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Survival With and Without HIV: Getting Closer

In industrialized countries, mortality rates among persons infected sexually with HIV are now similar — for the first 5 years after seroconversion — to rates for the general population.

Several studies have documented the dramatic improvements in survival for HIV-infected patients since the mid-1990s, when combination therapy became the standard of care. Now, CASCADE researchers have compared the risk for death in HIV-infected persons with that in the general population.

Data were drawn from 23 cohorts — 20 from Europe, 2 from Australia, and 1 from Canada — covering the period from 1981 through 2006. The analysis included 16,534 HIV-infected individuals; sex between men was the most common exposure category (57%), followed by heterosexual sex (24%) and injection drug use (18%). Dates of seroconversion were estimated based on documented evidence (for 95% of participants, a negative HIV antibody test result <3 years before the first positive result, with the date figured as midway between).

During follow-up (median duration, 6.3 years), 2571 CASCADE participants died, compared with an estimated 235 deaths in a general population cohort matched by age, sex, calendar year at risk, and country of origin. Excess mortality in the HIV group dropped markedly over time, from 40.8/1000 person-years before 1996 to 6.1/1000 person-years in 2004–2006. In 2004–2006, no evidence of excess mortality was seen among persons in the sexual HIV exposure groups during the first 5 years after seroconversion, although mortality curves diverged thereafter. Older age at seroconversion and HIV acquisition through injection drug use both conferred excess mortality within the 5-year window.

Comment: As with other studies from the CASCADE collaboration, a major strength of this analysis is the relatively accurate dating of HIV acquisition, allowing adjustment for duration of HIV infection. This distinctive aspect of CASCADE studies is also a limitation: HIV-infected patients with known dates of seroconversion likely differ in some ways from most HIV-infected individuals (few of whom know when they acquired HIV). Nonetheless, the finding that the 5-year survival after seroconversion is now similar to that of the general population is good news indeed. The period of equal survival will probably lengthen as HIV treatment continues to improve.

— Paul E. Sax, MD

Published in Journal Watch HIV/AIDS Clinical Care July 1, 2008

Citation(s):

Bhaskaran K et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA 2008 Jul 2; 300:51.

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