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Discordant Heterosexual Couples: condom use required or New HIV Cases Will Double Over 10 Years
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Relation between HIV viral load and infectiousness: a model-based analysis
......life expectancy for a 20-year-old HIV patient on cART increased from 36.1 years in 1996-1999 to 49.4 years in 2003-2005....a healthy 20-year-old could expect to live about another 60 years.....probably due to improvements in therapy and continuing declines in mortality rates among individuals on treatment for long periods...there is considerable variability between subgroups of patients, based on characteristics of patients, cd4 count, adherence, non-AIDS events, lifestyle, many factors unmentioned in this study...."These advances have transformed HIV from being a fatal disease, which was the reality for patients before the advent of combination treatment, into a long-term chronic condition"......during the study mortality rates dropping steadily and life expectancy increasing steadily with time.... late presentation of those infected with HIV remains a frustrating problem. Being an injecting drug user also leads to a 10-year deficit..."the changes in mortality and life expectancy over time might reflect not only the long-term tolerability and diminishing side-effects of antiretroviral drugs, but also reductions in rates of treatment discontinuation and non-adherence".....CD4 count affects survival...."Starting cART when one has become severely immunodeficient shaves an extra 10-20 years"....beginning therapy at a higher cd4 count appears to have an affect based on studies conducted..... "The SMART study3 suggests that the downstream effects of uncontrolled viral replication and immune activation could cause a good proportion of these serious non-AIDS diseases......"expand public-health programmes to encourage early testing for HIV entry into care" .....(from Jules: perhaps if we improve management of non-AIDS conditions such as heart disease, diabetes, bone disease, neurological conditions, and cancers if can expect continued improvement of survival, BUT researchers, care providers and patients MUST face these issues better: HIV & Aging is THE issue in the USA & the Western World.....authors said "Further research must be devoted to the ongoing improvement of antiretroviral therapy to lessen the gap between the life expectancy of HIV-infected patients and the general population, as well as to improve the quality of life of individuals living with HIV."
......."advances in treatment have transformed HIV from being a fatal disease, which was the reality for patients before the advent of combination treatment, into a long-term chronic condition".....The average number of years remaining to be lived by those treated with combination antiretroviral therapy at 20 and 35 years of age was estimated. Potential years of life lost from 20 to 64 years of age and crude mortality rates were also calculated.....there is considerable variability between subgroups of patients. The average number of years remaining to be lived at age 20 years was about two-thirds of that in the general population in these countries......20-year-old individual starting cART can expect to live for another 43 years on average, whereas a 35-year-old can expect 32 more years of life...."these figures are startling and will surely help clinicians to raise the hopes and expectations of patients during discussion of life choices and goals."....Despite these reassuring results, there is still a large discrepancy between the life expectancy of the general population and the life expectancy of an HIV-infected individual. A person starting combination therapy can expect to live about 43 years at 20 years of age, about two-thirds as long as the general population in these countries. This discrepancy in life expectancy could be attributed to active HIV infection or to other underlying lifestyle, socioeconomic, and health issues.....Life expectancy at age 20 years increased from 36·1 (SE 0·6) years to 49·4 (0·5) years. Women had higher life expectancies than did men. Patients with presumed transmission via injecting drug use had lower life expectancies than did those from other transmission groups (32·6 [1·1] years vs 44·7 [0·3] years in 2003-05). Life expectancy was lower in patients with lower baseline CD4 cell counts than in those with higher baseline counts (32·4 [1·1] years for CD4 cell counts below 100 cells per μL vs 50·4 [0·4] years for counts of 200 cells per μL or more).......Although the life expectancy for HIV patients on combination antiretroviral therapy (cART) has increased steadily since 1996 in developed countries, it still falls short of that in the general population......a healthy 20-year-old could expect to live about another 60 years.....Overall, 2,056 patients died during the study, with mortality rates dropping steadily and life expectancy increasing steadily with time, the researchers said.....otential years of life lost -- assuming any death before age 65 as premature -- fell from 366 to 189 per 1,000 person-years during the study....Life expectancy was shorter in patients with baseline CD4 cell counts below 100 cells per microliter compared with those with counts of 200 cells per microliter or higher (for a 20-year-old patient: 32.4 years versus 50.4), indicating an advantage to starting combination therapy earlier in the course of infection.....The progressive reductions in mortality and gains in life expectancy over the three periods studied here are probably the result of both improvements in therapy during the first decade of combination therapy and continuing declines in mortality rates among individuals on such treatment for long periods......David Cooper said "The prevention of CD4 loss and perhaps immune activation by early treatment above a CD4 T-cell count of 500 cells per μL, a band which contains the lowest rates of serious HIV-related clinical events, is perhaps the most important clinical trial that should be done in the post-cART era. Hopefully, the START study,5 which compares starting cART with a CD4 cell count above 500 cells per μL versus deferring to a CD4 cell count of less than 350 cells per μL, will provide the evidence base to bridge the gap so elegantly defined by the ART-CC group." (from jules: of course, many already feel that earlier therapy can be suggested than is currently recommended based on a fairly large amount of data that has already been accumulated)......
