Antiretroviral Therapy Tamed the HIV/AIDS Epidemic. The Mortality Stats Show It.

The introduction of antiretroviral therapy (ART) in 1996 changed HIV dramatically. It went from being an infection that led to early death by devastating the immune system and to one that could be contained with medication.

A study published in Lancet this week views the introduction of ART through the important if sober lens of cause-specific mortality rates. The research is a massive crunch of data from 17 longitudinal studies that included a total of nearly 190,000 adults with HIV who had been treated with ART. The results show that while still AIDS takes a toll among those with HIV, it has gotten considerably smaller and that mortality rate from all causes is half of what it was in the late 1990s.

There are a couple of exception to the improving mortality statics in the study, led by Adam Trickey, Ph.D., of the University of Bristol in the United Kingdom. The all-cause mortality rate for who women who acquired HIV by way of intravenous drug use increased during the beginning 1996-1999 time span of the study and the concluding 2016-2020 one. The findings also show an increase in death from substance abuse in North America among those with HIV but not in Europe, which Trickey and co-authors said is likely explained by the opioid epidemic in the U.S.

Longitudinal studies of people with HIV during the ART treatment era are not uncommon, but Trickey and his co-authors say theirs, to the best of their knowledge, is the largest and most detailed published.

From the pool of 189,301 people with people with, the researchers identified 16,832, of which 13,180 had identified causes. They analyzed the data related to those deaths in a variety of ways.

Just counting deaths by cause among the sum total 16,832 deaths, shows that AIDS was the most common cause of death, accounting for 4,203 deaths, or about 1 in 4. The next common cause of death was non-AIDS, nonhepatitis-related cancer, at 2,311 deaths, which works out to 13.7% of the total, followed by 1,403 cardiovascular or heart-related deaths, or 8.3%.

But comparing the 1996-1999 period to 2016-2020 showed that AIDS has diminished as a cause of death from HIV infection. The proportion of deaths due to AIDS declined from 49% during 1996-1999 to 16% during 2016-2020.
Another encouraging trend: The rate of mortality from all causes — inclusive of AIDS— fall by half in that period, 16.8 deaths per 1,000 person-years to 7.9 deaths.

Trickey and his co-investigators also analyzed the data by how people contracted HIV and by the cause of death. The decline in heart-related or cardiovascular mortality was largest for men who have sex with men; the author said that might be due to general improvements in cardiovascular and the reduced toxicity of ART during the later year of the period that the study covered. They didn’t explain why those factors might affect men who have sex with men more than other groups.

The decrease in all-cause mortality followed an age gradient. It was steepest in the youngest group, people ages 16-39, followed by those ages 40-59 and then those 60 and older. The same pattern held for AIDS-related mortality and cardiovascular and heart-related mortality.

In their conclusion, Trickey and his co-authors say that “although mortality among people with HIV on ART has decreased, there is still higher mortality among people with HIV than among the general population due both to the consequences of HIV infection and to a higher prevalence of comorbidities and risk behaviors among people with HIV.”

With non-AIDS deaths making up an increasingly large proportion of mortality, they continue, “expanding access to prevention, screening and treatment of these conditions is required to close the gap of comorbidity prevalence between adults with and those without HIV, and funders should recognize this.”

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