Background. Highly active antiretroviral therapy (HAART) has dramatically improved the prognosis for HIV-infected individuals, resulting in higher life expectancies and fewer deaths from AIDS. The dynamics of cause-specific (AIDS vs. non-AIDS) mortality among HIV-infected individuals in the HAART era remain relatively unexplored.
Methods. We used competing risks methods to estimate the proportions and timing of mortality from AIDS and non-AIDS causes in the Multicenter AIDS Cohort Study (MACS) and Women's Interagency HIV Study (WIHS), using age as the time scale. We compared the HAART era to the pre-HAART era, and within the HAART era, estimated cause-specific associations with several predictors of mortality. We compared subgroups of HAART initiators defined by CD4 cell count at therapy initiation, and stratified by hepatitis B or C infection. We used parametric mixture models to estimate cause-specific life expectancies and to compare median ages at both AIDS and non-AIDS death. We used multivariate proportional cause-specific hazards models to estimate and compare cause-specific hazard ratios. Throughout, we compared estimates with those for HIV-negative individuals drawn from the same cohort studies.
Results. Median ages at non-AIDS death were consistently lower among HIV-infected individuals relative to HIV-negative individuals despite dramatic improvement in the HAART era. In the multivariate analysis, hepatitis, unemployment, and depression were independently associated with higher hazards of each death category; relative hazards associated with hepatitis and injection drug use were lowest for AIDS death, higher for non-AIDS death, and highest for HIV-negative individuals. Those who initiated HAART at CD4 cell counts above 350 cells/μL had hazards of non-AIDS death that were not statistically different from those for HIV-negative individuals. Significantly higher hazards of both non-AIDS and AIDS death were noted for those who initiated HAART with CD4 cell counts below 200 cells/μL. Results were similar in populations with and without viral hepatitis.
Conclusions. The results give reason to expect that the gap in non-AIDS mortality between HIV-infected and HIV-negative individuals may continue to decrease. Identification of subgroups whose non-AIDS survival is similar to that of HIV-negative individuals, such as early HAART initiators in this study, may aid in targeting health care provision.
|School:||The Johns Hopkins University|
|School Location:||United States -- Maryland|
|Source:||DAI-B 73/04, Dissertation Abstracts International|
|Subjects:||Biostatistics, Public health, Epidemiology|
|Keywords:||Competing risks, HIV/AIDS, Highly active antiretroviral therapy, Mortality|
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