People living with HIV (PLHIVs) who are in antiretroviral therapy (ART), and who achieved CD4 counts over 350 cells/mm3 by the end of their first year of therapy have life expectancies approaching normal.
This may be surmised from a study of 88,504 PLHIVs on ART, published in The Lancet HIV, which found “substantial improvements in life expectancy in PLHIVs who started ART after 2008, even in their first year of therapy”. More specifically, “people who started ART between 2008 and 2010 and who achieved CD4 counts over 350 cells/mm3 by the end of their first year of therapy had life expectancies approaching normal”.
The study was done by the Antiretroviral Therapy Cohort Collaboration, a group of researchers from the various cohort countries, with funding from the UK Medical Research Council, UK Department for Overseas Development, and the European Union. The principal writers were Adam Trickey, Margaret May and Jonathan Sterne from the University of Bristol in the UK.
The researchers found that people starting therapy after 2008, who were still alive and whose CD4 counts were over 350 cells/mm3 a year after starting ART, now had a life expectancy at age 20 of 58 years or an expected age at death of 78.
In this study, the 88,504 people studied were taken from 18 different cohorts of patients – one Europe-wide (the EuroSIDA cohort); four in the US; two each in France, Spain and Canada; and one each in Italy, Switzerland, the Netherlands, the UK, Denmark, Austria and Germany. As per the researchers, their findings reflect the treated HIV-positive population in general.
The study was similar to earlier studies that found that life expectancy, at least in people in the second and third years on ART, increased substantially in each period studied since the late 1990s. PLHIVs still alive a year after starting ART between 2008 and 2010 were 43% less likely to die in their second and third years on ART compared with those starting between 2000 and 2003, and 53% less likely than those starting between 1996 and 1999.
Other key findings of the study include:
- There is still a high proportion of deaths in PLHIVs even when already on ART, particularly those in their first year of ART and whose CD4 counts may still be low.
- Improvements in life expectancy were only partly due to the direct effects of ART in reducing viral load and increasing CD4 cell counts. Improvements were also due to reductions in non-AIDS-related diseases, better medical care generally and reductions in so-called “unnatural deaths”, such as suicide and violence.
- Injecting drug users (IDUs) did not experience improvements in mortality; but there may be reduction in deaths due to overdose, also classed as unnatural deaths.
- The cause of death with the biggest single drop in the first year on ART was cardiovascular disease, falling by 81% in PLHIVs starting ART in 2008-2010. For the researchers, this is due to a combination of factors, including better monitoring of patients’ cardiovascular risk, fewer ART drugs that interact with statins and therefore more prescribing of them, and less use of abacavir, associated with heart attacks in PLHIVs already with higher-than-average risk.
- The cause of death with the biggest single drop in the second and third year after ART was liver-related disease, falling by 85% in PLHIVs starting ART between 2008 and 2010. This may reflect better rates of diagnosis and better therapies for PLHIVs who also have hepatitis B and C.
As per the researchers, in general, these trends reflect “superior antiretroviral agents, more options for people developing resistance, fewer drug interactions, better management of opportunistic infections (OIs) and chronic diseases, and the introduction of screening and prevention programs for co-morbidities in people who benefited from treatment.”
The Antiretroviral Therapy Cohort Collaboration. Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013; a collaborative analysis of cohort studies. The Lancet HIV, online publication. 10 May 2017. See http://dx.doi.org/10.1016/S2352-3018(17)30066-8.
Katz, I.T. and Maughan-Brown, B. Improved life expectancy of people living with HIV: who is left behind? The Lancet HIV, online publication. 10 May 2017. See http://dx.doi.org/10.1016/S2352-3018(17)30086-3.