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Despite dramatic increases in life expectancy in the decade since the introduction of combination therapy, Americans diagnosed with HIV are still dying an average of 21 years younger than their HIV-negative peers, report researchers from the Centers of Disease Prevention and Control in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Although women’s life expectancy is longer than men’s, it has not improved as much as men’s, and the situation of black and Hispanic men is significantly worse than that of white men.

A number of cohort studies have already provided strong evidence of important declines in the risk of death amongst people with HIV in developed countries since combination therapy became available. Moreover, attentin has always been drawn to the long life expectancy of some groups of people with HIV, especially those diagnosed at a young age.

However studies have also continued to find poorer outcomes than among HIV-negative people. One study of over 43,000 patients in 14 cohorts found that whilst a 20 year old starting treatment could expect to live to be 63, this life expectancy was only two-thirds of that in the general population.

Another study, this time based on over 16,000 people in 23 European cohorts, found that whilst mortality rates were similar to the general population in the first five years after diagnosis, an increased risk of death became apparent with longer-term infection.

Studies have also identified groups of people with HIV who tend to have a poorer prognosis, including injecting drug users, older people, those co-infected with hepatitis C, and people whose CD4 cell count is low when starting treatment.

The new study is based on routine anonymised data collected on people newly diagnosed with HIV. Other studies have used data on people with HIV who are accessing treatment or care, which may somewhat over-estimate life expectancy.

Data was provided by 25 of 50 states, representing approximately a quarter of Americans living with HIV. Some key states such as New York and California are not included, and Hispanic people are under-represented in the sample. Diagnoses between 1996 and 2005 were included, with follow-up until 2007.

Over 22,000 people were included in the study, of whom 10,366 died.

Life expectancy
On average, life expectancy after diagnosis increased from 10.5 years in 1996 to 22.5 years in 2005. HIV-positive women, overall, had a longer life expectancy than men (23.6 years for women in 2005, compared to 21.8 years for men).

Among men, the greatest improvements in life expectancy were experienced by white men. Black men diagnosed in 2005 could expect to live for five years less than their white counterparts.

	1996 life expectancy	2005 life expectancy
White men	10.3 years	25.5 years
Black men	9.5 years	19.9 years
Hispanic men	10.1 years	22.6 years

Because there are fewer women in the sample, the estimates for life expectancy for women of a particular ethnicity diagnosed in a single year are not particularly accurate. The researchers therefore provide pooled figures for the years 2001 to 2005. These show that black women have a shorter life expectancy than other groups, with the greatest improvements in life expectancy being experienced by Hispanic women.

However the authors note that the most important improvements in life expectancy took place in the first five years of the study, and increases have slowed since then.

	1996 life expectancy	2001-2005 life expectancy
White women	12.8 years	22.1 years
Black women	12.5 years	20.6 years
Hispanic women	11.2 years	24.2 years

Life-expectancy was longer for gay and bisexual men (28.3 years in 2005) than for other men. Injecting drug users had the shortest life expectancy (15.2 years for men, and 15.9 years for women in 2005).

Average years of life lost
The authors also calculated how many years a person’s life is shortened, in comparison with a person of the same age, sex and ethnicity in the general population.

In interpreting these figures, it is important to note that there may be higher rates of substance use, hepatitis C co-infection and socio-economic problems in people with HIV than in the general population. These factors will also contribute to the lower life expectancy.

Moreover, the particular nature of the healthcare system in the United States may mean that different results would be seen in other developed countries.

Comparing the life expectancy of people diagnosed with HIV in 2005 with that in the general population, it was 21.1 years shorter.

Men could expect to die an average of 19.1 years before their HIV-negative peers, but this figure varies by age. A man diagnosed aged 20 would die 25 years early, a 40-year old 18 years early and a 60-year old 10 years early.

HIV-positive women’s life expectancy was an average 22.7 years less than in the general population, with more variation according to age. A woman diagnosed aged 20 would die 31 years early, a 40-year old 21 years early and a 60-year old 11 years early.

The greatest number of years lost was seen in Hispanic people, followed by blacks and whites. The authors note that other data show that Hispanics have high rates of discontinuation of treatment and of late presentation to care, which may account for premature deaths.

Conclusions
The authors believe that as well as being useful for policy makers, “these results can guide clinician communication with patients about their life expectancies after HIV diagnosis”.

They sum up the picture presented by the data: “Although life expectancy and average years of life lost have significantly improved for persons diagnosed from 1996 to 2005 in 25 states, life expectancy remains shorter than for the general population and sex and race/ethnic disparities persist.”

For more than a decade, researchers have been trying to develop a product that women could use independently to protect themselves against HIV. The results of a three-year study now show that the latest microbicide is not nearly as promising as researchers hoped.

Carraguard, a gel made from a derivative of seaweed, is the first virus-killing microbicide to make it to the final phase of a large-scale clinical study. Since 2004, more than 6,000 South African women participated in the study.

Though Carraguard worked against HIV in the laboratory, the real-world results were disappointing, according to Robin Maguire of the Population Council, which sponsored the study.

"The study did not show that Carraguard was effective," Maguire says.

Some 134 women converted to HIV positive in the Carraguard group compared with 151 in the placebo group, which Maguire says wasn't statistically significant. Part of the problem may have been that there was a great deal of variability in how often women used the gel — only 10 percent of the participants used it consistently every time. Researchers did learn, however, that unlike many prior gels and foams, the product does not increase the risk of HIV, which could be helpful.

"We know that it is safe to be used as a vehicle to deliver another HIV agent. It can be used in combination with something else to make it more potent," Maguire says.

Consequently, the Population Council plans to move ahead with another study that combines Carraguard with an antiretroviral that appears to be effective against the virus in the laboratory, but is not absorbed into the blood stream.

Finding a microbicide that is strong enough to knock out HIV and gentle enough be used every day is a challenge, says Anna Forbes, the deputy director of the Global Campaign for Microbicides.

"It has to be something very compatible with the body as the body blocks the virus from attaching to the cell or to disable the HIV in some other way so it can't take hold and enter the blood stream," she says.

There's one other obstacle that researchers will have to overcome: finding a product that women will use consistently.

"Any of us who have experience using insertive birth-control methods — diaphragm, foam, cervical cap or sponge or putting in condoms — we know a million and one things can get in between your intention to use the product and using the product," Forbes says.

Looking on the bright side, this study proves what many have doubted, she says — that thousands of women in a developing country will hang in for the duration of a large-scale clinical study.