Over the past few decades, advances in antiretroviral therapy (ART) have enabled many HIV-infected patients to live longer lives. Despite these successes, substantial avoidable losses in life expectancy of HIV-infected persons persist in the United States. The factors that exert a significant impact on survival include:
• Late diagnosis.
• Late initiation of care.
• Premature discontinuation of therapy.
• Background behavioral risk factors, such as alcohol, substance abuse, and smoking, which are prevalent in individuals with HIV.
Assessing Survival Losses
In the November 15, 2009 issue of Clinical Infectious Diseases, my colleagues and I published a study in which we estimated survival losses related to HIV disease in the U.S. This included 1) behavioral risk factors in the absence of HIV, 2) HIV disease per se, and 3) late initiation and/or early discontinuation of life saving ART. For individuals who were not infected with HIV and had risk profiles similar to those who were infected, we found that the projected life expectancy, starting at age 33, was 34.6 years, compared with 42.9 years for the general U.S. population. These findings suggested that about 8 fewer years, or a 19% reduction, in life expectancy is due to substance abuse and other high-risk behaviors even in the absence of HIV. These losses underscore the critical importance of interventions which focus on reducing substance abuse and other high-risk behaviors.
Patients infected with HIV lost an additional 11.9 years of life if they received HIV care that was concordant with guidelines (representing an additional 28% reduction). The estimated life expectancy for HIV-infected patients who initiated ART very late—when CD4 cell counts reached less than 50 cells/mL—was 8.83 years lower than it was for patients who initiated ART according to current guidelines. Overall, late ART initiation combined with early discontinuation led to additional 3.3 years survival loss (representing an 8% loss of life). These results further emphasize the gap between guideline-concordant and actual care.
Years of life lost from late initiation and early discontinuation were greatest for Hispanic HIV-infected individuals, accounting for 3.90 years. Losses in life expectancy from high-risk behaviors were greater for women than men across all races and ethnicities.
Our study demonstrated that the high-risk profile of people infected with HIV, the infection itself, and late initiation and early discontinuation of care all appear to lead to substantial decreases in life expectancy. Considering these findings, clinicians must strive to use interventions that address risky behaviors. Earlier linkage to care and better retention in care are also important, especially among racial/ethnic minorities. The U.S. Department of Health and Human Services has implemented several HIV prevention programs that target racial and ethnic minorities, but greater efforts are required at all levels of healthcare.
Recent efforts to expand routine HIV testing throughout the U.S. may further address the problem of earlier diagnosis. Improving access to medical and social services could address additional risk factors for early mortality. The hope is that these efforts may ultimately lead to improved survival for HIV-infected individuals.
Readings & Resources (click to view)
Losina E, Schackman BR, Sadownik SN, et al. Racial and sex disparities in life expectancy losses among HIV-infected persons in the United States: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy. Clin Infect Dis. 2009;49:1570-1578. Available at: www.journals.uchicago.edu/doi/pdf/10.1086/644772.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. December 1, 2009;1-161. Available at: www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.
Wood E, Hogg RS, Lima V, et al. Highly active antiretroviral therapy and survival in HIV-infected injection drug users. JAMA. 2008;300:550-554.
Nijhawan A, Kim S, Rich J. Management of HIV infection in patients with substance use problems. Curr Infect Dis Rep. 2008;10:432-438.
Freedberg KA, Losina E, Weinstein MC, et al. The cost effectiveness of combination antiretroviral therapy for HIV disease. N Engl J Med. 2001;344:824-831.