January 30, 2017
Life expectancy among HIV-positive people with higher education in Switzerland nearly matched life expectancy of people in the lowest education bracket in the general population, according to results of a large matched comparison. But highly educated people with HIV lagged highly educated HIV-negative people by 5.6 years in life expectancy. And HIV-positive people with only a compulsory education lagged their education-level peers in the general population by 8.8 years.
Studies generally show life expectancy of HIV populations approaching but not matching that of the general population. Estimating life expectancy in HIV populations is difficult because many people with HIV have multiple risk factors such as smoking, drug use and sexually transmitted diseases. Matching HIV populations to general populations for such factors is impossible because vital registration systems lack risk factor data. To address this issue, Swiss HIV Cohort Study (SHCS) researchers matched HIV and general populations by education level because an association between education and life expectancy is well documented.
The SHCS is an ongoing observational cohort study that began enrolling HIV-positive people in 1988. The cohort study uses the same education categories as the Swiss National Cohort, a census-based longitudinal study of mortality in Switzerland: compulsory schooling, vocational training and higher education. The SHCS team calculated life expectancy in five combination antiretroviral therapy (cART) periods: monotherapy era (1988-1991), dual therapy era (1992-1995), early cART era (1996-1998), later cART era (1999-2005) and recent cART era (2006-2013). For this analysis, HIV patients had to be at least 20 years old when they enrolled in the SHCS. Those alive in 2001 were matched to as many as 100 Swiss residents by sex, birth year and education. The investigators used parametric survival regression to model life expectancy.
Life expectancy at age 20 (additional life years) rose from 11.8 years in the monotherapy era, to 20.8 years in the dual therapy era, 44.7 years in the early cART era, 50.8 years in the later cART era and 54.9 years in the recent cART era. From the dual therapy era (1992-1995) to the recent cART era (2006-2013), life expectancy of 20-year-olds with HIV jumped from 24.3 to 52.7 years in people with compulsory schooling, from 25.3 to 52.6 years in people with vocational training and from 26.7 to 60.0 years in people with higher education.
From 2001-2005 to 2006-2013, in the general population life expectancy at age 20 (additional life years) inched up from 61.1 to 61.5 years in people with compulsory education, from 61.2 to 62.2 years in people with vocational training and from 65.4 to 65.6 years in those with higher education. Thus HIV-positive people lagged their education-level peers even in the recent cART era: For the groups with compulsory schooling, people with HIV had a life expectancy 85.6% that of the general population; for the groups with vocational training, people with HIV had a life expectancy 84.5% that of the general population; and for the groups with higher education, people with HIV had a life expectancy 91.5% that of the general population.
The SHCS team concluded that life expectancy in people with HIV rose most substantially with the advent of cART in 1996-1998 and continued to climb in more recent years. But in the most recent cART era (2006-2013), life expectancy in people with HIV continued to lag life expectancy in the general population and in each of the three educational groups analyzed. In the most recent study period, HIV-positive people with higher education had a life expectancy similar to that of people in the general population with compulsory schooling (60.0 and 61.5 years). The SHCS team proposed that life expectancy with HIV could be further improved by early cART initiation, smoking cessation programs tailored to HIV-positive people and early treatment of hepatitis B and C infection.
Mark Mascolini writes about HIV infection.
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