Patients taking antiretroviral therapy have the same
mortality risk as individuals in the general population, according to Danish
research published in the open-access journal PLoS One. However, this was only the case when the patients
responded to treatment and did not have other factors that increased the risk
of serious illness and death, such as co-infections or co-morbidities, or drug and alcohol misuse.
“Mortality was associated mainly with well-known HIV and
non-HIV-associated risk factors which are identifiable prior to or in the
initial phase of HAART [highly active antiretroviral therapy] treatment,”
comment the investigators. “Mortality in HIV-infected patients with no identifiable
risk factors was almost identical to that of the general population with no
Effective antiretroviral therapy means that many
HIV-positive patients have an excellent prognosis. Nevertheless, numerous
studies have shown that the overall mortality risk of patients treated with
anti-HIV drugs is still higher relative to that observed in the general
A number of reasons for this have been proposed including
HIV-related illness, co-infections, lifestyle issues, treatment side-effects
and accelerated ageing.
Danish investigators wanted to establish a better
understanding of this important question.
They therefore designed a study with two aims. The first was
to establish the impact on mortality of risk factors that could be identified
at the time HIV treatment was started. The second was to estimate the relative
risk of death for patients with and without such factors when compared to age-
and sex-matched controls from the general population.
The study population comprised 2267 people aged between 25 and 65
who started HIV therapy between 1998 and 2010. The medical records of each
patient were checked to see if they had risk factors that could increase the
risk of death. These were divided into three broad categories:
Each patients was matched with four HIV-negative controls
from the general population.
Patients aged between 45 and 65 who had a good response to
antiretroviral treatment and who did not have any co-morbidities/co-infections
or drug/alcohol problems had a mortality risk ratio (MRR) of 1.14, comparable
to that observed in the control population. The risk was somewhat higher for
younger patients (25 to 45) who were doing well on therapy, but who had no
additional risk factors (MRR = 2.02).
However, the risk of death was increased between four-fold
and 20-fold for patients with either co-morbidities/co-infections or problems with drug/alcohol use.
“Increased risk of death was observed only in patients
registered with one or more risk factors in the initial phase of HAART
treatment,” emphasise the authors.
Individuals in the control group had an 88% probability of
surviving until they were 65. The overall chance of survival to this age for
patients with HIV was much lower at only 48%.
However, the probability of survival was massively affected
by the presence of identifiable risk factors.
Patients with poor response to HIV therapy had a 58% chance
of surviving until 65 years of age. This fell to 30% for patients with
co-morbidities or co-infections, and to just 3% in those with high levels of drug or alcohol use.
In contrast, patients with none of these risk factors had a
chance of survival to age 65 that was comparable to that seen in the general
population (86 vs 88%).
“As we did not observe substantially increased mortality
among HIV patients without risk factors, our data does not support the theory
of premature ageing,” write the authors. “Rather, the data establish that the
increased risk of death in the HIV population mainly stems from classic risk
They conclude: “Future management of the HIV-infected
population should focus on early diagnosis, timely and effective HAART, and
treatment of co-morbidity and alcohol/drug abuse.”
The authors also believe that it is important to give
patients optimistic and accurate information about their potential prognosis,
commenting: “Stressing the impact of HIV on mortality after HAART initiation
may severely hamper the patients’ quality of life and be at odds with present data.”