Exploring Factors Linked to Longer Survival Among ART Users

January 2014

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In the UK, Professor Caroline Sabin, Ph.D., from University College London has been analysing different studies of HIV-positive people and how such studies estimate life expectancy. She has confirmed in a recent analysis that many studies conducted in high-income countries have found a dramatic reduction in AIDS-related deaths among ART users since 1996.

Factors Unrelated to HIV

In drilling deeper into the data, Professor Sabin has found that factors unrelated to HIV can have a major impact on survival in the recent era. Those factors include the following:

  • smoking (significantly increases the risk for serious cardiovascular disease, cancers and diabetes)
  • excessive alcohol use
  • substance use

Studies have found that some HIV-positive people tend to have higher rates of those factors than HIV-negative people. Furthermore, smoking tobacco can have such a profound impact on survival that it may shorten people's lifespan in ART users more than HIV does.


One large observational study called ART-CC comprises 70,000 HIV-positive participants from Europe and North America. In one analysis of health-related information, researchers with ART-CC examined data on life expectancy and found that the proportions of ART users with a life expectancy similar to that of HIV-negative people were as follows:

  • 46% of MSM
  • 42% of heterosexuals
  • 0% of IDU

Analysing the data slightly differently, looking for the proportions of participants with the greatest risk of death, researchers found this distribution:

  • 4% of MSM
  • 14% of heterosexuals
  • 47% of IDU

In a Danish study examining clinical events in the period from 1995 to 2008, researchers found that non-AIDS-related causes of death fell significantly among people who did not inject street drugs, while such deaths rose over the same period among IDUs.

These findings confirm the serious effect of injecting drugs -- overdoses, accidents and exposure to germs with major consequences, such as serious bacterial infections and viruses that cause hepatitis which can lead to liver failure and, in some cases, liver cancer.

Professor Sabin also calls attention to another study, done in Alabama, which found that patients who missed clinic appointments in the first year after initiating ART "had over twice the rate of long-term [death] compared with those attending all scheduled appointments. ..."

Factors Related to HIV

Late Diagnosis

Studies in Brazil, Western Europe and North America suggest that a diagnosis late in the course of HIV disease is a factor associated with an increased risk of death. This risk arises because the body and the immune system have been severely weakened.

Getting to 500 Cells With ART

In one European study called COHERE, with more than 80,000 HIV-positive participants, researchers found that the risk of subsequent death fell tremendously among men who achieved a CD4+ count of at least 500 cells after starting ART, approaching the risk seen in HIV-negative men. However, for HIV-positive women, even when they maintained CD4+ counts of 500 cells or more for over five years, the results were not the same. The reasons for this may be that HIV-positive women are more likely than HIV-negative women to smoke tobacco and to have a history of injecting street drugs.

When researchers segregated their analysis of survival among women who were not IDU, then their survival after three years of attaining and maintaining a CD4+ count of 500 cells or more became similar to that of HIV-negative women.

Among IDUs who achieved a CD4+ count of 500 cells, death rates were elevated compared to non-IDU HIV-negative people "even after five years of maintaining a CD4+ count of [at least 500 cells]," the COHERE researchers reported.

The COHERE team also explored survival among older HIV-positive ART users. Among people aged 60 or older who had a CD4+ count of at least 500 cells, both men and women had a risk of death similar to that seen among HIV-negative people. The COHERE researchers explained that this finding was due to at least the following two factors:

  • fewer IDUs among older HIV-positive people
  • increasing risk of death among HIV-negative people

Are Neighbourhoods a Factor?

Another study in British Columbia has found that HIV-positive people living in different neighbourhoods have different rates of death. They compared one neighbourhood where there was a relatively high concentration of people who injected street drugs to another neighbourhood with a relatively high concentration of gay men. The researchers said, "We found significant differences between patients from the two neighbourhoods for all socioeconomic variables. Patients in the neighbourhood with a high concentration of injecting drug users were more likely to be female, have a history of injecting drug use, have a less HIV-experienced physician and be less adherent." They also found that even among those who used ART the risk of death for IDUs in that neighbourhood was threefold greater than that of gay men using ART in another neighbourhood.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication TreatmentUpdate. Visit CATIE's Web site to find out more about their activities, publications and services.

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