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AIDS-related deaths significantly reduced since 1999

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There has been a significant reduction in risk of death from AIDS, cardiovascular disease and liver disease among people with HIV compared with more than a decade ago, according to data published in The Lancet, ahead of the 20th International AIDS Conference in Melbourne, Australia.

Non-AIDS cancers are now the leading non-AIDS-related deaths, accounting for 23% of deaths in people with HIV in 2009-2011, according to the report.

Overall, the death rates have been cut nearly in half since 1999. AIDS-related deaths and deaths due to liver disease reduced by 50% and deaths related to cardiovascular disease reduced by more than 65%.

“These recent reductions in rates of AIDS-related deaths are linked with continued improvement in CD4 count and provide further evidence of the substantial net benefits of [antiretroviral therapy],” Colette Smith, PhD, of the research department of infection and population health at University College London, said in a press release. “But despite these positive results, AIDS-related disease remains the leading cause of death in this population.”

Smith and colleagues followed 49,731 individuals from the Data Collection on Adverse Events of anti-HIV Drugs (D:A:D) study from March 1999 until death, loss to follow-up or Feb. 1, 2011. The researchers calculated the overall mortality rates and also specific causes of death among this cohort, which included patients with HIV from Europe, Australia and the United States.

There were 3,909 deaths during 308,719 person-years of follow-up, for a crude incidence mortality rate of 12.7 per 1,000 person-years (95% CI, 12.3-13.1). AIDS-related deaths were most common, accounting for 29% of the deaths, followed by non-AIDS-defining cancers (15%), liver disease (13%) and cardiovascular disease (11%).

The incidence of non-AIDS cancers rose slightly from 1.6 per 1,000 person-years in 1999-2000 to 2.1 per 1,000 person-years in 2009-2011. The percentage deaths due to non-AIDS cancers increased from 9% in 1999-2000 to 23% in 2009-2011.

The incidence of death from liver disease decreased from 2.7 to 0.9 per 1,000 person-years and the percentage of deaths related to liver disease declined from 16% in 1999-2000 to 10% in 2009-2011. The incidence of death related to cardiovascular disease also decreased from 1.8 to 0.9 per 1,000 person-years, but the percentage of deaths due to cardiovascular disease remained constant at 10%.

In an adjusted analysis, accounting for CD4 count and other continually changing factors, there was no change in the incidence of AIDS-related deaths from 1999-2000 to 2009-2011 and AIDS-related deaths remain the most common cause of death. But all-cause mortality decreased (RR=0.72; 95% CI, 0.61-0.83), as did death related to cardiovascular disease (RR=0.33; 95% CI, 0.2-0.53) and liver-related disease (RR=0.48, 95% CI, 0.32-0.74).

“Continued efforts to ensure good ART adherence and to diagnose more individuals at an earlier stage before the development of severe immunodeficiency are important to ensure that the low death rate from AIDS is sustained and potentially decreased even further,” Smith said.

In an accompanying editorial, Steven Deeks, MD, and Peter Hunt, MD, of the University of California, San Francisco, said the benefits of ART are unquestioned and their benefits continue to grow.

“Still, clear limitations exist because many patients are not accessing treatment, and some problems persist even in those on ART, including a higher than expected risk of non-AIDS cancers and other morbidities,” they wrote. “Finally, it needs to be emphasized that we are still early in the ART era. In the absence of a cure, most patients will need to continue on ART for decades. Continued monitoring for unexpected consequences of treatment will be needed indefinitely.”

For more information:

Smith C. Lancet. 2014;384:241-248.

Disclosure: The researchers report financial relationships with Abbott, AbbVie, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead Sciences, GlaxoSmithKline Vaccines, Janssen, Merck Sharp and Dohme, Pfizer, Roche and ViiV Healthcare. Deeks and Hunt report no relevant financial disclosures.