What Is My Risk of Dying from HIV?

Despite Gains in Life Expectancy, Risk of Death Remains High

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Concillia Muhau from Zambia holding a photograph of herself showing how she looked just 90 days ago prior to starting HIV antiretroviral therapy. Photo Credit: The Lazarus Effect (2010) from HBO

While impressive gains in life expectancy have been made in the past decade among people living with HIV, mortality rates continue to paint a somewhat different picture. A number of recent studies have compared mortality rates in the "middle years" (between the ages of 35-70) of HIV-infected people versus those of the general population.

As part of the long-standing Multicenter AIDS Cohort Study (MACS) and the Women's Interagency HIV Study (WIHS), a total of 6,669 HIV-positive participants on combination antiretroviral therapy (cART) were observed from as early as 1985 through 2010 in order to quantify mortality rates among those under active medical care.

When compared to matched cohort of HIV-negative individuals, the overall annual mortality rate in people living with HIV was seen to be as high as seven times greater (0.37% versus 2.32%, respectively). Furthermore, during the entire course of the study, 540 out of 2,953 people with HIV had died (18.2%) compared to only 165 out of 3,854 HIV-negative people (3.4%).

Generally speaking, AIDS-related deaths tended to occur among earlier participants, likely due to inferior drug regimens available before 2000. With recent advances in HIV therapy, the incidence has decreased significantly. However, non-HIV-related illnesses such as cancer and heart disease have largely offset those gains and are seen to be on the increase—so much so that, in fact, non-AIDS-defining cancers are today considered the single leading cause of death among people with HIV in the developed world.

Factors Associated with Increased Mortality Risk

Despite the disparity in mortality cause, the study once again highlighted was the clear association between the early initiation of cART and reduced deaths. In fact, among those who started cART with a CD4 count over 350 cells/mL, mortality due to non-HIV-related infections was no higher than that of the general population.

By contrast, mortality rates due to non-HIV-related illnesses were seen to be far greater among those who delayed cART. When compared to the HIV-negative cohort, individuals starting cART between 200 and 300 cells/mL were at 66% greater risk of death, while those starting below 200 cell/mL were at 115% greater risk. Co-factors such as untreated high blood pressure and smoking also contributed to the higher rates, increasing the risk of death by as much as 42% and 120%, respectively.

Of all the possible co-factors, however, hepatitis B or C coinfection was seen to have the greatest impact on mortality, literally doubling the risk of death while reducing life expectancy by some 15 years. Recent advances in the treatment of HIV/hepatitis C coinfection may reduce those numbers in coming years, particularly with newer drug regimens able to effect a nearly 100% cure rate in coinfected populations.

According to a 2014 update by MACS, people with HIV who start cART at CD4 counts above 350 cells/mL may be able to have a life expectancy equal to or even greater than that of the general population.

In light of these statistics, the need to address the long-term complications of infection (including the impact persistent chronic inflammation) remains an imperative in the face of an ever-aging HIV population.

Sources:

Wada, N.; Jacobson, L.; Cohen, M.; et al. "Cause-specific mortality among HIV-infected individuals, by CD4(+) cell count at HAART initiation, compared with HIV-uninfected individuals." AIDS. January 14, 2014; 28(2):257-265.

Hleyhel, M.; Belot, A.; Bouvier, A., et al. "Risk of AIDS-defining cancers in HIV-1 infected patients (1992-2009): results from FHDH-ANRS CO4." Journal of the International AIDS Society. November 11, 2012; 15(Supplement 4):18196.

Wada, N.; Jacobson, L.; Cohen, M; et al."Cause-specific mortality among HIV-infected individuals, by CD4+ cell count at HAART initiation, compared with HIV-uninfected individuals." AIDS. January 14, 2014; 28(2):257-265.

Sanchez-Calvo, M.; Perelló, R.; Pérez, I.; et al. "Differences between HIV-infected and uninfected adults in the contributions of smoking, diabetes and hypertension to acute coronary syndrome: two parallel case-control studies." HIV Medicine. October 22, 2012; 14(1):40-48.

Manns, M. and Cornberg, M. "Sofosbuvir: the final nail in the coffin for hepatitis C?" Lancet. March 15, 2013; 13(5):378-379.

Hasse, B,; Ledergerber, B.; Egger, M., et al. "Aging and (Non-HIV-associated) Co-morbidity in HIV-positive Persons: The Swiss Cohort Study (SHCS)." 18th Conference on Retroviruses and Opportunistic Infections (CROI). Boston, Massachusetts; February 27-March 2, 2011; abstract 792.

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