Gender Difference in All-Cause Mortality of People Living With HIV in Iran

Findings From a 20-Year Cohort Study

Z Gheibi; M Dianatinasab; A Haghparast; A Mirzazadeh; M Fararouei


HIV Medicine. 2020;21(10):659-667. 

In This Article

Abstract and Introduction


Objectives: Gender differences in the efficacy of treatment and the mortality of HIV-infected patients have not yet been fully elucidated. For the first time, we used data from a 20-year cohort of people living with HIV (PLWH) in four provinces (Fars, Bushehr, Bandar Abbas, and Kohgiluyeh and Boyer-Ahmad) in the southern part of Iran to assess the gender difference in all-cause mortality in PLWH in Iran.

Methods: We analysed data for 1216 patients aged ≥ 15 years who were diagnosed with HIV/AIDS between 1997 and 2017. Three hundred and fourteen (25.8%) were women.

Results: The death rate from all causes among women was 13.7% vs. 43.8% among men (P < 0.001). All-cause mortality was significantly associated with gender [the adjusted hazard ratio (aHR) for men compared with women was 3.20], not being on antiretroviral therapy (ART) compared with being on ART at the last visit (aHR 5.42), older age (aHR 1.03), delayed HIV diagnosis compared with early diagnosis (aHR 1.72), history of incarceration (aHR 1.57), higher log CD4 count at diagnosis (aHR 0.54), and prophylaxis for Pneumocystis pneumonia (aHR 0.09).

Conclusions: The results of this 20-year cohort study suggest that gender is an important predictor of survival among HIV-infected patients. Improving early HIV diagnosis and early ART initiation in men, as well as increased access to hepatitis C virus treatment are needed to increase the survival rate of HIV-infected patients in Iran.


Improved access to antiretroviral treatment (ART) has significantly increased the survival rate of people living with HIV (PLWH).[1] In developed countries, PLWH are living almost as long as the general population;[2] however, in most less-developed countries, the survival rate of PLWH is lower than that of the general population.[3] In previous studies, factors such as a history of drug injection, African American race, and lower CD4 count at diagnosis were associated with higher mortality rates among PLWH.[4] Gender has been reported as a modifier for the risk of HIV infection and its clinical outcomes.[5]

According to Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates in 2016, women comprise about half of all HIV-infected people worldwide.[6,7] Gender differences in the efficacy of treatment and the mortality of HIV-infected patients have not yet been fully elucidated. Studies comparing HIV treatment outcomes and mortality between men and women have reported contradictory findings.[8–11] For example, several studies have reported a gender difference in the response to ART among PLWH,[12–15] while some have suggested a better response to ART only in women.[16–18] However, a few studies have suggested no difference between men and women in the response to ART.[19–21] For example, two studies in Australia[22] and Switzerland[23] reported no significant difference between men and women regarding viral load suppression. Given structural and cultural variation across settings, it is possible that the response to ART in men and women is different in less-developed countries. The observed gender differences in diagnostic delay and treatment adherence,[24] HIV viral load at diagnosis,[25] and access to treatment services have been suggested as reasons for potential gender differences in HIV treatment outcomes and mortality.[26]

In Iran, all HIV diagnostics and treatment services are free. However, use of such services is reported to be very low.[27] According to available estimates, of the 61 000 PLWH estimated to be living in Iran, approximately 22 000 are aware of their HIV status.[28] In 1998, less than 10% of identified Iranian HIV-infected patients were women. In 2018, this number had increased to 33%.[29] In the light of the importance of understanding the factors influencing response to ART, for the first time, we used 20 years of data for a cohort of PLWH in the southern part of Iran to assess the gender difference in all-cause mortality among PLWH in Iran.