July 18, 2014
News Review From Harvard Medical School -- Deaths Drop Sharply in HIV Population
People infected with HIV in wealthier countries are 28% less likely to die early than they were in 1999, a new study shows. Only 29% of deaths were related to AIDS, the disease caused by HIV. They were still the most common cause of death, but death rates fell by about one-third. The study authors looked at medical data on about 50,000 HIV-infected people. They lived in Australia, Europe or the United States. The study covered the years 1999 through 2011. During these years, HIV medicines improved so much that many infected people who get regular treatment can live a normal life span. About 4,000 people in the study died. The rates of death from heart disease, stroke and related causes dropped by about two-thirds during the study period. Deaths from liver disease were cut in half. Death rates from cancers not linked with AIDS remained stable. These cancers were the leading cause of non-AIDS death, with 23% of all deaths. Most of these (15% of all deaths) were caused by lung cancer. About 13% died from liver disease, mainly hepatitis, and 11% from heart disease. The journal Lancet published the study. HealthDay News wrote about it July 17.
By Mary Pickett, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Advances in treatments have made HIV into a different disease than it was in the early years.
In the 1990s, the life expectancy for a person with HIV was about 10 years. Now HIV infection doesn't reduce your life expectancy, if you get recommended treatment and you take your medicine reliably.
I vividly remember a conversation with a patient from almost 20 years ago. I was having an office visit with a man who had HIV. When he was diagnosed, there was no treatment for HIV or its more advanced stage, AIDS. He watched his close friends die with AIDS. Then he resolved to live well in what he expected to be his final days. What I remember from our conversation was his desperate life planning.
"HIV was my death sentence," he said. "Death was a certainty for me. I quit my good job, and I spent my careful savings. I don't have children to leave my money to. Because I knew I would die from HIV, I traveled and splurged, and have done things that I have always wanted to do. I have given away my prized possessions. I timed my spending so that my life savings would run out right now -- but doctor, I am supposed to be dying!"
We looked at each other knowingly. A few months before, I had put him on treatment with a drug that was new for HIV back then, AZT. It was a game changer. People were no longer dying quite so "reliably" from HIV.
On AZT, my patient's infection was improving beautifully. The idea that he might live for years -- even decades, or perhaps a normal life span -- was startling for both of us.
"So what do I do now, doctor?" he asked me. "I have to start over. How can I do that when I spent everything and I don't have a job?"
Some years later I lost track of this patient. As treatments improved, my patient and many others became people living with HIV, instead of people dying with HIV. Doctors now think of HIV as a chronic illness, not a "death sentence," as my patient called it.
To punctuate the changes in HIV, this week we have updated information about the causes of death for HIV-positive adults. It applies to high-income countries, where treatment is broadly available.
The study included almost 50,000 patients with HIV. It found that cancers unrelated to HIV, liver disease and heart disease are now the leading causes of death in HIV patients. Only 29% of HIV-positive adults appear to be dying of AIDS-related causes. For those of us who have cared for HIV patients across several different decades, this is an astonishing statistic.
Another article, published in December in the journal PLoS One, estimated these life expectancies for HIV in the United States and Canada:
- A young adult appropriately taking combination antiviral treatment for HIV would be expected to live into the early 70s (essentially, a normal life span)
- Some people with HIV don't take their medicines. So average life expectancy for people with HIV overall is lower, in the early 60s.
- For a young adult injection drug user with HIV, average life expectancy is slightly less than 50 years old.
What Changes Can I Make Now?
If you have HIV, taking medicine to suppress the virus is highly effective, long-term treatment.
Most people who die from HIV-linked infections now are people who do not take medicines to treat it.
If you have HIV, make a plan with your doctor about appropriate treatment. For most people with HIV, it is helpful to be seen by a specialist in HIV care. This type of doctor is familiar with HIV medicines and will be able to monitor your virus for signs of resistance to drugs.
Since treatment is so effective, knowing who has HIV infection is really important. Many people infected with HIV don't know it. Some experts estimate that about 17% of those with HIV do not know that they have the infection. But at least one study (in Boston) estimated that the number was closer to 25%. It is recommended that everyone get tested for HIV once. This way we can find some of these hidden HIV infections.
What Can I Expect Looking to the Future?
We are still not able to cure HIV. Research is focused on work to produce a vaccine, and methods that might someday completely cure the virus. Even stem cell transplants are being explored.
For now, it is wonderful to be able to offer patients treatment for HIV that makes it a less threatening disease.