The Impact of Income Disparity on the Life Expectancy of HIV Patients

The life expectancy of people with HIV starting combination antiretroviral therapy (cART) significantly differed between high-income and low/middle-income countries, according to NAM.

In a meta-analysis published in HIV medicine, researchers found that a 20-year-old who started cART had a total life expectancy of 63-years-old in high-income countries. Meanwhile, in low/middle-income countries, men starting treatment at the same age had a total life expectancy of 43-years-old, and women a life expectancy of 53-years-old.

Researchers also found that the life expectancy improved over time, which was a reflection of the improvements in HIV care and treatment.

“This is the first meta-analysis study to estimate the life expectancy of people living with HIV after starting cART by income region,” study authors wrote, as reported by NAM. “We found that life expectancy after starting cART differed markedly between income regions. There were no gender differences in life expectancy in high-income countries, but life expectancy was consistency higher in women than men in low/middle income countries.”

The meta-analysis was conducted to establish a better understanding of the life expectancy of HIV patients starting cART, and to determine the extent to which prognosis differs between the different income countries.

The inclusion criteria for the analysis was strict, requiring cohort studies of adult HIV-positive individuals who were taking a combination of 3 antiretrovirals. Additionally, each study was required to systematically report on the life expectancy at the age the patient started cART.

The mortality data was gathered through active patient follow-up. Eight studies in total met the inclusion criteria with patient cohorts in Canada, Europe, Rwanda, South Africa, UK, and the United States.

The studies in the high-income countries were conducted between 1996 and 2011, while studies in the middle/low-income countries were conducted between 2001 and 2011. Life expectancy after cART initiation was reported at 20- and 35-years-old.

There were a total of 154,670 individuals in the studies, 58% of which were men. The high-income cohorts mostly consisted of men who have sex with men (MSM). The median age of cART initiation was 37-years-old and the median CD4 count at the start of treatment was between 100 and 300 cells/mm³.

Overall, when the life expectancy from all the studies were pooled together, researchers found it was 37 and 29 years from the start of cART at 20- and 35-years-old, respectively. On average, a 20-year-old who started cART was expected to live until 57-years-old, while a 35-year-old would live until 64-years-old, according to the study.

Next, researchers stratified the life expectancy according to income level and region. In high-income countries, the overall life expectancy was estimated at 43-years-old if cART was started at 20-years-old, and 32 years if treatment started at 35-years-old.

For the middle/low-income countries, the life expectancy appeared to differ by gender. Men who started cART at 20-years-old had an additional 23 years of life (total life expectancy 43 years), and 33 years for women (total life expectancy 53 years).

When cART began at 35-years-old, life expectancy for men was 22 years (total life expectancy of 57 years), and 30 years for women (total life expectancy of 65 years). Authors noted that the disparities in life expectancy by gender in middle/low-income countries was most likely due to differences in access to HIV testing, diagnosis, and retention in care.

The analysis also showed a consistent trend with the increase of life expectancy with more recent calendar year of cART initiation. For example, a 20-year-old in a high-income country who initiated cART in 2006 or 2007 had a total life expectancy of 71 years, according to the study.

“We believe that this is probably attributable to improvements in drug treatment, changing guidelines that advocate starting cART with higher CD4 counts in all settings, better adherence and support programs, increased CD4 and viral load monitoring, and cART scale-up with increased access to care in low/middle-income countries over time,” the study authors wrote.

To assess the effect of changes in care coverage, care cascades, and treatment guidelines, the study authors conclude that it’s important for all countries to continue to monitor the life expectancy of HIV-positive individuals who are starting cART.