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

Abstract

Background: Most persons with human immunodeficiency virus (HIV) infection in the United States present to care with advanced disease, and many patients discontinue therapy prematurely. We sought to evaluate sex and racial/ethnic disparities in life-years lost as a result of risk behavior, late presentation, and early discontinuation of HIV care, and we compared these survival losses for HIV-infected persons with losses attributable to high-risk behavior and HIV disease itself.

Methods: With use of a state-transition model of HIV disease, we simulated cohorts of HIV-infected persons and compared them with uninfected individuals who had similar demographic characteristics. We estimated non-HIV-related mortality with use of risk-adjusted standardized mortality ratios, as well as years of life lost because of late presentation and early discontinuation of antiretroviral therapy (ART) for HIV infection. Data from the national HIV Research Network, stratified by sex and race/ethnicity, were used for estimating CD4+ cell counts at ART initiation.

Results: For HIV-uninfected persons in the United States who have risk profiles similar to those of individuals with HIV infection, the projected life expectancy, starting at 33 years of age, was 34.58 years, compared with 42.91 years for the general US population. Those with HIV infection lost an additional 11.92 years of life if they received HIV care concordant with guidelines; late treatment initiation resulted in 2.60 additional years of life lost, whereas premature ART discontinuation led to 0.70 more years of life lost. Losses from late initiation and early discontinuation were greatest for Hispanic individuals (3.90 years).

Conclusions: The high-risk profile of HIV-infected persons, HIV infection itself, as well as late initiation and early discontinuation of care, all lead to substantial decreases in life expectancy. Survival disparities resulting from late initiation and early discontinuation of therapy are most pronounced for Hispanic HIV-infected men and women. Interventions focused on risk behaviors, as well as on earlier linkage to and better retention in care, will lead to improved survival for HIV-infected persons in the United States.

Figure 1

Model-generated survival curves from seroconversion for four different population groups: 1) HIV-infected patients receiving “actual use” ART; 2) HIV-infected patients receiving guideline-concordant care; 3) HIV-uninfected persons with risk profiles similar to HIV-infected persons; 4) a general population of HIV-uninfected persons. Time denotes years from the time of seroconversion; mean age at seroconversion is 33.0 years [23]. See Methods. ART: antiretroviral therapy

Figure 2

Change in potential life expectancy for women, depending on the CD4 count at the time of antiretroviral therapy initiation and rate of discontinuation associated with White women. Estimated life expectancy for White women (from age 33.0) after adjusting for excess risk due to risk behavior prevalent for HIV-infected persons is 19.56 years.