Introduction of highly active antiretroviral therapy (HAART) in the mid-1990s brought significant improvement in the survival of people living with diagnosed HIV infection (PLWDH). Previous estimates of survival or life expectancy after HIV diagnosis showed an increase from 10.5 years in 1996 to 22.5 years in 20051 among people who were diagnosed with an HIV infection during that period. As treatments have evolved further, it is plausible that life expectancy after an HIV diagnosis has improved since the last estimates. Survival and life expectancy are also important measures to determine disparities in HIV care and treatment outcomes and contribute to monitoring national objectives to reduce disparities and HIV-related mortality set by National HIV/AIDS Strategy and the Healthy People 2020.2,3 Another quantitative measure of changes in life expectancy is the average years of life lost (AYLL), after a change in health status, such as diagnosis of a disease. The AYLL (also called potential years of life lost) is an estimate of the number of years of life “lost” because of premature mortality occurring in a person with a certain health condition. At the population level, in HIV's context, AYLL represent the average number of additional years a person living with diagnosed HIV would have lived if that person had not died prematurely.4 The knowledge of AYLL can be useful in drafting legislation and resource allocation, and serve as a measure of an individual's disease burden for improving planning for clinical care.5
Although some estimates of mortality and life expectancy are available,6–11 the studies were either performed outside the United States or on a subset of PLWDH, such as those receiving care at a particular health care facility, and therefore did not represent large population-based estimates of life expectancy. The only large surveillance data–based estimates of life expectancy available from the United States1 covered PLWDH, with HIV diagnosed by year 2005 and included data from only 25 states. With advancements in treatment and the potential impact on life expectancy after HIV diagnosis, these estimates need to be updated with new and more recent data representing the entire country.
We used National HIV Surveillance System (NHSS) data from all 50 states and Washington, D.C. to estimate the life expectancy among people who were diagnosed with an HIV infection during 2008–2011. We also estimated AYLL in the year 2010 by comparing the life expectancy estimates generated by our analysis with the life expectancy of the general US population for that year.
As part of NHSS, all states and the District of Columbia have reported cases of AIDS to the Centers for Disease Control and Prevention (CDC) since the early 1980s. Starting in 1994, jurisdictions that adopted confidential name-based HIV surveillance started reporting cases of HIV infection to the CDC. By April of 2008, all 50 states and the District of Columbia had implemented confidential name-based HIV surveillance. In this analysis, NHSS data from the entire country were used to estimate the life expectancy after HIV diagnosis among adults and adolescents (≥13 years of age) during 2008–2011. All data reported to the CDC through June 2013 were used. This allowed for a minimum period of 18 months for reporting deaths occurring by the end of 2011. All deaths, irrespective of cause, among people with diagnosed HIV infection were included in this analysis, and data were adjusted for reporting delays and missing risk factors.12,13
Following National Center for Health Statistics' approach, we modeled life expectancy after HIV diagnosis using the period life table method14 that is based on the mortality experience of a hypothetical cohort and assumes that the age-specific death rates remain unchanged in future years. This means that persons who will be in a given age bracket in the future will experience the same age-specific death rates as the one experienced by persons currently in that age bracket. We used an exponential model for estimating age-specific death rates, in which the death rates within 1 year after diagnosis of HIV and deaths rates more than 1 year after diagnosis were estimated separately because the death rates in the 2 time periods are quite different.15
We estimated overall life expectancy in each of the 4 years of diagnosis (2008–2011) and by selected characteristics of interest that included sex at birth, race/ethnicity, HIV stage at diagnosis, and HIV transmission category. Race/ethnicity was categorized into 4 categories: black/African American (hereafter referred to as black), Hispanic/Latino, white, and “other races” representing a cumulative category for all minority races/ethnicities other than blacks and Hispanics/Latinos. HIV stage at diagnosis was categorized into 2 categories: stage 3 [AIDS] vs. other that included persons whose stage at diagnosis was unknown. We also estimated life expectancy separately for males and females by the 4 HIV transmission categories among males [male-to-male sexual contact, injection drug use (IDU), male-to-male sexual contact and IDU, and heterosexual contact] and by the 2 transmission categories among females (IDU and heterosexual contact).
