Mortality gap narrows between patients with HIV, general population
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The mortality rate among patients entering HIV care “dramatically decreased” in the United States from 1999 to 2017, according to researchers.
Jessie K. Edwards, PhD, an assistant professor in the department of epidemiology at the University of North Carolina at Chapel Hill, and colleagues estimated that the 5-year mortality rate was only 2.7 percentage points higher among patients entering HIV care between 2011 and 2017 compared with the general population.
“HIV-related mortality has been decreasing since the introduction of effective treatment in 1996 due to improving treatment options and evolving care guidelines, but the extent to which persons entering HIV care in the United States have higher risk for death over the following years compared with peers in the general population over the same period remains unclear,” the researchers wrote in Annals of Internal Medicine. “Prior work to elucidate temporal trends in mortality among adults with HIV in the years after entering care has not made comparisons with the general U.S. population.”
Edwards and colleagues used data from the National Center for Health Statistics to compare all-cause mortality over 5 years among 82,766 patients entering HIV care at 13 U.S. sites and a subset of the U.S. population. The participants were matched based on calendar time, age, gender, race, ethnicity and county.
Among the HIV-positive cohort, 84% of participants were men, 46% non-Hispanic Black and 16% were Hispanic. The median age upon entering care was 42 years.
Overall, the researchers reported that the 5-year, all-cause mortality rate was 10.6% among patients entering HIV care and 2.9% among the general population, yielding a difference of 7.7 (95% CI, 7.4-7.9) percentage points. This mortality difference decreased over time, from 11.1 percentage points between 1999 and 2004 to 2.7 percentage points between 2011 and 2017.
In a related editorial, infectious disease experts at Weill Medical College of Cornell University said an “important caveat” of the study is that the HIV cohort was limited to patients who were diagnosed and engaged in care. The authors — Marshall J. Glesby, MD, PhD, associate chief of the division of infectious diseases and director of the HIV clinical trials unit, and Roy M. Gulick, MD, MPH, professor of medicine and chief of the division of infectious diseases — cited data from the CDC that indicate 14% of people living with HIV are not diagnosed, “and only 58% receive continuous medical care.”
“Although the mortality gap relative to the general population seems to be narrowing over time, this trend is predicated on prompt diagnosis and receipt of ongoing appropriate care,” they wrote.
Still, Glesby and Gulick noted that the mortality trends appear to be “promising,” and recent advancements, including the FDA approval of a long-acting injectable regimen, could further improve outcomes for people living with HIV.
“Reducing mortality is a key goal, but it is also important to improve quality of life in people with HIV, which may be adversely affected by comorbidities and aging-related issues,” they wrote. “The past 40 years of the epidemic saw remarkable progress in improving survival in people living with HIV; with ongoing commitment and innovations, further gains can be anticipated.”
References:
Edwards JK, et al. Ann Intern Med. 2021;doi:10.7326/M21-0065.
Glesby MJ, Gulick RM. Ann Intern Med. 2021;doi:10.7326/M21-2586.
Perspective
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W. David Hardy, MD
This is an important study directly demonstrating not only the fruits of improvements in HIV treatments, but also significant improvements in the whole spectrum of HIV care. In order to appreciate these reductions in mortality, we need well-tolerated, lifesaving treatment, as well as health care systems that make it easier and more comfortable for people to get tested, diagnosed, and to encourage people to engage in and stay in care — because HIV care is lifelong — and adhere to medication regimens.
Several other studies evaluating the health of people living with HIV have looked at life expectancy — how long patients are expected to live. The well-known, ongoing Kaiser Permanente study is comparing life expectancy of about 90,000 HIV-positive persons within the Kaiser system in Northern California, Southern California and the mid-Atlantic region to almost 1 million HIV-negative persons within the same health system. It is important to remember that life expectancy is based on modeling, not on when people have reportedly died. The current study looks at vital status (life or death) over a 5-year period of time, which shifted from 1999 to 2004, 2005 to 2010 and 2011 to 2017. That gives this paper even more credence because it is looking at hard and fast numbers, not projections or modeling.
Another advantage of this paper is that it compares HIV-positive persons to the general U.S. population based on age, race, time period, socioeconomic group and other more specific parameters, whereas the Kaiser population is limited to participants with Kaiser insurance. That gives this paper much greater comparability at a granular level.
In the first 5-year time period, there was a fairly large difference in mortality between HIV-positive and HIV-negative persons. During this period, the 5-year mortality rate was 14.5% for HIV-positive persons and 3.4% for HIV-negative persons. That dropped to 8.7% for HIV-positive persons vs. 2.9% for HIV-negative persons between 2005 and 2010, then to 5% for HIV-positive persons and 2.3% for HIV-negative persons between 2011 and 2017. The gap in mortality starts off very wide, then narrows dramatically over just a 15-year period following the introduction of effective antiretroviral therapy in 1996.
When looking at race and ethnicity, most individuals in this cohort are non-Hispanic Black. This has been one of the fastest growing groups of newly diagnosed HIV-positive persons in the U.S. for quite some time. However, this cohort is not entirely representative of the U.S. population. As a practitioner on the West Coast, I have noticed that the No. 1 fastest growing group of persons with HIV is Latinx/Hispanic persons, primarily Hispanic men. So, there is a bit of a demographic slant in this study toward Northeast and Southeast regions, where the study sites are located. The message is still the same, though.
The greatest reductions in mortality in this study occurred among Black HIV-positive persons. Mortality was highest in this group in the first 5-year period of analysis, and has dropped the greatest, even more so than other demographic groups. This finding is very important. Previous papers have shown a higher mortality rate among African American persons often due to later diagnosis or later entry into care. This paper shows a different trend, which is very reassuring.
There is a lot of great news coming out of this paper. I would also like to point out that these data come from a highly fruitful collaboration that combines more than 20 HIV clinical cohorts from around the U.S. and Canada called NA-ACCORD. It takes this high number — more than 82,000 persons with HIV — to do an analysis as striking as this paper.
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