Survival Following HIV Infection of a Cohort Followed up From Seroconversion in the UK

Fiona M Ewings; Krishnan Bhaskaran; Ken McLean; David Hawkins; Martin Fisher; Sarah Fidler; Richard Gilson; Demelza Nock; Ray Brettle; Margaret Johnson; Andrew Phillips; Kholoud Porter; for the UK Register of HIV Seroconverters

Disclosures

AIDS. 2008;22(1):89-95. 

In This Article

Abstract and Introduction

Objectives: To estimate changes over calendar time in survival following HIV seroconversion in the era of HAART and to provide updated survival estimates.
Methods: Using data from a UK cohort of persons with well estimated dates of HIV seroconversion, we analysed time from seroconversion to death from any cause using Cox models, adjusted for prognostic factors. Kaplan-Meier methods were then used to determine the expected survival in each calendar period.
Results: 2275 seroconverters were included with 18 695 person-years of follow up. A total of 444 (20%) died. The relative risk of death, compared with pre-1996, decreased over time to 0.63 [95% confidence interval (CI), 0.48-0.81], 0.24 (0.17-0.34), 0.14 (0.10-0.21), 0.08 (0.05-0.13) and 0.03 (0.02-0.06) in 1996-1997, 1998-1999, 2000-2001, 2002-2003 and 2004-2006, respectively. An elevated risk of death was associated with older age at seroconversion [hazard ratio (HR), 1.49; 95% CI, 1.34-1.66 per 10-year increase] and HIV infection through injecting drug use (HR, 1.53; 95% CI, 1.17-2.00). In 2000-2006, the proportion of individuals expected to survive 5, 10 and 15 years following seroconversion was 99%, 94% and 89%, respectively.
Conclusions: Survival following HIV seroconversion has continued to improve over calendar time in our cohort, even in the more recent years of HAART availability. HIV seroconverters, by definition identified early in their infection, are likely to have the greatest opportunity for intervention; if similar high survival expectations are to be seen in the wider HIV-infected population, early diagnosis is likely to be crucial.

The advent of HAART in 1996 changed HIV disease in developed countries from a condition with a poor short-term prognosis to one with prolonged survival needing long-term management. Major improvements in survival were observed in the first years following its introduction, with over 87% of individuals expected to be alive 10 years following infection in 1999-2001.[1] However, an unacceptably high proportion of infected persons still present at advanced stages of HIV. Indeed, one-third of the estimated 63 500 individuals aged between 15 and 59 years living with HIV in the UK in 2005 were unaware of their infection[2] and are therefore at risk of missing the benefits of initiating HAART before becoming immunologically compromised[3,4] or progressing to symptomatic disease.

Advances in patient management over the last decade, as well as the availability of more potent drugs, have led to continuing improvement in virological response to therapy.[5,6] However, whether this will translate into further survival benefits, given the emergence of drug resistance and the increasing risk of cardiovascular disease, is less clear.

A small proportion of those presenting for care do so close to the time when they first became infected with HIV. If a recent negative HIV antibody test result is available, this allows a reliable estimate to be made of their date of HIV seroconversion. Although such individuals are likely to differ from the majority of the clinical population, given their perception of risk which led them to seek repeated HIV tests, their known duration of infection provides a unique opportunity to estimate survival expectations following HIV infection and therefore evaluate the population effectiveness of therapy. These data are important not only to patients and their clinicians, but also to healthcare planners attempting to predict the HIV disease burden on healthcare systems. Since seroconverters are by definition diagnosed early in their HIV infection, this allows maximum opportunity for intervention. Derived survival estimates from such a cohort in a country with universal access to effective therapy, which is free at the point of care, can therefore be interpreted as the optimum which may be expected with current management practice and therapy.

We provide current survival estimates and temporal changes in the risk of death, along with corresponding changes in therapy use, from a cohort of patients followed up from HIV seroconversion in the UK.

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