Death Rates for HIV Patients Decrease Dramatically

[pacerintl]

http://health.usnews.com/articles/health/healthday/2008/07/01/death-rates-for-hiv-patients-decrease-dramatically.html


Death Rates for HIV Patients Decrease Dramatically
Study found 5-year survival rate for those on HAART now equals general population
Posted July 1, 2008

 By Amanda Gardner
HealthDay Reporter

TUESDAY, July 1 (HealthDay News) -- Death rates for HIV-infected people lucky enough to get their hands on antiretroviral medications have decreased dramatically since the introduction of these drugs in 1996, new British research shows.

For most, the five-year, post-diagnosis survival for those infected sexually is now about equal to that of the general population.

Death rates were higher, however, for older individuals, for those who had been infected for a longer time, and for those who had been infected through intravenous drug use.
Dramatic declines in death rates for HIV-infected individuals following the introduction of highly active antiretroviral therapy (HAART) in industrialized nations in the mid-90s have already been documented.

"HIV is now a complex chronic disease," said Dr. Michael Horberg, director of HIV/AIDS at Kaiser Permanente Health Plan in Santa Clara, Calif. "And, if aggressively treated with accepted medications, we should expect to see mortality similar to the general population in that same demographic."

"[This information] will help health policy makers or those who monitor the effectiveness of treatments to forecast the impact of AIDS on health-care needs," said Srikanth Kolluru, an assistant professor of pharmaceutical sciences with the Texas A&M Health Science Center in Kingsville. "One important thing to know is that the composition of HAART regimen will keep changing for a particular patient during his/her course of therapy depending on the development of tolerance to the particular drug. Hence, newer drugs with different mechanisms of action are continuously needed to be added to HAART regimen to maintain the low mortality rate."

The authors of the current study, published in the July 2 issue of the Journal of the American Medical Association, updates existing information, deliberately focusing on people whose seroconversion rates were relatively well-established. Seroconversion refers to the time when antibodies to HIV appear in the blood, usually from one week to several months or more after actual infection.

More than 16,000 individuals in multiple countries were followed for a median of 6.3 years. During the follow-up period, 2,571 individuals with HIV infection died compared with 235 who would be expected to die in an equivalent general population.

The excess mortality rate decreased from 40.8 per 1,000 person-years before the introduction of HAART to 6.1 per 1,000 person-years in the 2004 to 2006 period.

There was essentially no excess mortality in the first five years after seroconversion among individuals who had been infected sexually. However, over the first 10 years, those aged 15 to 24 years old and those 45 years or over at seroconversion did have higher death rates.

The authors calculated an 88 percent reduction in excess mortality in 2000-2001 compared with the period prior to 1996. This was very close to the 87 percent reduction seen in 1997-2001. In 2004-2006, the excess mortality was 94 percent lower than pre-1996 levels.

The study did not take into account adherence to medication or side effects, which can be severe.

"The study doesn't take into account adverse events and medication adherence. And, over a longer time frame, we don't know if there might be an effect from medications accumulating in the body," Horberg said.

"Despite all these side effects [including diarrhea, nausea, vomiting, fat redistribution], HAART therapy still improves the quality of life and life expectancy, which is nearing close to that of uninfected population," Kolluru said. "Prevention is still the best treatment for AIDS, and that has no side effects."

[John2038]

More than 16,000 individuals in multiple countries were followed for a median of 6.3 years. During the follow-up period, 2,571 individuals with HIV infection died compared with 235 who would be expected to die in an equivalent general population.

That's a mortality rate of 25.5 per 1,000 person-years for the HIV infected population and of 2.33 in an equivalent general population

So an excess mortality rate of 23.17 per 1,000 person-year for the HIV infected population

The excess mortality rate decreased from 40.8 per 1,000 person-years before the introduction of HAART to 6.1 per 1,000 person-years in the 2004 to 2006 period.

Means that in the post-HAART era, the excess mortality rate has continue to decrease, at least from 23.17 to 6.1  per 1,000 person-year ?

Confused 

However, over the first 10 years, those aged 15 to 24 years old and those 45 years or over at seroconversion did have higher death rates.

Very surprising. So the 24-45 have a lower death rates compared to the 15-24 ?

