As 2020 draws to a close, we asked David Alain Wohl, M.D., a professor of medicine in the Division of Infectious Diseases at the University of North Carolina and a highly respected HIV clinician-researcher, to take stock of the year's most momentous research developments and other critical events. In this exclusive series of articles, Wohl calls attention to 10 such developments that have tremendous short-term implications for our day-to-day efforts to improve HIV prevention, treatment, patient care, and policy in the U.S., and analyzes each development with his trademark wit and clinical savvy.
Given the decline in mortality among people living with HIV in the U.S., it’s no surprise that the difference in life expectancy between those with and without the virus is shrinking. To quantify this difference, researchers from Harvard Medical School and the Kaiser Permanente health care system compared calculated life expectancy for infected and uninfected members, as well as the number of years people lived that were free of several major comorbid conditions: chronic liver disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and cardiovascular disease.
Patients 21 years of age and up who were living with HIV and received care in the Kaiser Permanente health care systems of northern and southern California, Maryland, Virginia, and Washington, D.C., from 2000 through 2016 were matched 1 to 10 with random patients not living with HIV. Matching was done by age (in two-year groups), sex, race/ethnicity, medical center, and calendar year at the start of follow-up. This yielded 39,000 individuals with HIV infection and 387,785 matched uninfected adults.
Importantly, almost 90% of those studied were male. Only 25% were Black non-Latinx and 24% were Latinx.
As always, there were differences between those with and without HIV infection. Compared with the uninfected patients, the proportion of people living with HIV who had a history of drug use disorders was higher (4.5% vs 2.4%), as was the proportion who ever smoked (51.8% vs 40.8%). Fewer HIV-positive patients had ever been overweight or obese (73.2% vs 85.5%).
Among those with HIV infection, most were men who have sex with men (MSM), and over 80% were on HIV therapy. In addition, 29% had a CD4 cell count above 500/uL at the time they started antiretrovirals.
The difference in life expectancy between people with and without HIV dropped from 22 years during 2000-2003 to 9 years during 2014-2016. From 2014 to 2016, overall life expectancy at 21 years of age among individuals with HIV infection was an additional 56.0 years, compared with 65.1 years among the uninfected. During 2011 to 2016, patients with HIV infection who initiated HIV therapy with a CD4 cell count of 500/μL or greater had a life expectancy at 21 years of age of an additional 57.4 years, compared with an additional 64.2 years among uninfected adults (i.e., a difference of 6.8 years).
In contrast, when looking at years of life in which a person remained free from the selected co-morbidities, there was little change over time in the approximately 15-year gap between the HIV-positive and HIV-negative individuals. From 2014 to 2016, comorbidity-free life expectancy at 21 years of age was an additional 14.5 years for individuals with HIV infection and 30.9 years for uninfected adults, corresponding to a difference of 16.3 years.
Again, those with a high CD4 cell count when starting HIV therapy fared better: Their comorbidity-free expectancy at 21 years of age was an additional 19.5 years, compared to 29.0 years for uninfected adults, for a difference of 9.5 years.
Among the co-morbidities included in the analysis, chronic liver, renal, and lung diseases remained intransigent, with little change in the difference by HIV status. Encouragingly, this was not the case for diabetes, cancers, and cardiovascular disease, where the gaps narrowed between the HIV infected and uninfected in years of comorbidity-free life.
The Bottom Line on HIV Life Expectancy in 2020
There are a number of take-aways from this important paper.
First, even in a near-ideal healthcare setting, lower life expectancy for HIV-positive people persists. The difference is almost a decade, although it is nearly halved when HIV therapy is started above a CD4 cell count of 500/uL.
Second, the period of adulthood that is lived free from major chronic conditions is much shorter for those with HIV infection, and this has not changed over time.
Third, there were significant improvements in prevention of diabetes, cancer, and cardiovascular disease—conditions that regular health care likely impact.
Fourth, liver, renal, and lung diseases remain more common in people with HIV infection, and they are evidently less amenable to routine primary care intervention. Viral hepatitis and alcohol may drive liver issues, while smoking (including prior smoking) likely contributes to prevalent lung issues.
Lastly, despite the extensive matching, there were notable baseline differences between those with and without HIV, including living in areas with higher levels of poverty, more substance use, and more smoking. Many other differences that were not captured in this study are also likely to be at play.
When a friend of mine who is living with HIV first brought this article to my attention, he saw the odds stacked against him: He felt the differences in life expectancy between positive people and negative people as the number of precious years he could be robbed of. I understand that. As a healthcare provider, I also see the contours of the existing limits of care. I can screen for cancer, start a statin, and help patients to stop smoking. Maybe I can even do better at treating hypertension.
Yet, some things will take more than what I can offer during an office visit. Early diagnosis of HIV remains one the most powerful ways we can achieve parity in life expectancy. Preventing and curing hepatitis C has got to also make a dent.
And, no surprise: Addressing poverty, discrimination, and other stressors would likely also matter. In a different study from a different land, there was no difference seen in the life expectancy of people with HIV who started HIV therapy at a CD4 cell count above 350/uL compared to those without HIV. That different land was Switzerland, where more may be possible to achieve than what we’re able to do in the U.S.