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Trends in causes of death in people with HIV across 24 years

When used as directed, HIV treatment (antiretroviral therapy; ART) is highly effective. Researchers increasingly expect that many ART users will have near-normal life expectancy.

To better understand factors that can reduce life expectancy in people with HIV who use ART, a team of researchers in North America and Western Europe pooled their data collected between 1996 and 2020.

Among nearly 190,000 people studied, nearly 9% died. Over the course of the 24-year study, the overall risk of death decreased for most participants. Initially, the most common cause of death was from complications related to AIDS. However, such deaths fell markedly over the course of the study, and deaths from heart disease and cancers (unrelated to HIV or liver issues) increased.

Troublingly, deaths from complications related to drug use rose among participants from North America. Women who injected drugs were at heightened risk for dying compared to men who injected drugs.

The researchers recommended interventions to improve the health of people with HIV so that the benefits of ART can be experienced more equitably across different populations.

Study details

Researchers analysed data from 189,301 people with HIV. All participants entered the study when they began to use ART and their average profile at that time was as follows:

  • 77% men, 23% women
  • 37 years old
  • 19% had AIDS
  • 8% tested positive for antibodies to hepatitis C virus (HCV), indicating that they had been exposed to it

Results

Over the course of the study, 16,832 people (9%) died.

The most common causes of death were as follows:

  • AIDS-related complications – 25%
  • cancer unrelated to AIDS or hepatitis – 14%
  • heart disease – 8%

Note that data on the cause of death among 22% of participants was missing.

Trends in time

During the study, deaths from AIDS-related causes fell from nearly 50% in the period from 1996 to 1999 to 19% in the period from 2016 to 2020.

For certain populations—gay, bisexual and other men who have sex with men (gbMSM), heterosexual men and women who acquired HIV via sexual contact—the risk of death fell markedly.

Among men who acquired HIV via sharing equipment for drug use, the risk of death fell modestly.

Among women who injected drugs, the risk of death increased over time. Lung infections as a cause of death in these women increased over time.

People who were co-infected with HCV had a smaller decline in their risk of death than people who were not co-infected with this virus.

The importance of high CD4+ cell counts

In general, researchers found that people who had high CD4+ cell counts (from using ART) were less likely to die than people with lower CD4+ cell counts.

North America vs. Europe

Declines in the risk of death were generally greater for people living in North America than in Western Europe. An exception to this trend was as follows: People from North America who used drugs had an increased risk of death over time compared to people from Western Europe who used drugs. Researchers suggested that the reasons for this difference in the risk of death were as follows:

  • increased rates of opioid use in North America
  • increased risk of drug poisoning in North America
  • greater use of opioid substitution therapies (buprenorphine and methadone) in Western Europe

The researchers lacked access to important socioeconomic data such as the following:

  • levels of education
  • income
  • housing status

Such factors could have affected the survival of participants.

Women’s lives and what is needed

Carole Seguin-Devaux, PhD, a scientist at the Luxembourg Institute of Health, reviewed the study’s findings and commented in the journal Lancet HIV that “women who inject drugs are at increased risk of HIV because they face barriers in accessing harm reduction services and endure higher levels of stigma, discrimination, incarceration and gender-based violence than men.”

She encouraged health authorities to fund “evidenced-based harm reduction programmes” to help people who use drugs.

—Sean R. Hosein

REFERENCES:

  1. Trickey A, McGinnis K, Gill MJ, et al. Longitudinal trends in causes of death among adults with HIV on antiretroviral therapy in Europe and North America from 1996 to 2020: a collaboration of cohort studies. Lancet HIV. 2024 Jan 24: S2352-3018(23)00272-2.
  2. Seguin-Devaux C. HIV and people who inject drugs: inequality until death. Lancet HIV. 2024 Jan 24: S2352-3018(23)00295-3. 
  3. Krentz HB, Lang R, McMillan J, et al. The changing landscape of both causes and locations of death in a regional HIV population 2010-2021. HIV Medicine. 2024; in press.