Abstract
ObjectivesTo estimate mortality rates and prognostic factors in HIV-positive patients who started combination antiretroviral therapy between 1996–1999 and survived for more than ten years.MethodsWe used data from 18 European and North American HIV cohort studies contributing to the Antiretroviral Therapy Cohort Collaboration. We followed up patients from ten years after start of combination antiretroviral therapy. We estimated overall and cause-specific mortality rate ratios for age, sex, transmission through injection drug use, AIDS, CD4 count and HIV-1 RNA.ResultsDuring 50,593 person years 656/13,011 (5%) patients died. Older age, male sex, injecting drug use transmission, AIDS, and low CD4 count and detectable viral replication ten years after starting combination antiretroviral therapy were associated with higher subsequent mortality. CD4 count at ART start did not predict mortality in models adjusted for patient characteristics ten years after start of antiretroviral therapy. The most frequent causes of death (among 340 classified) were non-AIDS cancer, AIDS, cardiovascular, and liver-related disease. Older age was strongly associated with cardiovascular mortality, injecting drug use transmission with non-AIDS infection and liver-related mortality, and low CD4 and detectable viral replication ten years after starting antiretroviral therapy with AIDS mortality. Five-year mortality risk was <5% in 60% of all patients, and in 30% of those aged over 60 years.ConclusionsViral replication, lower CD4 count, prior AIDS, and transmission via injecting drug use continue to predict higher all-cause and AIDS-related mortality in patients treated with combination antiretroviral therapy for over a decade. Deaths from AIDS and non-AIDS infection are less frequent than deaths from other non-AIDS causes.
Highlights
HIV-positive patients who started combination antiretroviral therapy (ART) soon after it became widely available in Europe and North America in 1996 have been treated for up to 20 years[1]
Male sex, injecting drug use transmission, AIDS, and low CD4 count and detectable viral replication ten years after starting combination antiretroviral therapy were associated with higher subsequent mortality
CD4 count at ART start did not predict mortality in models adjusted for patient characteristics ten years after start of antiretroviral therapy
Summary
HIV-positive patients who started combination antiretroviral therapy (ART) soon after it became widely available in Europe and North America in 1996 have been treated for up to 20 years[1]. Current mortality rates in these patients are of great interest: they started ART regimens that are less tolerable and have lower antiviral potency than those available[2] and are likely to have switched ART regimen repeatedly as better drugs became available[3, 4]. As they age these patients are at increased risk of age-related comorbidities such as cardiovascular disease, cancer, liver and renal disease[5, 6]. For some successfully treated patient groups mortality rates may be similar to those of the background population[13, 14]
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