Survival Disadvantages Persist Among Persons With HIV

Initiating antiretroviral treatment (ART) at a CD4 cell count of 500/μL or greater can improve the average life expectancy of persons living with HIV; however, their overall and comorbidity-free—associated survival remain 6.8 and 9.5 years fewer than that of the population without HIV, report study results published today in JAMA Network Open.

“Greater attention is needed to prevention of comorbidities among individuals with HIV infections,” noted the study authors, due to a lack of data on life span and comorbidity-free years for this group compared with an HIV-free population.

The primary outcomes of this matched cohort study were overall remaining life expectancy and years free of 6 comorbidities—chronic liver disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and cardiovascular disease—from the age of 21 years. Because of treatment advances resulting longer life expectancies, individuals with HIV are starting to die more of age-related causes than they are those directly attributable to AIDS, and these are some of the most common.

The 2 patient groups, matched 1:10, consisted of 39,000 HIV-positive and 387,785 HIV-negative individuals living in the United States who received care at Kaiser Permanente medical centers in northern and southern California; Washington, DC; Maryland; and Virginia between January 1, 2000, and December 31, 2016.

Matching was performed based on age, sex, race/ethnicity, medical center, and calendar year when follow-up began. All study participants were at least 21 years old, and there was a mean (SD) age of 41.4 (10.8) years. The most common races/ethnicities were non-Hispanic black (25.1%) and Hispanic (24.3%). Most patients (87.7%) were male, and they all were followed until death, health plan disenrollment, or December 31, 2016—whichever occurred first.

The results demonstrate an ongoing gap in survival between the HIV-positive and -negative groups. Per 100 person-years, there were mortality rates of 1.3 (95% CI, 1.3-1.4) and 0.4 (95% CI, 0.4-0.4), respectively. In addition, among 11,366 from the HIV group and 60,707 from the matched cohort who had at least 1 comorbidity, there were mortality rates of 10.0 (95% CI, 9.8-10.2) and 3.8 (95% CI, 3.7-.8), respectively.

For someone aged 21 years between 2000 and 2003, the first range of years investigated, the overall life expectancy was 37.6 years for persons with HIV vs 59.7 years in the HIV-free group (difference, 22.1 years; 95% CI, 20.2-24.0). Both of these numbers rose through 2014 to 2016, the final range of years investigated: to 56.0 vs 65.1 years, respectively. However, there was still a difference in survival of 9.1 years (95% CI, 7.9-10.2).

Closure of this gap can be seen by the authors’ investigation into CD4 level at ART initiation. Between 2011 and 2016, a 21-year-old HIV-positive individual who began ART with a CD4 level of 500/μL or greater was expected to live to age 57.4 years compared with 64.2 (difference, 6.8 years; 95% CI, 5.0-8.5) among the HIV-free cohort.

Less of an improvement was seen when comorbidity-free years were considered. Results for 2000 through 2003 show that the HIV-positive cohort had just 11.3 more comorbidity-free years compared with 26.6 (difference, 15.3; 95% CI, 13.9-16.6) among the uninfected group. This disparity only increased through 2014 to 2016, when the groups were shown to live 14.5 and 30.9 (difference, 16.3; 95% CI, 15.3-17.4) additional comorbidity-free years, respectively.

Meanwhile, having the CD4 level at 500/μL or greater when initiating ART translated into remaining comorbidity-free years, from age 21, of 19.5 among HIV-positive persons but 29.0 (difference, 9.5; 95% CI, 7.7-11.2) in the HIV-free group.

“The life expectancy of adults with HIV infection may be near that of the life expectancy of individuals without HIV infection, but greater attention is needed to prevention of comorbidities among individuals with HIV infection,” the authors concluded.

Solutions for progress include comorbidity screening and prevention methods tailored to the HIV-positive population and data-driven clinical guidance for how to optimize care for complex patients with HIV and age-related comorbidities.

A commentary on this study also suggested addressing social determinants of health and modifiable lifestyle factors. The importance of this can be seen in these additional study results, which demonstrate that the HIV-positive study population faced several disadvantages compared with the HIV-negative group:

• Median annual household income below $35,000: 14.5% vs 10.4%
• History of drug use disorders: 4.5% vs 2.4%
• History of smoking: 51.8% vs 40.8%

Reference

Marcus JL, Leyden WA, Alexeeff SE, et al. Comparison of overall and comorbidity-free life expectancy between insured adults with and without HIV infection, 2000-2016. JAMA Netw Open. Published online June 15, 2020. doi:10.1001/jamanetworkopen.2020.7954