Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. Lancet HIV
The Antiretroviral Therapy Cohort Collaboration aimed to examine changes in 3 year survival and life expectancy of patients starting combination antiretroviral therapy (ART) between 1996 and 2013. The study used data for 88’504 people with HIV who started antiretroviral treatment between 1996 and 2010 from 18 European and North American studies.
During 84’621 person-years, 2’106 (2%) patients died in the first year after starting ART and 2’302 (3%) died during the second or third year of ART. Compared with patients who started ART in 2000–03, all-cause mortality during the first year of ART was substantially lower for those who started ART in 2008–10 (adjusted hazard ratio [HR] 0.71). All-cause mortality in the second and third years after starting ART declined over calendar time (adjusted HR per calendar period 0.78). The decline in mortality was less in people who inject drugs (adjusted HR per calendar period 0.90). Rates of non-AIDS deaths were lower in patients who started ART in 2008–10 (vs 2000–03) in the first year (0·48) and second and third years (0·29) after initiation of ART. Between 1996 and 2010, life expectancy in 20-year-old patients starting ART increased by about 9 years in women and 10 years in men. Projections based on death rates in the second and third year of treatment for Europeans and North Americans, estimated that 20-year olds starting therapy between 2008-2010 who survived the first year of treatment would live to 73 for men and 76 for women.
In conclusion, even in the late ART era, survival during the first 3 years of ART continues to improve, which probably reflects transition to less toxic antiretroviral drugs, improved adherence, prophylactic measures, and management of comorbidity. Since modern ART is highly effective and has low toxicity, the excess mortality in people living with HIV is unlikely to be addressed by further development of antiretroviral drugs. Instead, lifestyle issues that affect adherence to ART and non-AIDS mortality, and diagnosis and treatment of comorbidities in people living with HIV should be addressed.