[John2038]

Complete study
http://jama.ama-assn.org/cgi/content/full/300/1/51

1. Characteristics of the Study Population



2. Changes in Overall and Excess Mortality Rates



3. Reduction in All-Cause Mortality pre-1996 to 2006 and Comparison With That of the General Population, by Age Group





Choosen extracts of this study

METHODS

Data were used from CASCADE (Concerted Action on Seroconversion to AIDS and Death in Europe), which has been described elsewhere.12 It is currently a collaboration of 23 cohorts of individuals with well-estimated dates of HIV seroconversion from Europe (20 cohorts from Denmark [1], France [4], Germany [1], Greece [1], Italy [1], the Netherlands [2], Norway [2], Spain [4], Switzerland [1], and the United Kingdom [3]), Australia (2 cohorts), and Canada (1 cohort).

Estimated Excess Mortality by Duration of Infection

The cumulative excess probability of death in the first 10 years from seroconversion estimated to be 4.8% (95% CI, 2.5%-8.6%) in those aged 15 to 24 years and 4.3% (95% CI, 0.0%-10.5%) in those 45 years or older at seroconversion

Uptake of HAART

* The median time from HIV seroconversion to starting HAART was 1.6 (IQR, 0.7-3.5) years in 1996-1997 and 1.4 (IQR, 0.6-3.4), 1.8 (IQR, 0.7-5.6), 2.4 (IQR, 0.8-6.7), and 2.2 (IQR, 1.0-4. years in 1998-1999, 2000-2001, 2002-2003, and 2004-2006, respectively.
* After excluding time at risk when HAART would not be indicated, the proportion of person-time spent receiving HAART increased from 17% in 1996-1997 to 54%, 66%, 69%, and 73% in the same calendar periods, respectively.
* Ritonavir boosting of PI regimens also increased from 7.0% of person-time receiving PI-based HAART in 1996-1997 to 10.7%, 32%, 63%, and 79% in 1998-1999, 2000-2001, 2002-2003, and 2004-2006, respectively.

COMMENTS

The excess mortality rate per 1000 person-years was 40.8 (95% confidence interval [CI], 35.8-43.0; 1275.9 excess deaths in 31 302 person-years) pre-1996, decreasing in each subsequent calendar period to 6.1 (95% CI, 4.8-7.4; 89.6 excess deaths in 14 703 person-years) in 2004-2006.

To further explore the differences between HIV exposure groups, we considered causes of death in 2004-2006. Of the 127 individuals who died in this period, 95 had known cause of death (as recorded in clinic records or death certificates), the most common being AIDS for 27 individuals (28%), non-AIDS malignancy for 14 (15%), and suicide or intentional harm for 13 (14%). The pattern of causes of death among those exposed through IDU differed from that of other groups: no non-AIDS malignancies were reported, and there was a higher proportion of reported liver-related causes (7/22 [32%], compared with 2/73 [3%] among sexual exposure groups). The proportion of deaths reported as suicide among those exposed through IDU was only slightly higher than among those with reported exposure category of sex between males (4/22 [18%] vs 8/51 [16%]).


LIMITATIONS

Our study has some limitations. Ideally we would like to quantify the excess mortality associated with HIV infection. To this end, we have compared mortality in CASCADE with that in the general population. Although we matched by age, sex, calendar time, and country, it is likely that HIV-infected individuals in our study differ from the general population in other ways. Rates of smoking have been shown to be high among some HIV-infected populations30; other risk behaviors, socioeconomic factors, and race/ethnicity are also likely to differ among HIV-infected persons. Those exposed through IDU in particular are likely to be at higher risk of mortality than the general population regardless of HIV infection, and we have presented our estimates of the cumulative excess mortality proportion excluding this group. Nonetheless, our results are interpretable as estimates of the excess mortality among HIV-infected individuals, who may differ from a general population not only in being infected with HIV but also in other factors.

A second limitation is that HIV seroconverters are not representative of the total HIV-infected population; mortality estimates derived from seroconverters, by definition diagnosed and monitored from an early stage, are likely to be optimistic compared with the experience of the wider HIV-infected population. In particular, further research will be needed before our finding of no excess mortality in the first 5 years of infection in 2004-2006 can be generalized beyond those diagnosed early in infection.

Despite these limitations, seroconverters provide a unique opportunity to study and adjust for the effect of duration of HIV infection on mortality and excess mortality. Our results show the progress in reducing mortality among HIV-infected individuals toward the levels experienced by the general uninfected population. However, there is continuing excess mortality, particularly evident in those infected for 10 years or more. Ongoing monitoring of excess mortality will be important as new treatment advances are implemented in an attempt to further reduce mortality rates among HIV-infected individuals.


