高效联合抗逆转录病毒疗法的问世，使艾滋病的相关死亡率大幅下降并延长生存期。HIV感染者由于各种慢性非HIV相关的合并症，仍面临更大的风险，但对于那些在最佳时期开始治疗的感染者和对HIV病毒的长期抑制的感染者来说，这种风险会降低。

    来自于英国哥伦比亚艾滋病卓越中心的Hasina Samji和北美艾滋病人群研究的研究员，评价了从2000年至2007年在美国和加拿大的采用抗逆转录病毒疗法的HIV阳性感染者的预期寿命随时间变化的情况。

    该分析包括22,937名感染者，他们年龄均在20岁以上，并采用包括至少3种药物的联合抗逆转录病毒疗法。他们之前并未使用抗逆转录病毒疗法，也并未采用次优疗法如核苷类似物单一疗法进行治疗。受试者约四分之三为男性，38％是白人，39％是男男性行为者，20％有注射吸毒史，约70％的感染者治疗前CD4 T细胞计数低于350个/mm3。抗逆转录病毒疗法开始时，20-34岁感染者占比为25％，35-44岁感染者占比为42％，45-54岁占比为25％，55岁以上占比为8％。

    受试者的随访调查从2000年1月1日开始，或从抗逆转录病毒疗法开始，直至死亡、随访失败，或至2007年12月31日结束。20岁人的预期寿命是指一个人预期能够继续生存的平均年数，如果研究期间按年龄的死亡率保持不变，可以使用简略生命表格对其进行评估。

结果

·        总体而言，在每年随访的82,022人中有1622人死亡。

·        粗死亡率为19.8/1000人-年

·        同性恋/双性恋男性死亡率为12.5/1000人-年，注射吸毒者为34.5/1000人-年，白人为16.0/1000人-年，非白人为22.4/1000人-年，CD4 细胞计数低于350个/mm3的感染者为23.3/1000人-年，那些较高的CD4细胞计数者为11.3/1000人-年。

·        20岁人的整体未加权的平均预期寿命在2000至2002年间从36.1年增加到2003-2004年间的45.2年，在2006-2007年间增加至51.4年。

·        对比加拿大和美国20岁普通人的平均预期寿命，男性分别为59.7年和57.0年，女性分别为63.9年和61.7年。

·        除2006-2007年（男性和女性平均预期寿命分别为53.4年和47.3年）以外，各个时期的HIV男性和女性感染者有着类似的平均预期寿命。

·        非白人感染者、注射吸毒史的感染者和那些CD4细胞计数小于350个/mm3的感染者，他们的平均预期寿命较低。

·        2006-2007年期间，这些组的平均预期寿命分别为48.4年, 28.8年和46.9年。

    “在美国或加拿大,一名接受抗逆转录病毒疗法的20岁HIV阳性的成年人有望活到70岁，其平均预期寿命可以接近普通人群，”该研究的作者得出结论。“根据性别、种族、HIV病毒感染高危人群以及CD4细胞计数的不同,结果存在一定的差异。”

    “由于从人口统计学，临床和行为特征角度看，许多HIV感染者比一般人群发病率和死亡率高，所以预期寿命的差别可能是由于他们的其他生活方式，而不仅仅是HIV感染，”他们在讨论中补充到。

    “平均预期寿命在性别方面无显著性差异，事实上在我们的研究中，近期男性的平均预期寿命较长，表明平均预期寿命存在性别差异，”研究人员继续说到，正如在高收入国家，妇女寿命一般比男性长。他们说，这可能是由于女性抗艾滋病病毒治疗比较晚​​或有注射吸毒史的女性比例较高。

    平均预期寿命在种族和注射吸毒史方面存在差异，“这可能反映出经济条件、能否得到医治和医疗保险体系的差异，也表明迫切需要一些有关的政策和方案来阻止这些不公平，”他们写到。不过，他们指出，白人和非白人感染者的预期寿命差距有较大幅度下降，由2000-2002年的23年降为2006-2007年的8.5年。

    他们还指出，CD4细胞计数较高的感染者平均预期寿命较长，这“也许是由于他们从早期抗逆转录病毒疗法中得到更多的支持。”

    作者警告说，这些研究结果只适用于联合抗逆转录病毒疗法有效的感染者，而不是较早的次优治疗方案的感染者，同时研究结果也不包括高死亡风险却不愿意寻求治疗的感染者。

    最后，他们承认“由于HIV阳性的成年人的年龄相关性合并症风险的增加，所以未来平均预期寿命可能平稳或下降，”“随着HIV感染者增加，这对于监测和评估平均预期寿命将是很重要的。”

2013年12月23日

参考文献

H Samji, A Cescon, RS Hogg, et al (NA-ACCORD).Closing the Gap:Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada.PLoS ONE 8(12): e81355.December 18, 2013.

