Int J Epidemiol. 2009 Dec;38(6):1624-33. doi: 10.1093/ije/dyp306. Epub 2009 Oct 9.
Mortality in HIV-infected patients has declined substantially with combination antiretroviral therapy (ART), but it is unclear whether it has reached that of the general population. We compared mortality in patients starting ART in nine countries of Europe and North America with the corresponding general population, taking into account their response to ART.
Eligible patients were enrolled in prospective cohort studies participating in the ART Cohort Collaboration. We calculated the ratio of observed to expected deaths from all causes [standardized mortality ratio (SMR)], measuring time from 6 months after starting ART, according to risk group, clinical stage at the start of ART and CD4 cell count and viral load at 6 months. Expected numbers of deaths were obtained from age-, sex- and country-specific mortality rates.
Among 29 935 eligible patients, 1134 deaths were recorded in 131 510 person-years of follow-up. The median age was 37 years, 8162 (27%) patients were females, 4400 (15%) were injecting drug users (IDUs) and 6738 (23%) had AIDS when starting ART. At 6 months, 23 539 patients (79%) had viral load measurements <or=500 copies/ml. The lowest SMR, 1.05 [95% confidence interval (CI) 0.82-1.35] was found for men who have sex with men (MSM) who started ART free of AIDS, reached a CD4 cell count of >or=350 cells/microL and suppressed viral replication to <or=500 copies/ml by the sixth month. In contrast, the SMR was 73.7 (95% CI 46.4-116.9) in IDUs who failed to suppress viral replication and had CD4 cell counts <50 cells/microL at 6 months. The percentage of patients with SMRs <2 was 46% for MSM, 42% for heterosexually infected patients and 0% for patients with a history of injection drug use. Corresponding percentages for SMRs >10 were 4, 14 and 47%.
In industrialized countries, the mortality experience of HIV-infected patients who start ART and survive the first 6 months continues to be higher than in the general population, but for many patients excess mortality is moderate and comparable with patients having other chronic conditions. Much of the excess mortality might be prevented by earlier diagnosis of HIV followed by timely initiation of ART.
采用联合抗逆转录病毒疗法（ART）后，HIV 感染者的死亡率大幅下降，但尚不清楚死亡率是否已与普通人群相当。我们比较了欧洲和北美洲 9 个国家开始接受 ART 的患者与普通人群的死亡率，同时考虑了他们对 ART 的反应。
合格的患者被纳入参与 ART 队列协作的前瞻性队列研究中。我们根据风险组、开始 ART 时的临床分期以及 6 个月时的 CD4 细胞计数和病毒载量，计算了所有原因导致的观察到的死亡人数与预期死亡人数之比（标准化死亡率比，SMR），测量时间从开始 ART 后 6 个月开始。预期死亡人数是根据年龄、性别和国家特定的死亡率得出的。
在 29935 名合格患者中，131510 人年的随访中记录了 1134 例死亡。中位年龄为 37 岁，8162 名（27%）患者为女性，4400 名（15%）为注射吸毒者（IDU），6738 名（23%）在开始 ART 时患有艾滋病。6 个月时，23539 名患者（79%）的病毒载量检测值<或=500 拷贝/ml。SMR 最低（1.05，95%置信区间 0.82-1.35）的是无艾滋病开始 ART 的男男性行为者（MSM），他们达到了>或=350 个细胞/μL 的 CD4 细胞计数，并在第六个月时将病毒复制抑制到<或=500 拷贝/ml。相比之下，未能抑制病毒复制且在 6 个月时 CD4 细胞计数<50 个/μL 的 IDU 的 SMR 为 73.7（95%置信区间 46.4-116.9）。SMR<2 的患者百分比为 46%的 MSM、42%的异性恋感染患者和 0%的有注射吸毒史的患者。SMR>10 的患者百分比分别为 4、14 和 47%。
在工业化国家，开始接受 ART 并在最初 6 个月存活下来的 HIV 感染者的死亡率继续高于普通人群，但对于许多患者而言，死亡率过高是适度的，与患有其他慢性疾病的患者相当。通过早期诊断 HIV 并及时开始 ART，大部分的超额死亡率可能会得到预防。