Comment
Life and death in the cART era
David A Cooper
National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW 2052, Australia
The Lancet, 26 July 2008
20-year-old individual starting cART can expect to live for another 43 years on average, whereas a 35-year-old can expect 32 more years of life
Before 1996, clinicians who saw patients with HIV had to give bad news almost daily. We tried to restore hope by telling patients the cold hard facts that only 50% would progress to AIDS or death within 10 years, often acknowledging to ourselves that the tell-tale clinical features of immune deficiency had already appeared and the inevitable demise would surely be sooner rather than later.1 Yet with the advent of life-saving combination antiretroviral therapy (cART) the outlook became less bleak, and patients began to contemplate the possibility of living fairly normal lives. During the past 10 years, the discourse with patients has changed. They want to know how long they have to live. They want to plan their lives better. Should they consider life insurance, health insurance, or superannuation for retirement? Of equal importance is the way in which clinicians inform policy makers. What should be done by policy makers who review the practical aspects of these choices and the risk involved to the public and private sectors?
The study by the Antiretroviral Therapy Cohort Collaboration (ART-CC) in today's Lancet provides new and exciting facts that will richly inform our discourse with patients.2 The study provides robust and compelling data on a large cohort of HIV-infected individuals from developed countries, and documents the extent of our success in the epidemiological language of life tables, mortality, life expectancy, and potential years of life lost. The bottom line is that a 20-year-old individual starting cART can expect to live for another 43 years on average, whereas a 35-year-old can expect 32 more years of life. These figures are startling and will surely help clinicians to raise the hopes and expectations of patients during discussion of life choices and goals. These data should also enable us to make confident predictions for the policy makers who decide about the microeconomics of this dramatically different outcome. We must advocate that this good news transforms their mind-set and populates their policy documents, most of which are still informed by, and written in, the pre-cART era.
Nevertheless, buried in these data are some sinister signs indicating that our work is not yet done. Life expectancy is still not normal. Even in the best scenarios with the most recent experience with cART, about 10 years is shaved off a normal lifespan. Starting cART when one has become severely immunodeficient shaves an extra 10-20 years. Despite access to cART, late presentation of those infected with HIV remains a frustrating problem. Being an injecting drug user also leads to a 10-year deficit. The disproportionate effect of injecting drug use on survival is a challenge for which we need innovative interventions. Moreover, what are not yet available in the data are the causes of death, the outcomes for children who are exposed to the virus during critical periods of growth and development, and robust outcomes for individuals infected when older than 20 or 30 years. Because this collaboration comes from developed countries, we cannot see the effect of our ever increasing but still insufficient programmes of cART roll-out in developing countries-but at least we can see what we should be aspiring to.
What should we be doing in the post-cART era? Death is now increasingly due to serious non-AIDS illnesses, such as cardiovascular disease, cancers, and end-stage liver and renal disease. The alarming rates of accidents and suicides are often dismissed as a property of the younger age and vulnerability of populations who are at risk of HIV infection, yet the effects of HIV on the brain are almost never factored in as a testable hypothesis. The SMART study3 suggests that the downstream effects of uncontrolled viral replication and immune activation could cause a good proportion of these serious non-AIDS diseases, in addition to traditional risk factors. Notwithstanding, several cohort studies show that there is a strong CD4 gradient for the development of these non-AIDS illnesses as well as our previously well-known foes of opportunistic diseases.4 Thus it makes good sense to expand public-health programmes to encourage early testing for HIV and entry into care of those found to be infected.
The most reasonable explanation for the 10-20-year gap in life expectancy so well documented by the ART-CC study is the previously unrealised clinical mischief of untreated HIV infection. The prevention of CD4 loss and perhaps immune activation by early treatment above a CD4 T-cell count of 500 cells per μL, a band which contains the lowest rates of serious HIV-related clinical events, is perhaps the most important clinical trial that should be done in the post-cART era. Hopefully, the START study,5 which compares starting cART with a CD4 cell count above 500 cells per μL versus deferring to a CD4 cell count of less than 350 cells per μL, will provide the evidence base to bridge the gap so elegantly defined by the ART-CC group.
I declare that I have no conflict of interest.
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