其他参考

Public Library of Science.Life expectancy increases among treated HIV-positive individuals in US and Canada.Press release.December 18, 2013.

HIV+ People on ART May Match General Population Life Expectancy   

Young adults with HIV in high-income countries who take effective antiretroviral therapy (ART) may live nearly as long as HIV negative people in the general population, according to findings from the NA-ACCORD collaboration published in the December 18, 2013, edition of PLoS ONE.

The advent of effective combination ART has led to a dramatic decline in AIDS-related mortality and increased survival. People with HIV remain at greater risk for a variety of chronic non-AIDS conditions, but this may be reduced among those who start optimal treatment early and maintain long-term viral suppression.

Hasina Samji from the British Columbia Centre for Excellence in HIV/AIDS and fellow investigators with the North American AIDS Cohort Collaboration on Research and Design estimated temporal changes in life expectancy among HIV positive adults on ART from 2000 to 2007 in the U.S. and Canada.

The analysis included 22,937 participants who were at least 20 years of age and taking combination ART consisting of at least 3 drugs. They were treatment-naive at ART initiation and had not previously used suboptimal therapy such as nucleoside analog monotherapy. About three-quarters were men, 38% were white, 39% were men who have sex with men, 20% had a history of injection drug use, and about 70% had a pre-treatment CD4 T-cell count below 350 cells/mm³. At ART initiation 25% were age 20-34, 42% were 35-44, 25% were 45-54, and 8% were older than 55.

Participants were followed from January 1, 2000 or ART initiation until death, loss to follow-up, or December 31, 2007. Life expectancy at age 20 -- defined as the average number of additional years a person would be expected to live -- was estimated using abridged life tables assuming age-specific mortality rates in effect during the study period remained constant.

Results

·        Overall, 1622 deaths occurred during 82,022 person-years of follow-up.

·        The crude mortality rate was 19.8 per 1000 person-years.

·        Mortality rates were 12.5 per 1000 person-years for gay/bisexual men, 34.5 for injection drug users, 16.0 for whites, 22.4 for non-whites, 23.3 for those with <350 cells/mm³ and 11.3 for those with higher CD4 counts.

·        Overall unweighted life expectancy at age 20 increased from 36.1 additional years during 2000-2002 to 45.2 years during 2003-2004 to 51.4 years during 2006-2007.

·        Comparable life expectancy estimates for the general population at age 20 were 59.7 and 57.0 years for men and 63.9 and 61.7 years for women in Canada and the U.S., respectively.

·        Men and women with HIV had comparable life expectancies during all periods except 2006-2007 (53.4 vs 47.3 additional years, respectively).

·        Life expectancy was lower for non-white study participants, people with a history of injection drug use, and those with a baseline CD4 count <350 cells/mm³.   

·        Predicted life expectancy during 2006-2007 for these groups were 48.4, 28.8, and 46.9 additional years, respectively.

"A 20-year-old HIV-positive adult on ART in the U.S. or Canada is expected to live into their early 70s, a life expectancy approaching that of the general population," the study authors concluded. "Differences by sex, race, HIV transmission risk group, and CD4 count remain."

"[G]iven that many individuals living with HIV have demographic, clinical, and behavioral characteristics associated with greater morbidity and mortality than the general population, the gap in life expectancy may be attributable to other lifestyle factors and not just HIV infection," they added in their discussion.

"The absence of significant differences in life expectancy by sex, and the higher life expectancy of men in the latest period suggests that there is in fact a sex differential in life expectancy in our study," the researchers continued, as women in high-income countries generally live longer than men. This may be due to women accessing HIV care later or a higher proportion of women having a history of injection drug use, they suggested.

Differences in life expectancy by race and those related to injection drug use "may be reflective of underlying differences in socioeconomic conditions, access to care, and health insurance coverage, suggesting an urgent need for strategies and programs to combat these inequities," they wrote. However, they noted that the gap in life expectancy between white and non-white participants decreased substantially, from 23.0 years in 2000-2002 to 8.5 years in 2006-2007.

They also noted that the longer life expectancy for people with higher CD4 counts "may lend additional support to the earlier initiation of ART."

The authors cautioned that these findings only apply to people starting with effective combination ART, not older suboptimal regimens, and may under-represent individuals at greatest risk of death who may be less likely to seek care.

Finally, they acknowledged that "due to the increased risk of age-related co-morbidities among HIV positive adults, it is possible life expectancy may plateau or decrease in the future" and "it will be important to monitor life expectancy estimates as more adults age with HIV."

12/23/13

Reference

H Samji, A Cescon, RS Hogg, et al (NA-ACCORD). Closing the Gap: Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada. PLoS ONE 8(12): e81355. December 18, 2013.

Other Source

Public Library of Science. Life expectancy increases among treated HIV-positive individuals in US and Canada. Press release. December 18, 2013.