Racial and Sex Disparities in Life Expectancy Losses among HIV-Infected Persons in the United States: Impact of Risk Behavior, Late Initiation, and Early Discontinuation of Antiretroviral Therapy
Racial and Sex Disparities in Life Expectancy Losses among HIV-Infected Persons in the United States: Impact of Risk Behavior, Late Initiation, and Early Discontinuation of Antiretroviral Therapy
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DOI：
10.1086/644772
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发表时间：
2009-11-15
影响因子：
11.8
通讯作者：
Freedberg, Kenneth A.
中科院分区：
文献类型：
--
作者：
Losina, Elena;Schackman, Bruce R.;Freedberg, Kenneth A.
背景在美国，大多数感染人类免疫缺陷病毒（HIV）的患者都是晚期疾病，许多患者过早地停止治疗。我们试图评估由于危险行为、晚期表现和早期停止HIV治疗而导致的生命年损失的性别和种族/民族差异，并将HIV感染者的这些生存损失与归因于高危行为和HIV疾病本身的损失进行比较。利用HIV疾病的状态转换模型，我们模拟了HIV感染者的队列，并将其与具有相似人口统计学特征的未感染者进行比较。我们使用风险调整的标准化死亡率比率估计非HIV相关死亡率，以及因HIV感染晚期出现和早期停止抗逆转录病毒治疗（ART）而损失的寿命。来自国家HIV研究网络的数据，按性别和种族/民族分层，用于估计ART启动时的CD 4（+）细胞计数。在美国，未感染艾滋病毒的人与感染艾滋病毒的人的风险状况相似，从33岁开始的预期寿命为34.58岁，而美国普通人口为42.91岁。如果艾滋病毒感染者接受与指南一致的艾滋病毒治疗，他们将额外失去11.92年的生命;晚开始治疗导致额外失去2.60年的生命，而过早停止抗逆转录病毒治疗导致多失去0.70年的生命。晚开始和早停止的损失是最大的西班牙裔个体（3.90年）。艾滋病毒感染者的高风险状况、艾滋病毒感染本身以及晚开始和早停止护理，都导致预期寿命大幅下降。晚期启动和早期停止治疗导致的生存差异在西班牙裔HIV感染男性和女性中最为明显。针对危险行为的干预措施，以及早期联系和更好地保留护理，将导致美国艾滋病毒感染者的生存率提高。
Background. Most persons with human immunodeficiency virus (HIV) infection in the United States present to care with advanced disease, and many patients discontinue therapy prematurely. We sought to evaluate sex and racial/ethnic disparities in life-years lost as a result of risk behavior, late presentation, and early discontinuation of HIV care, and we compared these survival losses for HIV-infected persons with losses attributable to high-risk behavior and HIV disease itself.Methods. With use of a state-transition model of HIV disease, we simulated cohorts of HIV-infected persons and compared them with uninfected individuals who had similar demographic characteristics. We estimated non-HIV-related mortality with use of risk-adjusted standardized mortality ratios, as well as years of life lost because of late presentation and early discontinuation of antiretroviral therapy (ART) for HIV infection. Data from the national HIV Research Network, stratified by sex and race/ethnicity, were used for estimating CD4(+) cell counts at ART initiation.Results. For HIV-uninfected persons in the United States who have risk profiles similar to those of individuals with HIV infection, the projected life expectancy, starting at 33 years of age, was 34.58 years, compared with 42.91 years for the general US population. Those with HIV infection lost an additional 11.92 years of life if they received HIV care concordant with guidelines; late treatment initiation resulted in 2.60 additional years of life lost, whereas premature ART discontinuation led to 0.70 more years of life lost. Losses from late initiation and early discontinuation were greatest for Hispanic individuals (3.90 years).Conclusions. The high-risk profile of HIV-infected persons, HIV infection itself, as well as late initiation and early discontinuation of care, all lead to substantial decreases in life expectancy. Survival disparities resulting from late initiation and early discontinuation of therapy are most pronounced for Hispanic HIV-infected men and women. Interventions focused on risk behaviors, as well as on earlier linkage to and better retention in care, will lead to improved survival for HIV-infected persons in the United States.