Changes in the risk of death after HIV seroconversion compared with mortality in the general population

Context Mortality among human immunodeficiency virus ( HIV) - infected individuals has decreased dramatically in countries with good access to treatment and may now be close to mortality in the general uninfected population. Objective To evaluate changes in the mortality gap between HIV- infected individuals and the general uninfected population. Design, Setting, and Population Mortality following HIV seroconversion in a large multinational collaboration of HIV seroconverter cohorts ( CASCADE) was compared with expected mortality, calculated by applying general population death rates matched on demographic factors. A Poisson- based model adjusted for duration of infection was constructed to assess changes over calendar time in the excess mortality among HIV-infected individuals. Data pooled in September 2007 were analyzed in March 2008, covering years at risk 1981- 2006. Main Outcome Measure Excess mortality among HIV- infected individuals compared with that of the general uninfected population. Results Of 16 534 individuals with median duration of follow- up of 6.3 years ( range, 1 day to 23.8 years), 2571 died, compared with 235 deaths expected in an equivalent general population cohort. The excess mortality rate ( per 1000 person- years) decreased from 40.8 ( 95% confidence interval [ CI], 38.5- 43.0; 1275.9 excess deaths in 31 302 person- years) before the introduction of highly active antiretroviral therapy ( pre- 1996) to 6.1 ( 95% CI, 4.8- 7.4; 89.6 excess deaths in 14 703 person- years) in 2004- 2006 ( adjusted excess hazard ratio, 0.05 [ 95% CI, 0.03- 0.09] for 2004- 2006 vs pre- 1996). By 2004- 2006, no excess mortality was observed in the first 5 years following HIV seroconversion among those infected sexually, though a cumulative excess probability of death remained over the longer term ( 4.8% [ 95% CI, 2.5%- 8.6%] in the first 10 years among those aged 15- 24 years). Conclusions Mortality rates for HIV- infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy. In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.