Elsevier

The Lancet HIV

Volume 8, Issue 5, May 2021, Pages e266-e273
The Lancet HIV

Articles
Estimated life expectancy gains with antiretroviral therapy among adults with HIV in Latin America and the Caribbean: a multisite retrospective cohort study

https://doi.org/10.1016/S2352-3018(20)30358-1Get rights and content

Summary

Background

There are few data on life expectancy gains among people living with HIV in low-income and middle-income settings where antiretroviral therapy (ART) is increasingly available. We aimed to analyse life expectancy trends from 2003 to 2017 among people with HIV beginning treatment with ART within the Caribbean, central America, and South America.

Methods

We did a multisite retrospective cohort study and included people with HIV who had started treatment with ART and were aged 16 years or older between Jan 1, 2003, and Dec 31, 2017, from Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru, who contributed person-time data from the age of 20 years until date of death, last contact, database closure, or Dec 31, 2017. We used the Chiang method of abridged life tables to estimate life expectancy at age 20 years for three eras (2003–08, 2009–12, and 2013–17) overall and by demographic and clinical characteristics at ART initiation. We used Poisson regression models to weight mortality rates to account for informative censoring.

Findings

30 688 people with HIV were included in the study; 17 491 (57·0%) were from the Haiti site and 13 197 (43·0%) were from all other sites. There were 2637 deaths during the study period: 1470 in Haiti and 1167 in other sites. Crude and weighted mortality rates decreased among all age groups over calendar eras. From 2003–08 to 2013–17, overall life expectancy for people with HIV at age 20 years increased from 13·9 years (95% CI 12·5–15·2) to 61·2 years (59·0–63·4) in Haiti and from 31·0 years (29·3–32·8) to 69·5 years (67·2–71·8) in other sites. Life expectancies at the end of the study period were within 10 years of those of the general population (69·9 years in Haiti and 78·0 years in all other sites in 2018). Disparities in life expectancy among people with HIV by sex or HIV transmission risk factor, CD4 cell count, level of education, and history of tuberculosis at or before ART initiation persisted across calendar eras.

Interpretation

Life expectancy among people with HIV receiving ART has significantly improved in Latin America and the Caribbean. Persistent disparities in life expectancy among people with HIV by demographic and clinical factors at ART initiation highlight vulnerable populations in the region.

Funding

National Institutes of Health.

Translation

For the Spanish translation of the abstract see Supplementary Materials section.

Introduction

As combination antiretroviral therapy (ART) has become increasingly available, life expectancy for people with HIV has greatly improved, particularly in Canada and the USA, although disparities in life expectancy among people with HIV remain based on level of education, income level, and access to health care.1 Studies from high-income settings have shown life expectancies among people with HIV increasing from approximately two-thirds of that of the general population in 2005, to now nearly that of the general population.1, 2, 3 However, few data exist on life expectancy in people with HIV in low-income and middle-income settings, where ART is increasingly available.

With improvements in infant and childhood mortality rates globally, life expectancy at birth in Latin America and the Caribbean has increased substantially in the general population, from 58·9 years in 1965–70 to 73·5 years in 2005–10.4 By contrast, trends in life expectancy in adults are more complex. Compared with high-income countries, low-income and middle-income countries in Latin America and the Caribbean have seen fewer gains in life expectancy at adult ages.5 In Latin America and the Caribbean, leading causes of premature mortality remain a mix of non-communicable diseases (namely heart disease and stroke) as well as violence, injury, and respiratory infections.6 Furthermore, examination of life expectancy gains in Latin America have shown noteworthy disparities in the general populations within and between its largest cities, highlighting the impact of social inequalities on longevity in the region.7 Little is known about life expectancy for those living with HIV in the region. ART first became available in Latin America in the 1990s, but its availability greatly expanded during the 2000s.4 Knowledge of life expectancies of people with HIV will help to anticipate health-care needs in the region and to identify persistent disparities and areas for improvement.

Research in context

Evidence before this study

Large cohort studies from Europe, the USA, and Canada (including the Antiretroviral Therapy [ART] Cohort Collaboration and the North American AIDS Cohort Collaboration on Research and Design) have shown significant increases in life expectancy and decreases in mortality for people living with HIV who begin treatment with ART. Studies of life expectancy among people with HIV in low-income and middle-income countries are limited to single-country analyses (namely from South Africa and Brazil). We searched PubMed from database inception to Oct 19, 2020, for publications in English, using the search terms “life expectancy”, “Latin America”, “HIV”, “ART”, and “sex”. We found no multisite or large studies describing life expectancy changes among people with HIV who began treatment with ART in Latin America.

Added value of this study

To our knowledge, this is the largest study to examine life expectancy changes in people with HIV beginning treatment with ART in Latin America and the Caribbean over time. There were significant increases in life expectancy at age 20 years in people with HIV from 2003–08 to 2013–17, with life expectancy in the 2013–17 era estimated to be within 10 years of that of the general populations of these countries. Disparities in life expectancy among people with HIV remain, however, including differences by sex or sexual HIV transmission risk factors, level of education, history of tuberculosis, and CD4 cell count at time of ART initiation.

Implications of all the available evidence

This study shows significant improvement in life expectancy among people with HIV in the socioeconomically, culturally, and geographically diverse region of Latin America and the Caribbean since the beginning of the treat-all era. Our findings show that ART can narrow the gap in life expectancy for people with HIV in low-income and middle-income regions.

We aimed to analyse trends in life expectancy from 2003 to 2017 among people with HIV who started treatment with ART in Latin America and the Caribbean, to examine how greater access to HIV care and ART affects life expectancy among people with HIV.

Section snippets

Study design and data sources

We did a multisite retrospective cohort study and included people with HIV who started treatment with ART at Caribbean, Central and South America network for HIV epidemiology (CCASAnet) sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru: Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil; Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru; Centro Medico Huesped, Buenos Aires, Argentina; Fundación

Results

We identified 42 453 people with HIV who contributed follow-up between Jan 1, 2003, and Dec 31, 2017. We excluded 11 765 people: 4154 who never started ART, 4044 who started ART before cohort entry, 1222 who received antiretroviral therapy other than combination ART before starting ART, 1819 who started ART before age 16 years, and 526 who did not contribute person-time data at age 20 years or older, started ART after Dec 31, 2017, or did not contribute any person-time after ART start. We

Discussion

With decreasing mortality rates over time, we observed that, among CCASAnet sites in Latin America and the Caribbean, life expectancy of people with HIV starting on ART significantly improved from 2003 to 2017 and now approaches that of the general population in these areas. However, differences in life expectancy among people with HIV by sex, HIV transmission risk factor, CD4 cell count at ART initiation, history of tuberculosis, and level of education remain and might be increasing in some

Data sharing

CCASAnet welcomes interested investigators to collaborate with us for use of our deidentified, patient-level data following research proposal review and approval by contributing sites. A data dictionary defining each field in the dataset is available upon request. Additional instructions are provided at https://www.ccasanet.org.

Declaration of interests

We declare no competing interests.

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