--

Notes

Demography  (http://en.wikipedia.org/wiki/Life_expectancy)

1) Overview







2) Data (per country table)
http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy

3) (out of topic)
The Life Expectancy in Zimbabwe is the Lowest In The World (37 y for males) but Mugabe is the oldest president in the world (82 yo) ..

[Miss Philicia]

Too bad for us pre-HAART folks these figures don't mean as much.

[John2038]

This study estimate the cumulative overall probability of death by duration (up to 15y)
For e.g. :

In the 2004-2006 period:

A HIV infected person with:
Age: 25-34y Infected since: 15y

have an estimated cumulative /excess probability of death of:
Excess probability: 2.4%

This same person in the pre-1996 era was having an estimated cumulative overall excess probability of death of:
Excess probability: 66.5%

http://jama.ama-assn.org/content/vol300/issue1/images/medium/joc80047f1.gif
http://jama.ama-assn.org/content/vol300/issue1/images/medium/joc80047t4.gif

[Dachshund]

I figured that since we weren't dying the death rate was decreasing.

[RapidRod]

I've always liked it (not) when the News broadcasts a speech, that after the speech you have some News Commentator trying to tell the people what they said in the speech. Like no one but them can understand what was just said.

[John2038]

I've always liked it (not) when the News Commentator  broadcasts a speech,
that after the speech you have some Anti-all trying to tell the people
what they said in the speech. Like no one but them can understand (not) what was just said.

1) Don't highjack
2) Love yourself and you will love others
3) Boring

[Miss Philicia]

lolwut

[Ann]

1) Don't highjack
2) Love yourself and you will love others
3) Boring

Pretty rich. Pot, kettle, black.

Ann

[Assurbanipal]

Too bad for us pre-HAART folks these figures don't mean as much.

I believe John's subsequent response was addressing this comment, although (apologies John) because of the English translation issues, one cannot always be sure.  At any rate, the study says it is addressing current mortality among those who were pre-HAART in the 15-year survival figures and that its figures might be pessimistic when applied to more recent seroconversions.

"Our long-term cumulative mortality estimates for 2004-2006 include data from individuals infected in the mid-1990s or earlier who may have started antiretroviral treatment later in the course of infection and with regimens inferior to those currently available; thus, such estimates may be pessimistic in terms of the long-term outlook for more recently infected individuals. Nevertheless, it is likely that even with current standards of HIV management, some long-term excess mortality would remain because problems of toxicity, resistance, and therapy adherence are likely to increase with time receiving HAART."

There's also another message buried in the data that many new readers of the forums may want/need to hear.  That is that not only is the chance of dying in the first 5 years no different from the general population, but that for the next 10 years the chance of dying due to HIV is under 1% higher per year -- and typically much less than 1%.  It's important that newly diagnosed people who are intensely worried about their life chances today understand that, while HIV today still increases the risk of death, the increased risk is quite small and can be dwarfed by other factors.  Of course, the study has limitations (e.g. "mortality estimates derived from seroconverters, by definition diagnosed and monitored from an early stage, are likely to be optimistic compared with the experience of the wider HIV-infected population") but many of those limitations would also apply to those concerned enough about their health to visit AIDSMEDS.

A

[Miss Philicia]

That's all nice and pretty, but in my small LTS support group we've had 2 people die in the last 2 years, so that's like 20%.  Oh, and this week the moderator's right side of his face became paralyzed for 5 days by some obscure virus I'd never even heard of.  Fierce, huh?

I don't need expensive studies by number crunching bureaucrats to tell me what I can see with my own eyes.

But whatever makes you folks sleep better I guess.

[John2038]

That is the representativity of a sample.
16'000 people are (much) more representative than  a dozen

[Assurbanipal]

That's all nice and pretty, but in my small LTS support group we've had 2 people die in the last 2 years, so that's like 20%.  Oh, and this week the moderator's right side of his face became paralyzed for 5 days by some obscure virus I'd never even heard of.  Fierce, huh?

I don't need expensive studies by number crunching bureaucrats to tell me what I can see with my own eyes.

But whatever makes you folks sleep better I guess.

