HIV-positive adults in high-income countries face a substantially reduced risk of death from AIDS-related causes, cardiovascular disease, and liver disease compared with a decade ago, according to a large international study published in The Lancet.
The study which involved nearly 50 000 HIV-positive adults receiving care and antiretroviral therapy (ART) at more than 200 clinics across Europe, USA, and Australia found that overall death rates have almost halved since 1999.
The development in the mid-1990s of antiretroviral treatment for the management of HIV infections is one of medicine’s greatest success stories. For individuals who can access and adhere to treatment at early stages of the infection, the risk of developing an AIDS-defining complication is vanishingly small. Treatment, however, does not fully restore health. Treated adults have a higher than expected risk of developing many non-AIDS complications including cardiovascular disease and cancer. The excess risk has been attributed to antiretroviral drug toxicity, traditional risk factors, immune dysfunction, or chronic inflammation. With the advent of effective antiretroviral treatment, the life expectancy for people with HIV is now approaching that seen in the general population. Consequently, the relative importance of other traditionally non-AIDS-related morbidities has increased. The team behind the study investigated trends over time in all-cause mortality and for specific causes of death in people with HIV from 1999 to 2011.
The team behind the study noted that their findings suggest that death rates in HIV-positive individuals with access to care and antiretroviral therapy have decreased since 1999-2000. They can detect no indication of an increase in risk of death from any specific cause as a potential result of long-term adverse effects of ART, and the risk of death from other causes – ie, those other than AIDs-related disease, cardiovascular disease, liver disease, and non-AIDS cancers – is low.
Rates of death from non-AIDS-related cancers have remained stable over time, and these types of cancers are now the most common cause of non-AIDS deaths in people with HIV. The finding of a stable rate of death from non-AIDS cancer in the study is of concern when compared with the experience in the general population, in which death rates have decreased over the same time period.
However a potential limitation to the study is that the investigators could only report on the outcomes of HIV-infected individuals who were followed up regularly in clinic, and thus excluded a large population of HIV-infected individuals who remain untreated because they are unaware of their infected status or not engaged in care.
Steven Deeks and Peter Hunt from the University of California in San Francisco, USA, say, ‘The benefits of ART are unquestioned, and their beneficial effect on the HIV epidemic continues to grow. Still, clear limitations exist because many patients are not accessing treatment, and some problems persist even in those on ART, including a higher than expected risk of non-AIDS cancers and other morbidities. Finally, it needs to be emphasised that we are still early in the ART era. In the absence of a cure, most patients will need to continue on ART for decades. Continued monitoring for unexpected consequences of treatment will be needed indefinitely.’
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