However, the higher burden of comorbidities would still imply some excess mortality among people with HIV
A Danish study published in HIV Medicine has shown the continued decline in mortality in people with HIV since the beginning of the epidemic until recently. Since 2006, mortality among those who survive the first two years after diagnosis is very similar to that of people without HIV. However, the study detects a high burden of comorbidities that still translates into higher mortality among those living with HIV than in the general population.
The arrival of highly active antiretroviral therapy (HAART) in the second half of the 1990s represented an absolute change in the prognosis associated with HIV infection.
Since those times, various studies have pointed to an increasing comparability of the life expectancy of people with HIV with that of the general population, especially if antiretroviral treatment is started quickly after the diagnosis of the infection and that said diagnosis takes place shortly after acquiring the virus (see The News of the Day 03/17/2020). However, comorbidities - much more present in people with HIV than in those of the general population of similar ages - pose a drag on hope and, especially, the quality of life of the population with HIV.
To shed some more light on this issue, the authors of the present study conducted a retrospective analysis of data from 1,043 people with HIV and 1,043 people without HIV (who acted as a control group). The data of these people were collected from registries that spanned the years 1985 to 2017. The controls were selected based on age, sex, and municipality, but not by ethnicity, socioeconomic status, or lifestyle factors.
The researchers collected data on alcohol use, chronic obstructive pulmonary disease (COPD), ischemic heart disease, liver disease, osteoporosis, kidney disease, diabetes, and psychiatric conditions.
The follow-up period was divided into three blocks: it was pre-HAART (1985-1996), it was initial HAART (1997-2005) and it was subsequent HAART (2006-2017).
Notable baseline differences were observed between the two groups compared. People with HIV were less likely to have been born in Western Europe (72% and 94% of people with or without HIV had, respectively), had lower income levels and lower education level.
At the time of diagnosis, the presence of the assessed comorbidities described above was already greater in people with HIV than in seronegative people (14% and 9% of people with or without HIV, respectively, had them). The prevalence of the comorbidities analyzed increased with the age of the participants and was always higher in the group with HIV (under 30 years: 6% and 5% of people with or without HIV, respectively; 31-40 years: 10% and 6% of people with or without HIV, respectively; 41-50 years: 14% and 9% of people with or without HIV, respectively; over 50 years: 36% and 24% of people with or without HIV, respectively;). The only comorbidities whose baseline prevalence was not higher in people with HIV were osteoporosis and diabetes.
After 10 years of follow-up, the percentage of people with at least one comorbidity was 42% in people with HIV and 24% in those who were HIV negative. 54% of those over 50 with HIV had some comorbidity, while the percentage in those over 50 without HIV was 36%.
Cases of liver disease were especially more common in people with HIV, with a 10-year cumulative incidence of 10.9% versus 1.2% in people without HIV. The 10-year cumulative incidence of kidney disease was also much more frequent in people with HIV than in seronegative people (4.1% and 1.2%; respectively), especially in the later HAART era (the last few years evaluated, what which could be indicating the effects of the widely described renal toxicity associated with tenofovir disoproxil fumarate [TDF, generic pharmaceutical specialty-EFG-, Viread®, in Truvada® and Atripla®]).
The 10-year incidence of problematic alcohol use (8.9% and 4.0% of people with or without HIV, respectively) and of mental health problems (18.6% and 8, respectively) was also much more prevalent. 6% of people with or without HIV, respectively)
The differences in the 10-year incidence of COPD were not very large (7.8% and 5.1% of people with and without HIV, respectively) and practically disappeared in the later follow-up periods. The overall incidence of diabetes did not differ significantly between the two groups, although a significant increase was observed in recent years evaluated among people with HIV (possibly due to metabolic effects of some antiretrovirals and / or inflammation associated with HIV), something that it was also observed in the case of osteoporosis. This change in bone health could be due, as in the case of kidney problems, by the toxicity associated with TDF.
At 10 years of follow-up, 23.0% of people with HIV had died, a percentage that was 3.5% among people without HIV.
The difference was maximum in the pre-HAART era (45.5% and 2.8% of people with or without HIV, respectively), it began to moderate in the initial HAART era (15.7% and 3.6 % of people with or without HIV, respectively) and decreased further in the later HAART era (9.4% and 4.0% of people with or without HIV, respectively).
The percentage of deaths 12 months after diagnosis - an important indicator of late diagnosis levels - was 20.3% in the pre-HAART era, 5.5% in the initial HAART era and 1.8% in the later HAART era.
By restricting testing to people with HIV diagnosed after 2006 and who were still alive two years after their diagnosis, the differences in death rates between people with and without HIV practically dissipated.
The results of the present study show how the difference in mortality rates has become smaller as diagnostic strategies and, especially, antiretroviral treatment, have been improved. In any case, the higher prevalence of some comorbidities –especially in recent years– would highlight the toxicity to some organs of certain antiretrovirals and possible effects of the low-intensity inflammation that HIV produces even when undergoing effective treatment.
Source: Aidsmap / Elaboración propia (gTt).
Reference: Jespersen HA et al. The burden of non-communicable diseases and mortality in people living with HIV (PLHIV) in the pre-, early- and late HAART era. HIV Medicine, published online ahead of print, 28 February 2021. doi.org/10.1111/hiv.1307