Changes in the risk of death after HIV seroconversion compared with mortality in the general population.

CONTEXT Mortality among human immunodeficiency virus (HIV)-infected individuals has decreased dramatically in countries with good access to treatment and may now be close to mortality in the general uninfected population. OBJECTIVE To evaluate changes in the mortality gap between HIV-infected individuals and the general uninfected population. DESIGN, SETTING, AND POPULATION Mortality following HIV seroconversion in a large multinational collaboration of HIV seroconverter cohorts (CASCADE) was compared with expected mortality, calculated by applying general population death rates matched on demographic factors. A Poisson-based model adjusted for duration of infection was constructed to assess changes over calendar time in the excess mortality among HIV-infected individuals. Data pooled in September 2007 were analyzed in March 2008, covering years at risk 1981-2006. MAIN OUTCOME MEASURE Excess mortality among HIV-infected individuals compared with that of the general uninfected population. RESULTS Of 16,534 individuals with median duration of follow-up of 6.3 years (range, 1 day to 23.8 years), 2571 died, compared with 235 deaths expected in an equivalent general population cohort. The excess mortality rate (per 1000 person-years) decreased from 40.8 (95% confidence interval [CI], 38.5-43.0; 1275.9 excess deaths in 31,302 person-years) before the introduction of highly active antiretroviral therapy (pre-1996) to 6.1 (95% CI, 4.8-7.4; 89.6 excess deaths in 14,703 person-years) in 2004-2006 (adjusted excess hazard ratio, 0.05 [95% CI, 0.03-0.09] for 2004-2006 vs pre-1996). By 2004-2006, no excess mortality was observed in the first 5 years following HIV seroconversion among those infected sexually, though a cumulative excess probability of death remained over the longer term (4.8% [95% CI, 2.5%-8.6%] in the first 10 years among those aged 15-24 years). CONCLUSIONS Mortality rates for HIV-infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy. In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.

[1]  Bg Gazzard and British HIV Association (BHIVA) guidelines for the treatment of HIV-infected adults with antiretroviral therapy. , 2005, HIV medicine.

[2]  A. Mocroft,et al.  Influence of hepatitis C virus infection on HIV-1 disease progression and response to highly active antiretroviral therapy. , 2005, The Journal of infectious diseases.

[3]  F. Ederer,et al.  Maximum utilization of the life table method in analyzing survival. , 1958, Journal of chronic diseases.

[4]  P. Grambsch,et al.  Proportional hazards tests and diagnostics based on weighted residuals , 1994 .

[5]  A. Telenti,et al.  CD4 T-lymphocyte recovery in individuals with advanced HIV-1 infection receiving potent antiretroviral therapy for 4 years: the Swiss HIV Cohort Study. , 2003, Archives of internal medicine.

[6]  B. Gazzard,et al.  British HIV Association (BHIVA) guidelines for the treatment of HIV‐infected adults with antiretroviral therapy , 2003, HIV medicine.

[7]  O. Kirk,et al.  Cardiovascular disease risk factors in HIV patients – association with antiretroviral therapy. Results from the DAD study , 2003, AIDS.

[8]  J. Jónasson,et al.  Variation in relative survival of thyroid cancers in Europe: results from the analysis on 21 countries over the period 1983-1994 (EUROCARE-3 study). , 2006, European journal of cancer.

[9]  M. Prins,et al.  Changes in the uptake of antiretroviral therapy and survival in people with known duration of HIV infection in Europe: results from CASCADE , 2000, HIV medicine.

[10]  D. Klein,et al.  Older age and the response to and tolerability of antiretroviral therapy. , 2007, Archives of internal medicine.

[11]  E Carrani,et al.  The EUROCARE-3 database: methodology of data collection, standardisation, quality control and statistical analysis. , 2003, Annals of oncology : official journal of the European Society for Medical Oncology.

[12]  Gitte Pedersen,et al.  Survival of Persons with and without HIV Infection in Denmark, 19952005 , 2007, Annals of Internal Medicine.

[13]  Cascade Changes in the uptake of antiretroviral therapy and survival in people with known duration of HIV infection in Europe: results from CASCADE. , 2000 .

[14]  H. Brenner,et al.  Long-term cancer patient survival achieved by the end of the 20th century: most up-to-date estimates from the nationwide Finnish cancer registry , 2001, British Journal of Cancer.

[15]  Kholoud Porter,et al.  Survival following HIV infection of a cohort followed up from seroconversion in the UK , 2008, AIDS.

[16]  Amalio Telenti,et al.  Mortality in the Swiss HIV Cohort Study (SHCS) and the Swiss general population , 2003, The Lancet.

[17]  M. Zwahlen,et al.  All cause mortality in the Swiss HIV cohort study from 1990 to 2001 in comparison with the Swiss population , 2004, AIDS.

[18]  V. Beral,et al.  Effect of ignoring the time of HIV seroconversion in estimating changes in survival over calendar time in observational studies: results from CASCADE* , 2000, AIDS.

[19]  Kholoud Porter,et al.  Determinants of survival following HIV-1 seroconversion after the introduction of HAART , 2003, The Lancet.

[20]  A. Ghani,et al.  Mortality in Patients With Successful Initial Response to Highly Active Antiretroviral Therapy Is Still Higher Than in Non-HIV-Infected Individuals , 2005, Journal of acquired immune deficiency syndromes.

[21]  A. Mocroft,et al.  Influence of age on CD4 cell recovery in human immunodeficiency virus-infected patients receiving highly active antiretroviral therapy: evidence from the EuroSIDA study. , 2001, The Journal of infectious diseases.

[22]  A. Swerdlow,et al.  Long-term survival in Hodgkin's disease patients. A comparison of relative survival in patients in trials and those recorded in population-based cancer registries. , 2000, European journal of cancer.

[23]  C. Hinkin,et al.  Medication adherence in HIV-infected adults: effect of patient age, cognitive status, and substance abuse , 2004, AIDS.

[24]  F. Ederer,et al.  The relative survival rate: a statistical methodology. , 1961, National Cancer Institute monograph.

[25]  J. Sterne,et al.  Prognosis of HIV-1-infected patients up to 5 years after initiation of HAART: collaborative analysis of prospective studies , 2007, AIDS.

[26]  B. Gazzard British HIV Association guidelines for the treatment of HIV‐1‐infected adults with antiretroviral therapy 2008 , 2005, HIV medicine.

[27]  Paul W Dickman,et al.  Regression models for relative survival , 2004, Statistics in medicine.

[28]  A. Mocroft,et al.  Decline in the AIDS and death rates in the EuroSIDA study: an observational study , 2003, The Lancet.

[29]  Michael S Saag,et al.  Treatment for adult HIV infection: 2006 recommendations of the International AIDS Society--USA panel. , 2006, Topics in HIV medicine : a publication of the International AIDS Society, USA.

[30]  F. Lert,et al.  Antiretroviral HIV treatment and care for injecting drug users: an evidence-based overview. , 2007, The International journal on drug policy.

[31]  Richard D Moore,et al.  Substance abuse and psychiatric disorders in HIV-positive patients: epidemiology and impact on antiretroviral therapy. , 2006, Drugs.