I'm sorry if my note came across as trying to minimize your personal experience. That was not my intent. I really enjoy reading your posts and have no desire to in any way offend.  And I agree that the study results can't be read to demonstrate low mortality rates for everyone who went through the precursors to HAART either individually or as a group.  Nor do they apply to those, like myself, who were diagnosed late.  As the study authors point out, people who were followed by doctors from close to the time of seroconversion are likely to have better medical care and better results than the overall population with HIV. 

But there are an awful lot of people posting in "I just tested Poz" who are very similar to the study population; they are recently diagnosed and will have access to care similar to the study population.  Plus there are those among the more experienced population for whom similar treatment applied.  It is important and life affirming for them to see the evidence of how far medicine has come.  Their life chances are demonstrably and significantly improving and I hope they read and take heart (and HAART).

A

[John2038]

Antiretroviral therapy has increased life expectancy by 13 years, researchers say

THURSDAY, July 24 (HealthDay News) -- Since 1996, the life expectancy of HIV patients in developed countries taking antiviral therapy has increased more than 13 years, and deaths have dropped by almost 40 percent, researchers report.

Despite these gains, life expectancy still falls short by some 20 years, compared with people in the general population. Life expectancy among injection drug users and those who start their treatment late is even shorter.

"People on [antiretroviral therapy] can live a fairly long life," said lead researcher Robert Hogg, from the British Colombia Centre for Excellence in HIV/AIDS in Vancouver. "If they are a woman, they can marry and have a child, and see the child grow up. If they're going to school, they can graduate from university, or they can continue to have a full adult life expectancy."

The report was published in this week's special HIV/AIDS issue of The Lancet.

For the study, Hogg's team collected data on 43,355 HIV patients from Europe and North America who participated in 14 studies. Among these patients, 18,587 started treatment in 1996 to 1999, another 13,914 began treatment in 2000 to 2002, and 10,584 started treatment between 2003 and 2005.

During the study period, 2,056 patients died. However, mortality decreased from 16.3 deaths per 1,000 person-years in 1996 to 1999 to 10 deaths per 1,000 person-years in 2003 to 2005. In addition, life expectancy for someone starting treatment at age 20 increased more than 13 years, from 56.1 years in 1996 to 1999 to 69.4 years in 2003 to 2005, the researchers found.

For some HIV patients, life expectancy is even shorter. For example, those who start treatment later in disease progression, life expectancy is 52.4 years, compared with 70.4 years for patients treated early. In addition, life expectancy among injection drug users is also lower at 52.6 years, compared with people who acquired HIV is another way at 64.7 years.

In addition, women had a longer life expectancy compared with men (64.2 versus 62.8 years). This may be due to women starting their treatment earlier, Hogg's group suggests.

"This sort of a mind shift for people, even physicians and researchers, that when you look at this life expectancy for these people is even longer than expected," Hogg said.

Rowena Johnston, vice president for research at the Foundation for AIDS Research, thinks that antiretroviral treatment has transformed HIV/AIDS from an early death sentence to a manageable chronic illness.

"One of the most striking successes of HIV/AIDS research has been the development of antiretroviral therapy that significantly extends the lives of people living with HIV," Johnston said.

Increasingly longer life expectancy is obviously a boon to patients and doctors, but it comes with increased risk of side effects and other difficulties associated with taking these medications for long periods of time, Johnston said. "Clearly, though, the benefits outweigh the risks," she added.

"Longer life expectancies are shifting what has been the traditional portrait of AIDS, such as body-wasting along with numerous rare infections, into a condition that is increasingly associated with some of the manifestations we traditionally think of with older age, like cancers, heart disease, kidney and liver disease, and insulin resistance," Johnston said.

However, Johnston thinks that many HIV patients continue to fall through the cracks. "What we haven't managed to do as well is to increase numbers of people getting tested, so that they find out about their HIV infection early enough to reap these benefits," she said.

http://health.msn.com/health-topics/aging/articlepage.aspx?cp-documentid=100211615

integrase inhibitor will boost the life expectancy when they will their impact will be measurable

[MYSTERY]

The real scoop on life expectancy is that no one really knows! People respond very differently to HIV and HIV therapies. There are also many different types of HIV, some more aggressive and difficult to control than others. Perhaps the most critical thing to realize is that the new more potent and effective HIV medications did not come into widespread use until mid-1996! Therefore, they haven't been around long enough to know what their ultimate effect will be on survival. There has certainly been a dramatic decrease in HIV morbidity and mortality that has been sustained since the introduction of HAART (highly active antiretroviral therapy).