Life expectancy, at age 20, for patients treated for HIV increased by more than 15 years from 1996 to 2008, a large cohort study from the UK has shown.¹ Mortality rates from HIV have decreased dramatically over the past few decades through the use of antiretroviral therapy (ART). The risk of death in patients treated successfully with ART is now similar to that of people with unhealthy lifestyles such as heavy smokers or drinkers, those who are obese or have chronic conditions such as diabetes. HIV infection has itself become a chronic disease with a good prognosis, provided treatment is commenced early and the patient maintains adherence to therapy.

The UK CHIC Study has been collecting routine data since 2001 on people with HIV attending major collaborating centres across the UK. Patients in the analysis were aged 20 or older and had started ART with at least three drugs between January 1996 and December 2008. Patients with incomplete data and those who were thought to have been infected through the use of injected drugs were excluded; the latter because of low prevalence and worse prognosis compared with other risk groups.

Data on 17,661 patients who started ART with CD4 counts ≤ 350 cells/mm3 during 1996 to 2008 were analysed. Crude mortality rates (per 1,000 person-years) for all ages and for individuals aged 20-44 years were calculated. Potential years of life lost were calculated as the sum of years lost because of premature death (death before age 65) and expressed per 1,000 person-years from age 20 to 64.

Overall 1,248 patients (7%) died during the 91,203 person-years of follow up. Life expectancy at age 20 increased from 30.0 (SE 1.2) in 1996-9 to 45.8 (SE 1.7) years in 2006-8. Life expectancy for a man with HIV was 39.5 (SE 0.45) and for a woman 50.2 (SE 0.45), compared with 57.8 and 61.6 years respectively in the general population (1996-2006).

Starting ART later than recommended in the guidelines2 resulted in up to 15 years of life lost; at age 20, life expectancy was 37.9 (SE 1.3), 41.0 (SE 2.2) and 53.4 (SE 1.2) years for those starting ART with CD4 count

There appears to have been an increase in life expectancy of more than 15 years for people treated for HIV during 1996-2008. However, compared with the general population, life expectancy is still 13 years less.

The authors argue that their findings ‘strongly support the concept of more widespread testing for HIV, especially initiatives to achieve universal testing.’ They conclude that: ‘It is also of clear benefit to the patient to have the prognosis made in terms of their life expectancy, and this might have considerable impact on patients’ uptake of testing.’

The UK HIV Testing Guidelines published in 20083 aim to facilitate an increase in HIV testing in all healthcare settings. In areas where diagnosed prevalence of HIV is > 2 per 1,000, HIV testing for all new adults registering with a general practice is strongly recommended. While this prevalence includes almost all PCTs in London, the PCT areas outside London where HIV prevalence is > 2 per 1,000 include: Brighton and Hove, Manchester, Luton, Salford, Blackpool, Heart of Birmingham, Leicester City, Coventry, Nottingham City, Bournemouth, Milton Keynes and Wolverhampton. Case finding for HIV is cost effective in these areas; not only do people have better outcomes if diagnosed early, they also reduce the risk of infecting others when they are undiagnosed.

The ‘Halve It’ campaign, led by a coalition of HIV and healthcare experts, aims to halve the proportion of people living with undiagnosed HIV and the proportion diagnosed late by 2015. Primary care professionals can help improve earlier diagnosis by considering HIV disease as a differential diagnosis in patients with diarrhoea, fever, night sweats and weight loss and by offering patients an HIV test at every opportunity (especially in high prevalence areas). For those who wish to improve their knowledge and skills in this area the booklet HIV in Primary Care should prove helpful. It can be downloaded free from www.medfash.org.uk .