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Krishnan Bhaskaran, MSc; Osamah Hamouda, MD; Mette Sannes, MLabTech; Faroudy Boufassa, MD; Anne M. Johnson, MD; Paul C. Lambert, PhD; Kholoud Porter, PhD; for the CASCADE Collaboration

JAMA. 2008;300(1):51-59.

Context  Mortality among human immunodeficiency virus (HIV)–infected individuals has decreased dramatically in countries with good access to treatment and may now be close to mortality in the general uninfected population.

Objective  To evaluate changes in the mortality gap between HIV-infected individuals and the general uninfected population.

Design, Setting, and Population  Mortality following HIV seroconversion in a large multinational collaboration of HIV seroconverter cohorts (CASCADE) was compared with expected mortality, calculated by applying general population death rates matched on demographic factors. A Poisson-based model adjusted for duration of infection was constructed to assess changes over calendar time in the excess mortality among HIV-infected individuals. Data pooled in September 2007 were analyzed in March 2008, covering years at risk 1981-2006.

Main Outcome Measure  Excess mortality among HIV-infected individuals compared with that of the general uninfected population.

Results  Of 16 534 individuals with median duration of follow-up of 6.3 years (range, 1 day to 23.8 years), 2571 died, compared with 235 deaths expected in an equivalent general population cohort. The excess mortality rate (per 1000 person-years) decreased from 40.8 (95% confidence interval [CI], 38.5-43.0; 1275.9 excess deaths in 31 302 person-years) before the introduction of highly active antiretroviral therapy (pre-1996) to 6.1 (95% CI, 4.8-7.4; 89.6 excess deaths in 14 703 person-years) in 2004-2006 (adjusted excess hazard ratio, 0.05 [95% CI, 0.03-0.09] for 2004-2006 vs pre-1996). By 2004-2006, no excess mortality was observed in the first 5 years following HIV seroconversion among those infected sexually, though a cumulative excess probability of death remained over the longer term (4.8% [95% CI, 2.5%-8.6%] in the first 10 years among those aged 15-24 years).

Conclusions  Mortality rates for HIV-infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy. In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.

Author Affiliations: Medical Research Council Clinical Trials Unit, London, United Kingdom (Mr Bhaskaran and Dr Porter); Robert Koch Institute, Berlin, Germany (Dr Hamouda); Ulleval University Hospital, Oslo, Norway (Ms Sannes); INSERM U822, Hôpital Bicêtre, Paris, France (Dr Boufassa); University College London, London, United Kingdom (Dr Johnson); and University of Leicester, Leicester, United Kingdom (Dr Lambert).

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