Life expectancy of patients treated with ART in the UK: UK CHIC Study Margaret May University of...

Life expectancy of patients Life expectancy of patients treated with ART in the UK: treated with ART in the UK:

UK CHIC StudyUK CHIC Study

Margaret May Margaret May

University of Bristol, Department of Social Medicine, BristolUniversity of Bristol, Department of Social Medicine, Bristol

BackgroundBackground UKCHIC

• Life expectancy (LE) is an important population health indicator that varies by country– Previous analyses of LE in HIV-1 infected individuals by ART-

CC included few patients from UK (Royal Free only) and were averaged over several countries Lancet 372(2008): 293-9

• For patients, knowing LE may affect lifestyle decisions:– Whether to have children, treatment for co-morbidities, save

for a pension…

• LE is also important for public health planning– estimating health burden of lifetime treatment with cARTg

• LE can be used by policy makers– Eg offers of life insurance depending on LE

• Mortgage and housing, providing for dependents

AimsAims UKCHIC

To estimate for the UK population of HIV-1 infected individuals:

• Mortality rates (per 1000 pyears)– Overall– Between the ages 20 and 44 years

• Potential years of life lost (PYLL) before age 65 (per 1000 pyears)

• Life expectancy– At exact ages 20 and 35– Percentage of patient surviving from 20 to 44 years

AimsAims UKCHIC

To estimate these health indicators overall and by:

– Period of follow up • 1996-1999, 2000-2002, 2003-2005, 2006-2008

– Gender and ethnicity• White males, non-white males, white females, non-white females

– CD4 cell count at start of cART• <100, 100-199, 200-350 cellscells/mm3

– Year of starting cART• 1996-1999, 2000-2002, 2003-2005

To estimate these health indicators in those who survive at least 6 months from start of cART

Patients included in analysisPatients included in analysis UKCHIC

• Patients – attended one of the UK clinics that contribute data to

UKCHIC– were aged 20 years and older– started cART on at least 3 drugs between 1996 and 2008

• IDU were excluded• Followed up for all cause mortality

– Linkage to death registry– Administratively censored on 31st December 2008

• CD4 analysis restricted to the subset of patients who had a measurement in 3 months before start of cART– 14868/17661 (84%) patients with CD4

MethodsMethods UKCHIC

• Crude mortality rates were calculated by dividing total no. deaths by total no. years follow up

• PYLL were calculated as the sum of years patients lost because of premature death before the age of 65

• Abridged life tables were constructed from age-specific mortality rates in 5-year bands

– These tables describe the mortality experience that hypothetical cohorts of individuals would have had if they were subjected to the mortality rates in the observed calendar periods

– The life expectancy at an exact age is the average no. of additional years that will be lived by a person after that age, according to the cross-sectional age-specific mortality rates recorded during the study period

Table 1: Characteristics of patients at cART startTable 1: Characteristics of patients at cART start UKCHIC

1996 - 1999 (N=5849)

2000 - 2002 (N=3609)

2003 - 2005 (N=4180)

2006 - 2008 (N=4023)

1996 – 2008(N=17661)

Age, median (IQR) 36 (31- 42) 36 (32-42) 37 (32-43) 38 (32-44) 37 (32-43)

Gender and ethnicity N (%)

Male White 3856 (66) 1703 (47) 1965 (47) 2077 (52) 9601 (54)

Male non-White 953 (16) 845 (23) 984 (24) 919 (23) 3701 (21)

Female White 229 (3.9) 120 (3.3) 132 (3.2) 116 (2.9) 597 (3.4)

Female non-White 811 (14) 941 (26) 1099 (26) 911 (23) 3762 (21)

Risk factor for transmission, N (%)

MSM 3835 (66) 1697 (47) 2067 (49) 2025 (50) 9624 (54)

Heterosexual 1517 (26) 1593 (44) 1863 (45) 1521 (38) 6494 (37)

Other or unknown 497 (8.5) 319 (8.8) 250 (6.0) 477 (11.9) 1543 (8.7)

CD4 count, median (IQR) 140 (50-230) 149 (61-225) 174 (90-235) 200(113-263) 166 (75-241)

AIDS stage C diagnosis 2179 (37) 1007 (28) 828 (20) 576 (14) 4590 (26)HIV-1 RNA (log copies/mL) Median (IQR) 4.9 (4.1-5.4) 5.0 (4.3-5.5) 4.9 (4.2-5.4) 4.7 (4.0-5.2) 4.9 (4.1-5.4)

No previous ART exposure 3145 (54) 3281 (91) 4014 (96) 3853 (96) 14293 (81)

