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  17th CROI
Conference on Retroviruses
and Opportunistic Infections
San Francisco CA
February 16-19, 2010
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Life Expectancy Approaches Normal in Dutch Without HIV Symptoms
  from Jules: studies like this try to model a prediction of future mortality which I think is impossible because as patients age they develop comorbidities which do not appear to be factored into this model, how can you model in anyway the possible development if comrbidities like diabetes, cognitive impairment, frailty, bone disease, liver disease both hepatitis and non-hepatitis related, and HIV/aging related senescence.
17th Conference on Retroviruses and Opportunistic Infections, February 16-19, 2010, San Francisco
Mark Mascolini
HIV-infected Dutch people without symptomatic disease have a life expectancy approaching that of the general population, according to an ATHENA cohort analysis [1]. Ard van Sighem and ATHENA coworkers cautioned, though, that their follow-up is short compared with the expected number of years lived.
ATHENA investigators analyzed 4612 adults diagnosed with HIV between 1998 and 2007. No one had started antiretrovirals within 24 weeks of diagnosis, but they probably started after that according to Dutch national guidelines. Four in 5 cohort members were men, 64% were born in Western countries, 15% in sub-Saharan Africa, and 20% elsewhere. Age 24 weeks after HIV diagnosis lay below 35 in 45%, between 35 and 50 in 44%, and above 50 in 11%. At diagnosis the median CD4 count measured 480 (interquartile range [IQR] 360 to 650). Follow-up stood at 3.3 years (IQR 1.6 to 5.8).
Using a multivariate hazards model, van Sighem compared cohort members' progression to death with that in age- and gender-matched people in the general population. He applied the model to 4174 people without AIDS within 24 weeks of their diagnosis, then used predicted survival distributions to calculate the life expectancy of HIV-infected people and the number of life years lost compared with the general population. The model did not consider antiretroviral therapy after 24 weeks.
During 17,580 person-years of follow-up, 118 people with HIV died compared with an expected 35 deaths in uninfected Dutch people of the same age and gender. For people with HIV, those 118 deaths translated into a mortality rate of 6.7 per 100 person-years (95% confidence interval [CI] 5.5 to 5.8). Three factors favored faster progression--older age 24 weeks after HIV diagnosis (relative hazard [RH] 1.07 per year, 95% CI 1.05 to 1.10), birth in a non-Western country (RH 4.9, 95% CI 2.3 to 10.4), and CDC stage B disease at 24 weeks (RH 4.9, 95% CI 2.1 to 11.5). CD4 count at 24 weeks did not predict progression, probably because three quarters of the cohort had more than 350 CD4s at that point.
For 25-year-olds, the expected median number of remaining years stood at 52.7 for asymptomatic people with HIV and at 53.1 for the general population, with broadly overlapping IQRs (44.2 to 59.3 with HIV and 44.9 to 59.5 without HIV). Expected life years lost in HIV-infected men rose with age from 0.4 if diagnosed at 25 to 1.3 if diagnosed at age 55. Women and people with a CDC stage B event had higher expected life years lost than asymptomatic men.
A larger study of several European cohorts found that HIV-infected men who kept their CD4 count above 500 for 3 or more years had a mortality rate equivalent to that of men in the general population [2]. But women who hit that CD4 target still had a higher death rate than women without HIV. (NATAP summarizes this study separately.)
The ATHENA researchers cautioned that follow-up in their analysis is short when considering the number of years left to live. They added that "predictions depend on continuing success of combination antiretroviral therapy well after the maximum time of follow-up."
And the ATHENA findings do not extend to people who already had symptoms of their HIV infection, and perhaps not to people diagnosed at lower CD4 counts. Other recent life-expectancy estimates using different methods in more heterogeneous European and US populations found that people with HIV still lag their uninfected coevals by 10 or more years in life expectancy [3-6].
1. van Sighem Gras L, Reiss P, Brinkman K, de Wolf F, and ATHENA Natl Observational Cohort Study. Life expectancy of recently diagnosed asymptomatic HIV-infected patients approaches that of uninfected individuals. 17th Conference on Retroviruses and Opportunistic Infections. February 16-19, 2010. San Francisco. Abstract 526.
2. Lewden C, the Mortality Working Group of COHERE. Time with CD4 cell count above 500 cells/mm3 allows HIV-infected men, but not women, to reach similar mortality rates to those of the general population: a 7-year analysis. 17th Conference on Retroviruses and Opportunistic Infections. February 16-19, 2010. San Francisco. Abstract 527.
3. Harrison KM, Song R, Zhang X. Life expectancy after HIV diagnosis based on national HIV surveillance data from 25 states, United States. J Acquir Immune Defic Syndr. 2010;53:124-130.
4. 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. http://www.journals.uchicago.edu/doi/full/10.1086/644772.
5. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;372:293-299.
6. Lohse N, Hansen AB, Pedersen G, et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Ann Intern Med. 2007;146:87-95.