Life Expectancy With HIV Treatment Continues to Rise
Life expectancy after starting antiretroviral therapy (ART) for HIV infection has risen over the years in both high-income and low/middle-income countries, according to a seven-study meta-analysis. But life expectancy when starting ART at age 20 is 15 years longer in high-income countries than in poorer countries.
Even as recently at 2006, a UNAIDS report determined that HIV infection decreased life expectancy by about 20 years. More recent analyses indicate that some ART responders who live in high-income countries and do not inject drugs have life expectancies that approach that of the general population. But in poorer countries with ART access, life expectancy with HIV infection remains about 10 years less than in high-income countries.
Researchers from the University of New South Wales and other centers conducted this meta-analysis to estimate life expectancy with HIV after ART begins and to compare those estimates between low/middle- and high-income countries. They searched Medline for studies published in English through December 2015 that assessed life expectancy in HIV populations receiving ART. They focused on cohort studies that used the abridged life table method to estimate life expectancy, which they defined as additional years of life expected after starting ART at age 20, 25, 35 or 40. They separated studies into those involving low/middle-income countries and high-income countries according to World Bank income categories. The researchers used random effects meta-analysis to pool data across studies.
Of the seven identified studies, four involved high-income countries (European countries, Canada, UK, U.S.) from 1996 to 2011 and three involved low/middle-income countries (Uganda, South Africa, Rwanda) from 2001 to 2011. Across studies, 58% of participants were men, median age was 37 years when ART began and median pre-ART CD4 count ranged from 100 to 350 cells/mm3.
In high-income countries, pooled life expectancy was 43.3 when starting ART at age 20 and 32.2 years when starting at age 35. In low/middle-income countries, pooled life expectancy was 28.3 years when starting ART at age 20 and 25.6 years when starting at age 35. Thus, life expectancy was 15 years shorter in low/middle-income countries when starting ART at age 20 and 6.6 years shorter when starting at age 35.
In low/middle-income countries, life expectancy was higher in women than men when starting ART at age 20 (33.0 versus 22.9 years) or at age 35 years (29.6 versus 22.3 years). In high-income countries, life expectancy after starting ART was similar in women and men. Three studies in high-income countries and one in a low/middle-income country stratified life expectancy by calendar period. Pooled analysis of these studies indicated increasing life expectancy in more recent years when starting ART at age 20 or 35.
The researchers note that in their meta-analysis life expectancy with HIV at age 20 still lags life expectancy at that age in the general population -- 60 years in high-income countries and 51 years in low/middle-income countries. They observe that life expectancy with HIV in high-income countries did not differ between women and men, whereas in the general population women have longer life expectancy than men. The authors suggest that underlying sex-based differences in life expectancy in the general population may not be large enough to appear in small HIV populations with shorter follow-up. The greater life expectancy with HIV in women than men in low/middle-income countries may reflect earlier access to HIV care by women and better retention in care. The researchers propose that life expectancy with HIV may continue to increase as national guidelines now often call for starting ART regardless of CD4 count.