We estimated AYLL by sex and by the age at HIV diagnosis, by subtracting the estimated life expectancy of the person with an HIV diagnosis from the life expectancy of an individual of the same age and sex in the general population in 2010, using National Center for Health Statistics vital statistics data for 2010.14
In the 4 years from 2008 to 2011, an estimated total of 184,749 persons were diagnosed with HIV in the United States. The total number of diagnoses each year decreased from 2008 through 2011. This decrease was also observed across both sexes, most races/ethnicities, and by the stage of disease at diagnosis. However, the distribution of diagnoses by sex, race/ethnicity, and stage at diagnosis remained similar across the years. By transmission category, a similar decline was observed except among males with infection attributed to male-to-male sexual contact [hereafter referred to as men who have sex with men (MSM)], which showed a slight increase (<2%) in numbers from 2008 to 2011 (Table 1).
In the 4-year period from 2008 to 2011, the overall average life expectancy after HIV diagnosis in the United States increased by 3.43 years from 25.43 (95% CI: 25.37 to 25.49) in 2008 to 28.86 (95% CI: 28.80 to 28.92) in 2011, representing a 13.5% increase over the 4-year period with an average and fairly steady increase of approximately 4.5% per year. Life expectancy in each of the 4 years represented a statistically significant increase from the previous year, as determined by the nonoverlapping 95% CIs. Although improvements were observed in both sexes, the life expectancy was better for males than for females. In each year from 2008 to 2011, males generally had a higher life expectancy than females and also experienced a larger increase in life expectancy (3.64 years) compared with females (2.64 years). Persons with late-stage disease at diagnosis (stage 3 [AIDS]) had a life expectancy that was on average 6.6 years lower than that for persons with HIV not classified as stage 3. This pattern and the magnitude of difference were consistent across all 4 years (Table 2).
By race/ethnicity, Hispanics/Latinos had a longer life expectancy than any other race/ethnicity throughout 2008–2011 (Table 2). The lowest life expectancy in 2008 was observed in blacks (23.68), whereas other races (minorities other than blacks and Hispanics/Latinos) had the lowest life expectancy in years 2009–2011. The largest difference between any 2 races/ethnicities was observed in 2010, when Hispanics/Latinos had a life expectancy 5 years longer than other races. The difference between life expectancies of Hispanics/Latinos and blacks that was 4.59 years in 2008 shrank steadily over the 4-year period to 2.34 years in 2011. When comparing whites with blacks, similar shrinking of difference with an eventual reversal was observed. In the year 2008, whites experienced 2.02 years longer life expectancy than blacks. However, this difference consistently reduced in the following years to 0.46 years in 2010 and eventually reversed to 0.68 years, favoring blacks (Table 2). Although all races/ethnicities experienced an improvement in life expectancy in the years 2008–2011, blacks experienced the largest gain (4.78 years), followed by Hispanics/Latinos (2.52 years), whites (2.08 years), and other races (1.42 years). Percent wise, blacks' life expectancy increased by 20.2%, Hispanics/Latinos by 8.9%, whites by 8.1%, and other races by 5.8% (Table 2).
By transmission category, among males, in each year from 2008 to 2010, the longest life expectancy was observed among MSM, followed by males with infection attributed to male-to-male sexual contact and IDU, heterosexual contact, and finally IDU (Table 2). In 2011, life expectancy of MSM (32.30, 95% CI: 32.22 to 32.39) was 12.06 years (60%) higher than the life expectancy of males with infection attributed to IDU (20.24, 95% CI: 20.0 to 20.48). Among females, in each of the 4 years, life expectancy was higher among those with infection attributed to heterosexual contact compared with those with infection attributed to IDU. In 2011, females with infection attributed to heterosexual contact had a life expectancy of 27.90 (95% CI: 27.75 to 28.05) vs. 21.36 (95% CI: 21.08 to 21.64) among females who inject drugs. This represents a 6.54 years (31%) higher life expectancy in females with infection attributed to heterosexual contact than females whose HIV infection was attributed to IDU. Persons in all transmission categories and both sexes experienced significant increases in life expectancy from 2008 to 2011. Percent wise, from 2008 to 2011, the largest (14.2%, 2.66 years) and smallest (7.6%, 1.96 years) increases were among females with infection attributed to IDU and heterosexual contact, respectively. Among males, increases of 13.4% (2.39 years), 12.8% (3.00 years), 12.7% (2.65 years), and 10.2% (3.00 years) were observed in males with infection attributed to IDU, male-to-male sexual contact and IDU, heterosexual contact, and male-to-male sexual contact, respectively (Table 2). Although overall, females had a lower life expectancy than males; when limited to either IDU or heterosexual contact, the life expectancy among females was longer than that among males. Females who injected drugs had 1–2 years longer life expectancy than males who injected drugs, whereas the life expectancy among females with HIV infection attributed to heterosexual contact was approximately 4–5 years longer than males with infection attributed to heterosexual contact.
