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HIV life expectancy ‘near normal’ due to antiretroviral therapy

Continued increase in survival for patients on treatment

Jo Carlowe

Thursday, 11 May 2017

Life expectancy of HIV-positive patients has increased to near normal levels, in the US and Europe, since the introduction of antiretroviral therapy.

Published in The Lancet HIV, the study,* Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies, shows improvements in survival, since the introduction of combination Antiretroviral Therapy (ART) 20 years ago. 

Between 1996 and 2010, life expectancy in 20-year-old patients starting ART increased by about 9 years in women and 10 years in men. Projections based on death rates in the second and third year of treatment for Europeans and North Americans, estimated that 20-year-olds starting therapy between 2008-2010 who survived the first year of treatment would live to 73 for men and 76 for women.

Some 88,504 patients were included in the analyses, of whom 2106 died during the first year of ART and 2,302 died during the second or third year of ART. Patients starting ART in 2008–10 had lower all-cause mortality in the first year after ART initiation than did patients starting ART in 2000–03. All-cause mortality in the second and third years after initiation of ART was also lower in patients who started ART in 2008–10 than in those who started in 2000–03.

Even in the late ART era, survival during the first three years of ART continues to improve. The authors say this probably reflects transition to less toxic antiretroviral drugs, improved adherence, prophylactic measures, and management of comorbidity. 

They argue, that prognostic models and life expectancy estimates should be updated to account for these improvements. They say the findings should also be used to encourage those diagnosed to start treatment as soon as possible and to continue it fully. 

However, life expectancy for people with HIV mostly remains lower than that of the general population.

“Our research illustrates a success story of how improved HIV treatments coupled with screening, prevention and treatment of health problems associated with HIV infection can extend the lifespan of people diagnosed with HIV. However, further efforts are needed if life expectancy is to match that of the general population,” says lead author Adam Trickey, the University of Bristol, UK.

“Combination antiretroviral therapy has been used to treat HIV for 20 years, but newer drugs have fewer side effects, involve taking fewer pills, better prevent replication of the virus and are more difficult for the virus to become resistant to.”

The improvements are likely to be a result of the transition to less toxic antiretroviral therapy with more drug options for people infected with a drug-resistant HIV strain, better adherence to treatment, improved treatment of co-occurring conditions and opportunistic infections, and increased use of screening and prevention programmes for conditions such as cardiovascular disease and cancer.

Antiretroviral therapy first became widely used in 1996. The WHO now recommends antiretroviral therapy to be given as soon as possible after diagnosis to all people with HIV.

The study focused on those who started ART between 1996-2010, used data from 18 European and North American studies. In order to estimate life expectancy, it tracked how many people died during the first three years of their treatment, their cause of death, HIV viral load, CD4 cell count and whether they were infected through injecting drugs.

During this time, measures of HIV improved – with the average CD4 count after a year of treatment increasing from 370 cells per microlitre of blood in 1996-1999, to 430 cells per microlitre in 2008-2010, while the proportion of people with a low HIV viral load increased from 71% to 93%.

However, the improvements were not seen in all people with HIV, with life expectancy of people who were infected through injecting drugs not increasing as much as in other groups.

“Since modern treatment is highly effective with low toxicity, deaths in people living with HIV are unlikely to be reduced by further development of drugs. Now we need to focus on the issues surrounding drug adherence, late diagnosis of HIV, and diagnosis and treatment of co-occurring conditions. In drug users we must promote therapy and improve access to therapy to treat addictions as well as increasing access to hepatitis C treatment for people with both infections,” says Trickey. “Although most people are likely to start treatment soon after diagnosis of HIV, this will only result in improved survival overall if the problems of late diagnosis and treatment access are addressed.”

* The Antiretroviral Therapy Cohort Collaboration. Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. DOI: 10.1016/S2352-3018(17)30066-8

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