Life-Expectancy Disparities Among Adults With HIV in the United States and Canada: The Impact of a Reduction in Drug- and Alcohol-Related Deaths Using the Lives Saved Simulation Model

Abstract

Improvements in life expectancy among people living with human immunodeficiency virus (PLWH) receiving antiretroviral treatment in the United States and Canada might differ among key populations. Given the difference in substance use among key populations and the current opioid epidemic, drug- and alcohol-related deaths might be contributing to the disparities in life expectancy. We sought to estimate life expectancy at age 20 years in key populations (and their comparison groups) in 3 time periods (2004-2007, 2008-2011, and 2012-2015) and the potential increase in expected life expectancy with a simulated 20% reduction in drug- and alcohol-related deaths using the novel Lives Saved Simulation model. Among 92,289 PLWH, life expectancy increased in all key populations and comparison groups from 2004-2007 to 2012-2015. Disparities in survival of approximately a decade persisted among black versus white men who have sex with men and people with (vs. without) a history of injection drug use. A 20% reduction in drug- and alcohol-related mortality would have the greatest life-expectancy benefit for black men who have sex with men, white women, and people with a history of injection drug use. Our findings suggest that preventing drug- and alcohol-related deaths among PLWH could narrow disparities in life expectancy among some key populations, but other causes of death must be addressed to further narrow the disparities.

Keywords: HIV; Hispanic adults; black women; drug- and alcohol-related deaths; health disparities; life expectancy; men who have sex with men; people who inject drugs.

Figure 1

A schematic of the Lives Saved Simulation model, an agent-based simulation model that randomly selects 20% of those who died to be “saved” and experience the subsequent mortality risk of their peers, as well as the opportunity to age into older age groups.

Figure 2

Observed increases in life expectancy (LE) at age 20 years among people with human immunodeficiency virus (left column, panels A, C, E, and G), and corresponding changes in disparities in key populations and their comparison groups (right column, panels B, D, F, and H) in the North American AIDS Cohort Collaboration on Research and Design, United States and Canada, 2004–2015. IDU, injection drug use; MSM, men who have sex with men.

Figure 3

Observed (solid lines) life expectancy from the North American AIDS Cohort Collaboration on Research and Design (United States and Canada, 2004–2015) and expected (dashed lines) life expectancy from the Lives Saved Simulation model, after a 20% reduction in drug- and alcohol-related deaths, as well as the proportion of drug- and alcohol-related deaths (bars) among key populations and their comparison groups, including black (purple) compared with white (gray) men who have sex with men (A), black (orange) compared with white (gray) women (B), Hispanic (teal) compared with non-Hispanic (gray) adults (C), and people who have a history of injection drug use (yellow) compared with those who do not (gray) (D). Expected life expectancy after a 20% reduction in drug- and alcohol-related deaths was estimated as the median estimate from 100 simulations using the Lives Saved Simulation model.