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Dr K Porter, MRC Clinical Trials Unit, London, UK;
What is the risk of death in HIV-infected people compared with the general population? Has this risk changed since the introduction of highly active antiretroviral therapy (HAART)?
inception cohort followed up for a median 6.3 years.
10 European countries, Australia, and Canada.
16 534 patients ⩾15 years of age at HIV seroconversion (median age 29 y, 78% men) who had well-estimated dates of seroconversion (within 18 mo) and exposure to HIV through injection drug use (18% of patients), sex between men (57%), or heterosexual sex (24%).
calendar period of follow-up (before 1996, 1996–7, 1998–9, 2000–1, 2002–3, and 2004–6), sex, age at seroconversion, and HIV exposure category.
mortality, excess mortality compared with the general uninfected population, and excess mortality in recent years compared with before 1996.
2571 HIV-infected people died compared with 235 expected deaths in a matched general population cohort. Overall mortality was 23 per 1000 person-years (95% CI 22 to 24), and excess mortality over that of the general population was 21 per 1000 person-years (CI 20 to 22). Data by calendar period are shown in the table. Risk of excess mortality was higher in men, people who were older at seroconversion, and those with HIV exposure from injection drug use. In people with sexual HIV exposure, by 2004–6, mortality in the first 5 years since seroconversion did not differ from that in the general population, although mortality remained increased in people with longer duration of infection.
People infected with HIV had higher mortality than the general population, but mortality and excess mortality have greatly decreased in the past 10 years. By 2004–6, HIV seroconversion from sexual exposure was not associated with increased mortality in the first 5 years.
A modified version of this abstract appears in ACP Journal Club and Evidence-Based Medicine.
Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA 2008;300:51–9.
Clinical impact ratings: Family/general practice 5/7; General/internal medicine 6/7; Infectious disease 5/7
Since the introduction of HAART in 1996, patients with HIV infection have benefited from prolonged disease-free survival, sustained virological suppression, immunological recovery, and reduced HIV morbidity. It has been estimated that with comprehensive HIV care and improved drug efficacy, survival after a diagnosis of AIDS is >13 years compared with 1.6 years in the absence of treatment.1 In some cohorts, patients with HIV infection who started HAART with a higher CD4 cell count had mortality rates comparable to those of patients with other chronic medical conditions.2 The study by Bhaskaran et al provides further evidence of declining HIV mortality, and although not studied directly, this effect is likely related to better HAART regimens.
Although more people are living with HIV infection as a result of HAART, we cannot forget that much is still unknown about HIV disease and the medications used to treat it as shown by the study’s finding of excess mortality with longer duration of infection. Long-term chronic HIV therapy has been linked to endocrine and metabolic abnormalities, cardiac disease, bone disorders, and renal disease. Along with these adverse effects, many patients with HIV still have liver disease, mental health disorders, pain syndromes, cancer, and substance abuse, all of which negatively affect the disease process. Because of longer survival, nurses in general and specialty care areas will be called upon to manage chronic comorbid conditions and health problems, with HIV as the primary, and increasingly, the secondary health condition.
Source of funding: European Union.
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