comparative mortality estimates. 

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