Divisions of General Medicine, Department of Medicine, MA 02114, USA.
Clin Infect Dis. 2009 Nov 15;49(10):1570-8. doi: 10.1086/644772.
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.
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.
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).
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.
大多数美国的人类免疫缺陷病毒（HIV）感染者在疾病晚期才开始接受治疗，许多患者过早停止治疗。我们试图评估由于风险行为、晚期就诊和过早停止 HIV 护理导致的预期寿命损失方面的性别和种族/族裔差异，并将这些 HIV 感染者的生存损失与高危行为和 HIV 疾病本身造成的损失进行比较。
我们使用 HIV 疾病的状态转换模型，模拟了 HIV 感染者队列，并将其与具有相似人口统计学特征的未感染者进行了比较。我们使用风险调整后的标准化死亡率比来估计非 HIV 相关死亡率，以及由于晚期就诊和过早停止抗逆转录病毒治疗（ART）而导致的 HIV 感染的预期寿命损失。国家 HIV 研究网络的数据按性别和种族/族裔进行分层，用于估计 ART 开始时的 CD4+细胞计数。
对于美国的 HIV 未感染者，如果其风险概况与 HIV 感染者相似，从 33 岁开始，预期寿命为 34.58 岁，而普通美国人群的预期寿命为 42.91 岁。如果 HIV 感染者接受符合指南的 HIV 护理，他们将额外损失 11.92 年的生命；治疗开始较晚导致额外损失 2.60 年的生命，而过早停止 ART 则导致额外损失 0.70 年的生命。晚期开始和早期停止治疗导致的损失在西班牙裔个体中最大（3.90 年）。
HIV 感染者的高风险状况、HIV 感染本身以及晚期开始和早期停止治疗都会导致预期寿命显著下降。由于治疗开始较晚和过早停止治疗而导致的生存差异在西班牙裔 HIV 感染者中最为明显。关注风险行为以及更早地与护理建立联系并更好地保持护理，将改善美国 HIV 感染者的生存。