Using the life expectancy in the general population by age, sex, and race as reference, in 2010, the AYLL were 12.80 years for males and 16.53 years for females. At ages 20, 40, 60, and 80 years, males who were diagnosed with an HIV infection in 2010 had AYLL of 17.57, 14.14, 10.35, and 6.16 years, respectively. For females diagnosed with HIV infection in 2010, at ages 20,40, 60, and 80 years, the AYLL were 24.53, 18.29, 12.08, and 7.31 years, respectively. By race/ethnicity, on average, blacks (13.26 years) and whites (13.43 years) had fewer AYLL than Hispanic/Latinos (14.72). Life expectancy along with AYLL, among persons diagnosed with HIV infection in year 2010 at 5-year age intervals and sex are presented in Table 3. Estimated AYLL at age at diagnosis in 2010, by sex and by race/ethnicity are graphically presented in Figures 1 and 2, respectively.
The life expectancy of people who were diagnosed with an HIV infection during 2008–2011 presented in this article represents the first estimates using data from all 50 US states and the District of Columbia. The results show that the life expectancy improved over the 4-year interval 2008–2011 for all populations from 25.43 years in 2008 to 28.86 years in 2011, representing an increase in life expectancy of 3.43 years or 13.5%. Although similar life expectancy estimates have been reported by other studies in the era of HAART,9,16 the direct comparison of results is difficult because the published estimates in contemporary literature show a large variation because of varying methodologies, time spans studied, and populations of interest. Our results also indicate that during 2008–2011, the life expectancy for persons diagnosed with HIV infection has continued to improve since the publication of last estimates using more limited HIV surveillance data from 25 states that compared pre- and post-HAART eras.1
MSM consistently had longer life expectancy than persons with HIV infection attributed to any other transmission category and on average expected to live more than a decade longer than persons with HIV infection attributed to IDU, who in turn had a worse life expectancy than persons in any other transmission category, consistent with earlier findings.17 The high mortality among persons who inject drugs may be due to other risk factors related to IDU that lead to premature mortality, such as cigarette smoking, comorbidities, drug overdose, and barriers to accessing HIV care and medications. A recent study found that among a cohort of approximately 18,000 HIV-infected individuals, smokers had higher mortality than nonsmokers (mortality rate ratio; 1.94, 95% CI: 1.56 to 2.41).18,19 Persons who inject drugs are also more likely to have other comorbidities, such as hepatitis-C infection and mental illnesses, and also face health care access challenges.20–23 A study in New York City found that among HIV-HCV coinfected individuals, 60% had their infection attributed to IDU.22 In addition, the role of social determinants of health such as low education, high poverty, and discrimination in and low access to and poor retention in health care that negatively affect life expectancy cannot be ruled out.24–28 All these factors have been shown to have an association with IDU.29–31
Life expectancy of females was lower than that of males, and because life expectancy of females in the general population is longer than that of males, the AYLL for females in 2010 were higher than that for males at all ages at diagnosis. We found that in 2011, the life expectancy of younger females (<40 years at HIV diagnosis) was less than that of males that were the same age at HIV diagnosis. However, this pattern reversed in older age groups, where females who were 40 years of age or older at HIV diagnosis had slightly better life expectancy than men who were diagnosed at age 40 or older. Because men with infection attributed to male-to-male sexual contact have longer life expectancy than men with infection attributed to other causes and because a large proportion of HIV-infected MSM are diagnosed at a young age,32 it helps explain the better life expectancy seen among males in the younger age groups. This explanation is further supported by the fact that when comparisons across sex are made within the transmission categories common to both sexes, ie, IDU and heterosexual contact, females have longer life expectancy than males (Table 2).
