HIV Life Expectancy Approaching Normal

By Michael Smith
NEW YORK, 28 june 2008-- In the early days of the HIV pandemic, patients could expect only a few years between diagnosis and a final fatal AIDS-associated illness. Now, people with HIV in the developed world are living long enough that other causes of death -- such as cardiovascular disease -- are starting to assume an ever-greater importance.Indeed, some physicians counsel new patients that they can expect an essentially normal lifespan -- as long as they keep taking their HIV medication and don't drop dead of something else.
At the 2006 World AIDS Conference in Toronto, for instance, Stefano Vella, M.D., a former president of the International AIDS Society, told reporters: "Today, I can tell my patients with HIV that they can have a normal life expectancy."
The most recent analyses show that Dr. Vella is wrong -- but not by much.
A computer simulation, using data from U.S. sources, calculated the median lifespan of an adult entering HIV care to be 24.2 years, according to Bruce Schackman, Ph.D., of Weill Medical College of Cornell University, and colleagues. The study appeared in Medical Care in November 2006.
In the study, the median age for entering care was 39, which yields a potential lifespan of 63 years, Dr. Schackman said. On the other hand, a 39-year-old without HIV can probably expect to live well into his or her 70s, he said.
In fact, according to the CDC's national Vital Statistics Report, issued June 11, a 40-year-old American can expect to live another 40.2 years.
"There's still a gap," Dr. Schackman said, but it's a far cry from 1993, when one study estimated a lifespan of just 6.4 years for an HIV patient entering care with a CD4 T cell count of about 500 cells per microliter of plasma.
The major difference is highly active antiretroviral therapy (HAART). Its use began in 1996 and it caused an immediate and precipitous decline in HIV/AIDS mortality, Dr. Schackman said.
But even compared with the first years of HAART, that 24.2 years is a huge jump: a 1997 analysis suggested that the early HAART regimens would add only four years of life expectancy.
By 2006, however, the number of drugs available had expanded and their ease of use -- often a barrier -- had increased, to the point where some patients are able to suppress HIV replication with just one pill a day.
Indeed, Dr. Schackman said, the available drugs and drug regimens "have only gotten better since then."
In an analysis that took a different tack, researchers in British Columbia looked at the life expectancy of a 20-year-old starting HAART in one of three periods -- 1996 through 1999, 2000 through 2002, and from 2003 through 2005.
Rather than using a simulated cohort, as Dr. Schackman and colleagues did, Robert Hogg, M.D., of the University of British Columbia and colleagues looked at more than 26,000 people who started HAART in those periods.
As might be expected, they found that the years of life available to their standardized 20-year-old increased over time -- from 24.3 years in the earliest period to 27.1 in 2000-2002 and 33.2 in 2003-2005.
Living to your early 50s is a far cry from a normal life span, but it is a far cry from not making it out of your 20s.
Dr. Hogg and colleagues reported their findings at the 2007 Conference in Retroviruses and Opportunistic Infections, held a few months after Dr. Schackman and colleagues published their analysis.
Although the exact figures aren't identical to those of Dr. Schackman -- and the starting point of care is different -- they're in the same ballpark.
But even the 24 years suggested by the computer simulation is probably an underestimate, if you consider only medication issues, Dr. Schackman said.
"We were being overly conservative by not considering the fact that innovation will continue in the future," he said. "We could only focus on the technology that existed in 2006, but 24 years from now, there will probably be many new ideas."
In another analysis by Dr. Schackman and colleagues, antiretroviral medications accounted for 70% of the lifetime costs of HIV medical care.
On the other hand, Dr. Schackman said, the researchers also did not consider some of the implications of a long life with HIV -- such as the increased risk of cardiovascular disease.
Indeed attendees at the 2006 AIDS meeting were told that 9% of HIV patients now die from heart disease, 15% from liver disease, and 8% from cancer.
The interaction between HIV, the medications, and the human body is still not well understood and it will require years of study on large numbers of patients to work out the details, Dr. Schackman said.
"There may be things about HIV disease itself that affect the risk of other chronic diseases," he said, and what those are will only emerge with time.
Luckily, for people with HIV who have access to HAART, time is what they have.
The study was supported by the National Institute of Allergy and Infectious Diseases, the National Institute on Drug Abuse, and the Agency for Healthcare Research and Quality. Dr. Schackman did not report any conflicts.
Primary source: Medical CareSource reference:Schackman BR, et al "The lifetime cost of current human immunodeficiency virus care in the United States" Med Care 2006; 44: 990-997. Additional source: CROI 2007Source reference: Hogg R, at al "Life expectancy of persons at the time of initiating cART in high-income countries" 14th Conference on Retroviruses and Opportunistic Infections 2007; Abstract 972.