LE overall and by calendar periodLE overall and by calendar period UKCHIC

Table 2: Health indicators stratified by period of follow-up UKCHIC

MeasurePeriod of Follow-up

1996 — 1999 2000 — 2002 2003 — 2005 2006 — 2008 1996 — 2008

Number patients N=5471 N=8493 N=12029 N=15152 N=17661

Mortality rates (per 1000 pyears)

Overall26.8

(23.7 – 30.1)16.3

(14.6 -18.3)12.2

(11.0 – 13.6)9.5

(8.6 -10.6)13.7

(12.9 – 14.5)

Between the ages 20 and 44 years

22.7 (19.5-26.2)

14.5 (12.7 – 16.7)

10.0 (8.6 – 11.5)

7.5 (6.4 – 8.8)

11.7 (10.9 – 12.6)

Mortality rates are deaths per 1000 person-years (95% CI).Se Standard error for the estimated life expectancy



1996 — 1999 2000 — 2002 2003 — 2005 2006 — 2008 1996 — 2008



Overall26.8

(23.7 – 30.1)16.3

(14.6 -18.3)12.2

(11.0 – 13.6)9.5

(8.6 -10.6)13.7

(12.9 – 14.5)


22.7 (19.5-26.2)

14.5 (12.7 – 16.7)

10.0 (8.6 – 11.5)

7.5 (6.4 – 8.8)

11.7 (10.9 – 12.6)

Potential years of life lost before age 65 years (per 1000 pyears)

20 to 64 years 611.3 365.5 248.5 175.1 285.3




1996 — 1999 2000 — 2002 2003 — 2005 2006 — 2008 1996 — 2008



Overall26.8

(23.7 – 30.1)16.3

(14.6 -18.3)12.2

(11.0 – 13.6)9.5

(8.6 -10.6)13.7

(12.9 – 14.5)


22.7 (19.5-26.2)

14.5 (12.7 – 16.7)

10.0 (8.6 – 11.5)

7.5 (6.4 – 8.8)

11.7 (10.9 – 12.6)


20 to 64 years 611.3 365.5 248.5 175.1 285.3

Life expectancy (years;adjusted)

At exact age 20 years (Se) 30.0 (1.2) 39.4 (1.2) 43.1 (1.0) 45.8 (1.7) 41.1 (0.5)





1996 — 1999 2000 — 2002 2003 — 2005 2006 — 2008 1996 — 2008



Overall26.8

(23.7 – 30.1)16.3

(14.6 -18.3)12.2

(11.0 – 13.6)9.5

(8.6 -10.6)13.7

(12.9 – 14.5)


22.7 (19.5-26.2)

14.5 (12.7 – 16.7)

10.0 (8.6 – 11.5)

7.5 (6.4 – 8.8)

11.7 (10.9 – 12.6)


20 to 64 years 611.3 365.5 248.5 175.1 285.3




Percent surviving from 20 to 44 years 60.8% 74.7% 81.6% 82.3% 77.3%


Table 3: Health indicators stratified by gender and ethnicity UKCHIC

MeasureCategory

White MalesNon-White

MalesNumber patients N=9601 N=3701


Overall14.9

(13.9-16.0)14.9

(13.2 – 16.9)

Between the ages 20 and 44 years12.2

(11.1 -13.5)14.1

(12.1 – 16.4)

Potential years of life lost before age 65 years (per 1000 pyears)20 to 64 years 291.4 332.7

Life expectancy (years;adjusted)At exact age 20 years (Se) 39.2 (1.2) 40.3 (1.7)At exact age 35 years (Se) 30.0 (0.3) 30.6 (0.7)

Percent surviving from 20 to 44 years 74.7% 74.1%

Table 3: Health indicators stratified by gender and ethnicity UKCHIC

MeasureCategory

White MalesNon-White

MalesWhite Females

Non-White Females

Number patients N=9601 N=3701 N=597 N=3762


Overall14.9

(13.9-16.0)14.9

(13.2 – 16.9)11.0

(7.8 – 15.3)10.4

(9.0 – 12.0)

Between the ages 20 and 44 years12.2

(11.1 -13.5)14.1

(12.1 – 16.4)10.6 (7.1 – 15.7)

9.6 (8.1 – 11.4)

Potential years of life lost before age 65 years (per 1000 pyears)20 to 64 years 291.4 332.7 247.3 252.4

Life expectancy (years;adjusted)At exact age 20 years (Se) 39.2 (1.2) 40.3 (1.7) 50.8 (3.4) 47.0 (1.3)At exact age 35 years (Se) 30.0 (0.3) 30.6 (0.7) 39.8 (2.5) 35.1 (1.1)

Percent surviving from 20 to 44 years 74.7% 74.1% 80.0% 82.4%

Table 4: Health indicators stratified by CD4 count UKCHIC

MeasureCD4 cell count

< 100 cells/mm3 100-199 cells/mm3 200-350 cells/mm3

Number patients N=4585 N=4434 N=5849


Overall 21.0 (19.4-22.9) 12.1 (10.8-13.6) 8.0 (7.0-9.2)

Between the ages 20 and 44 years 19.1 (17.2-21.2) 9.3 (7.9-11.0) 6.6 (5.5-7.8)


20 to 64 years 452.5 238.6 160.3


At exact age 20 years (Se) 34.9 (1.3) 41.0 (1.6) 51.7 (1.2)


Percent surviving from 20 to 44 years 66.8% 79.9% 86.4%

CD4 cell count at start of cART (N=14868).

