All-Cause Mortality of Chinese Patients With HIV Declined During Past Decade, Study Says

From 2013 to 2022, antiretroviral therapy (ART) coverage substantially increased among patients with HIV in China as all-cause mortality declined, according to a study published in China CDC Weekly.

The researchers explained that when ART began to be more widely used in China, the life expectancy increased for patients with HIV. Before ART, the predominant cause of death for patients with HIV was AIDS-related illnesses, like tuberculosis, pneumocystis pneumonia, and toxoplasmosis. Conversely, non–AIDS-related illnesses, including viral hepatitis, cardiovascular and cerebrovascular diseases (CCVDs), and non–AIDS-defining cancers (NADCs), have become the predominant causes of death more recently for patients with HIV.

Although China has implemented a universal ART access strategy over the past decade, there has not been a comprehensive analysis of mortality rates and changing patterns of cause of death nationally among patients with HIV. Because of this, the investigators conducted a retrospective analysis to investigate mortality rates across patients with HIV in China from 2013 to 2022.

“The insights gained from this study are instrumental in pinpointing challenges and enhancing health outcomes moving forward,” the authors wrote.

The researchers conducted the study using data from the nationwide HIV/AIDS Comprehensive Response Information Management System (CRIMS), which mandates the reporting of all confirmed HIV-positive individuals. They used a multiple cross-sectional design to investigate changes in mortality rates and causes of death from 2013 to 2022.

HIV virus | Image credit: RAJCREATIONZS - stock.adobe.com

From 2013 to 2022, the all-cause mortality rate among patients with HIV in China declined from 5.4% to 2.7% (P < .05). Simultaneously, ART coverage saw a substantial rise from 58.4% to 92.8% (P < .05), exhibiting a strong inverse relationship with the mortality rate (r = −0.964; P < .05).

The subgroups with the highest all-cause mortality rates included those with CD4+T cell counts below 200 cells/mm³ (7.5%), those 50 years or older (4.8%), those who contracted HIV via heterosexual transmission (3.4%), residents of Southwest China (3.3%), and male patients (2.9%). Additionally, cause-specific mortality rates among patients who received ART were lower compared with the overall patient population (all-cause mortality, 1.6% vs 2.7%; AIDS-related mortality, 0.3% vs 0.4%; non-AIDS related mortality, 1.1% vs 1.8%; deaths from unknown causes: 0.3% vs 0.4%).

During the study period, pneumocystis pneumonia was the most frequent cause of AIDS-related deaths, accounting for 15.4% to 19.9% of cases. Also, CCVDs emerged as the leading non–AIDS-related cause of death as the proportion of attributable deaths increased from 16.3% in 2013 to 26.1% in 2022. The researchers noted that non–AIDS-related deaths have increased since the widespread use of ART, which they linked to persistent inflammation and immune activation, consequences of chronic HIV infection.

“Consequently, routine medical examinations, consistent adherence to ART regimens, lifestyle adjustments such as a nutritious diet, regular exercise, and smoking cessation, as well as proactive management of underlying health conditions, particularly cancer and cardiovascular diseases, are instrumental in decreasing the risk of both AIDS-related and non-AIDS-related deaths,” the authors wrote.

Although China has made progress in expanding ART, and subsequently reducing mortality rates, late HIV diagnoses remain prevalent; within Asia, between 34% and 72% of patients with HIV present late, which is associated with an elevated risk of treatment failure, higher mortality, and significant economic impacts.

Additionally, an aging population of patients with HIV is more pronounced than ever, as the authors noted 221,621 HIV cases were reported in patients 60 years and older between 2015 and 2022. Older patients with HIV are at higher risk of many comorbidities, including cardiovascular events, frailty, and mental health disorders. To prevent late diagnoses, China has launched initiatives geared toward early HIV detection, including anonymous urine testing and advocating the use of novel rapid and self-testing methods among high-risk groups.

Conversely, the researchers acknowledged their study’s limitations, one being that the categorization of fatalities and specific causes of death relied on the reporting individual; this subjectivity may have resulted in an undetermined number of patients with HIV with causes of death that cannot be classified. Also, this study is a real-world observational study that relies on routine reporting systems, so there is a risk that mortality rates may be underestimated due to delays in death reporting. Despite these limitations, the researchers relied on their findings to make future suggestions.

“Efforts to enhance health outcomes should persist in emphasizing the advancement of ART strategies, with a particular focus on mitigating non-AIDS-related mortality in the future,” the authors wrote.

Reference

Zhao Y, Wei L, Dou Z, et al. Changing mortality and patterns of death causes in HIV infected patients - China, 2013-2022. China CDC Wkly. 2023;5(48):1073-1078. doi:10.46234/ccdcw2023.201