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Survival Improvement with ART — Not Only for the Developed World

Summary and Comment |
May 6, 2013

Survival Improvement with ART — Not Only for the Developed World

  1. Helmut Albrecht, MD

ART was associated with improved survival in a large South African study, but retention in care and sustainability remain challenges to long-term success.

  1. Helmut Albrecht, MD

The use of potent combination antiretroviral therapy (ART) has dramatically reduced the morbidity and mortality associated with HIV infection. In the developed world, the age-adjusted average life expectancy of patients living with HIV is now estimated to be close to that of their uninfected peers. Although similar improvements have been shown in studies conducted in low-income countries, population-based data on ART's mortality benefit in such settings have been scarce.

To fill this void, researchers studied the life expectancy of HIV-infected adults from six cohorts in South Africa who initiated ART between March 2001 and February 2010 (N=37,740). Using survival modeling, they calculated excess mortality attributable to HIV.

Life expectancy for HIV-infected patients on ART was approximately 80% of the normal expectancy, but varied by age at ART initiation, baseline CD4-cell count, and sex: Younger age at initiation, higher baseline CD4-cell count, and female sex were associated with the greatest mortality benefit. Patients who survived the first 24 months after starting ART had a 15% to 20% higher life expectancy than patients of the same age who just started therapy.

Comment

These findings convey an encouraging message: ART scale-up in the developing world is working. Although this fact may not be surprising to most experts involved, the implications are huge: More than 90% of new HIV infections globally are in developing countries. The results should benefit the efforts of policy makers and global financial planners to sustain — or, preferably, increase — the support for such programs.

Although ART clearly improved the life expectancy of HIV-infected patients in South Africa, not all the news is good. More than one third of the patients were lost to follow-up, which is disturbing, given the benefit that ART was seen to provide in this setting. Furthermore, patients initiating therapy late — whether due to late diagnosis or intentional delay — showed significantly less benefit.

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