Table 5: Health indicators stratified by year of starting cART UKCHIC

Have not estimated for 2005-2008 as fup too short

MeasureYear of starting cART

1996-1999 2000-2002 2003-2005

Number patients N=5849 N=3609 N=4180


Overall 15.9 (14.9-17.1) 10.9 (9.5-12.4) 10.0 (8.5-11.7)

Between the ages 20 and 44 years 14.2 (12.9-15.5) 9.0 (7.6-10.6) 7.8 (6.3-9.6)


20 to 64 years 333.3 221.0 203.1




Percent surviving from 20 to 44 years 73.5% 84.8% 86.7%

Summary of resultsSummary of results UKCHIC

• The average LE at age 20 over the study period was 41 years– 43 years in those who survived first 6 months after starting cART

• LE improved from 30 to 46 years between 1996-99 and 2006-08– 31 to 47 years in those who survived at least 6 months from start of cART – LE higher in ART-CC analysis which was restricted to naïve patients

• As in the background population, females have better LE than males by 7 years or more

• There is no difference in LE between white and non-white males – Very few white females

• 67%, 80% and 86% of patients aged 20 who start cART with CD4<100, 100-199, 200-350 respectively survive to age 44

LimitationsLimitations UKCHIC

• Only 13 years of cART follow up from 1996– LE is extrapolating outside the range of the data using cross-sectional data

• Only 2% of patients were aged 60 years and over– Very imprecise mortality estimates in the age group that should have the

highest mortality– Adjusted mortality rates in the highest age group using trends across

younger ages and information on rates in the UK population

• Less than 4% of patients were white women so estimates for this group are imprecise

• Changes in LE over time might reflect changes in demographics (eg increase in proportion of women) as well as improvements in drugs/care

ConclusionConclusion UKCHIC

• Individuals treated for HIV infection in the UK can expect to live many years after starting cART, depending on their age/sex/CD4 count

• The average LE of HIV infected individuals remains less than in the background UK population (to be quantified), but there has been substantial improvement since 1996

• Differences in LE between men and women partially reflect those in the background population, but may also be due to earlier diagnosis and treatment or better adherence and response to treatment in women

• The impact of HIV infection on PYLL could be reduced by initiating treatment at higher CD4 counts

AcknowledgementsAcknowledgements

UK CHIC is funded by the Medical Research Council, UK UK CHIC is funded by the Medical Research Council, UK (Grant number G0000199)(Grant number G0000199)

Loveleen Bansi for data managementLoveleen Bansi for data management

Caroline Sabin, Mark Gompels for suggestions on Caroline Sabin, Mark Gompels for suggestions on analysesanalyses

Table 6: Health indicators stratified by period of follow upfor patients who survived first 6 months of cARTfor patients who survived first 6 months of cART

UKCHIC

Only 196 deaths in 1st 6 months, but 756 lost to fup or with fup shorter than 6 months.


1996 — 1999 2000 — 2002 2003 — 20052006 — 2008

1996 — 2008



Overall26.1

(22.7 – 30.0)15.3

(13.6-17.3)11.2

(10.0 – 12.6) 9.0

(8.1-10.1)12.6

(11.9 – 13.4)Between the ages 20 and 44 years

22.1 (18.6-26.3)

14.0 (12.1 – 16.2)

9.1 (7.8 – 10.6)

6.9 (5.8 – 8.1)

10.8 (10.0 – 11.7)

Potential years of life lost before age 65 years (per 1000 pyears)20 to 64 years 588.3 348.8 226.3 161.5 259.9

Life expectancy (years;adjusted)At exact age 20 years (Se) 31.2 (1.2) 42.2 (1.2) 44.6 (1.0) 47.0 (1.9) 42.9 (0.5)At exact age 35 years (Se) 20.5 (0.7) 30.8 (0.8) 32.6 (0.5) 36.4 (0.5) 32.0 (0.2)

Percent surviving from 20 to 44 years 63.8% 76.6% 83.7% 84.0% 79.8%

Life expectancy of patients treated with ART in the UK: UK CHIC Study Margaret May University of...

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