Hispanics/Latinos had higher AYLL in 2010 than either blacks or whites, and the difference between Hispanics and whites, and Hispanics and blacks increased slightly with increasing age at diagnosis until about age 50 and then reduced a little as age at diagnosis pushed into older years (Fig. 2). Hispanics/Latinos are more likely to enter care late and are more likely to discontinue treatment than whites,33,34 which helps explain the higher AYLL among Hispanics/Latinos infected with HIV. Although life expectancy of blacks in the general population is slightly lower than that of whites, and blacks with diagnosed HIV have a higher rate of death than whites diagnosed with HIV, the life expectancy of the 2 groups was similar, with blacks showing a slightly longer life expectancy than whites in 2011. The apparent paradox is explained by the fact that HIV tends to be diagnosed at an earlier age in blacks as compared with whites. Indeed, among persons diagnosed with HIV in 2011, among blacks, 27.4% were diagnosed before reaching 25 years of age, and 53.4% were diagnosed before age 35. The percentages among whites were 13.6 and 39.8, respectively.35
The results of these analyses can be a useful resource for clinicians and policy makers. They can guide patient-provider communications on prognoses and expectations after an HIV diagnosis; whereas policy makers may find these results to be a useful guide for estimating costs for care and resource allocation.
Our estimates' biggest strength is that they are based on data from the entire country with documented high completeness of reporting, instead of a subsample of states. However, there still are a few limitations of our analysis. Not all HIV diagnoses may have been included, as some states offer anonymous HIV testing, which are not reported to HIV surveillance. In addition, persons who are HIV infected, but not yet diagnosed, are also not included in the surveillance data. However, these factors are unlikely to have a significant impact on our estimates because it has been estimated that HIV-infected, yet undiagnosed, persons make up only approximately 12.8% of the total persons infected with HIV in the United Sates.36
Another limitation of our estimates is that we did not take into account the influence of comorbidities, HIV treatment, and viral load suppression status, all of which influence mortality and thus the life expectancy. Also, some deaths among persons with HIV may not yet have been reported to surveillance. Therefore, our estimates could be an overestimate or underestimate of the true life expectancy after HIV diagnosis. However, we do not expect any systematic association with any of the factors that can lead to net overestimation or underestimation of life expectancy. For this reason and because we used a very large data set covering the entire country with high degree of completeness, we expect our estimates to be reliable estimates.
In summary, our analysis shows that the persons diagnosed with an HIV infection during 2008–2011, experience better life expectancy than those diagnosed in previous years and that the life expectancy continued to improve during 2008–2011, with consequent reduction in AYLL, overall, and across all sex, race, and transmission categories. However, the life expectancy of PLWDH still remains shorter than the life expectancy of the general population of the United States. While further improvements in the life expectancy of HIV-infected persons are possible as treatment regimens continue to evolve, with improvements, other factors (eg, early diagnosis, availability and access to treatment, adherence to treatment, side effects of antiretroviral therapy, etc.) come to play a greater role in determining the period one can expect to live after an HIV diagnosis.37–40 Our analysis demonstrates that the life expectancy after HIV diagnosis has continued to improve in the HAART era. Because the proportion of persons living with HIV who know their status (ie, diagnosed) continue to increase and the access to HAART and adherence to treatment continue to improve, more accurate estimates should be generated in the future for continued monitoring of the progress of the status of the disease. Not all subgroups show similar improvements in life expectancy; therefore, individualized treatment plans, taking into consideration the actual needs and challenges of each subgroup, can help improve life expectancy in these subgroups and reduce disparities.
We thank the HIV surveillance staff in all jurisdictions within the United States for their efforts in collection of data used in this article.
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