Issues That Divide Expert Opinion: When to Start, HIV and Aging and the Impact of HIV on Life Expectancy

Comment

These three issues are closely related, but luckily the middle ground for most people reduces the urgency of each extreme viewpoint, which should be informed by data from well designed studies.

ART clearly increases life expectancy for all groups, and this may be normalised in people without late diagnosis, complicated HIV histories, comorbidities or injecting drug use, especially if CD4 count return to >500 on treatment. Whether any additional health benefit is derived for people starting treatment at much higher CD4 counts is only likely to be adequately answered by START and its critical substudies.¹⁴

The largest impact on population mortality is more likely to come from reducing modifiable risk factors including earlier diagnosis and access to care and reducing risks associated with IDU.

References

Unless stated otherwise, references are to the Programme and Abstracts of the 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012, published as a supplement to Journal of the International AIDS Society 2012, 15 (Suppl 4).

1. Saag M. When to start: as soon as possible. 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012. Oral abstract O112.
2. Lundgren J. When to start: not so fast. 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012.Oral abstract O113.
3. High KP et al. HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group. JAIDS: 1 July 2012, Volume 60 -- Supplement 1.
4. Justice A et al. Aging with HIV: one size does not fit all. 19th Conference on Retroviruses and Opportunistic Infections, 5-8 March 2012, Seattle. Oral abstract 175. Webcast.
5. Reiss P. HIV, co-morbidity and ageing. 11th Intl Congress, Glasgow, 2012. Oral abstract O121.
6. Shiels MS et al. Age at Cancer Diagnosis among persons with AIDS in the U.S. Ann Intern Med 2010:153:452-460.
7. Schouten J et al. Comorbidity and ageing in HIV-1 infection: the AGEhIV Cohort Study. 19th IAS Conference, Washington, 2012. Abstract THAB0205.
8. Sabin C. Review of life expectancy in people with HIV in settings with optimal ART access: what we know and what we don't. 11th International Congress on Drug Therapy in HIV Infection, 11-15 November 2012. Oral abstract O131.
9. Antiretroviral Therapy Cohort Collaboration (ART-CC). Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;372:293-299.
10. May M et al. Impact of late diagnosis and treatment on life expectancy in people with HIV-1: UK Collaborative HIV Cohort (UK CHIC) Study. BMJ 2011;343: doi: 10.1136/BMJ.d6016.
11. Nakagawa F et al. Projected life expectancy of people with HIV according to timing of diagnosis. AIDS 2012; 26:335-43.
12. Losina E. Racial and Sex Disparities in Life Expectancy Losses among HIV-Infected Persons in the United States: Impact of Risk Behavior, Late Initiation, and Early Discontinuation of Antiretroviral Therapy. Clin Infect Dis 2009; 49:1570-8.
13. Lewden C. All-cause mortality in treated HIV-infected adults with CD4 ≥500/mm³ compared with the general population: evidence from a large European observational cohort collaboration. Collaboration of Observational HIV Epidemiological Research Europe (COHERE) in EuroCoord. Int J Epidemiol 2012; 41:433-45. April 2012. Epub 28 Nov 2011.
14. Strategic Timing of AntiRetroviral Treatment (START) study.

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