Despite the tremendous success of HIV treatment in the US over the past 15 years, substantial avoidable losses in life expectancy persist due to non-HIV-related risk, as well as late presentation and early discontinuation of care. We estimated that the increased mortality due to substance abuse and other high-risk behaviors led to mean per-person survival losses of 8.33 years, even in the absence of HIV disease. Since SMRs for women (7.06) were greater than SMRs for men (2.31; ), losses in life expectancy due to high-risk behavior were greater in women than in men across all races/ethnicities. These losses were comparable to those due to HIV infection itself and underscore the critical importance of interventions focused on reducing substance abuse and other high-risk behaviors. These findings support previous research highlighting the risk of premature death and mortality attributable to substance abuse [44
]. This non-HIV premature mortality includes drug overdose, as well as homicide and suicide [1
We estimated that HIV infection acquired on average at age 33.0 years, and treated according to current US guidelines with current regimens, led to 11.92 years of life lost. We found that 3.30 more years were lost per-person on average due to late presentation and early discontinuation of ART. Survival losses from late presentation and early discontinuation were greater for Hispanics than for Whites or Blacks, regardless of gender, with overall survival losses of 3.90 (21% and 30% more than Whites and Blacks). Among all HIV-infected patient subgroups, Hispanic men had the greatest losses in life expectancy, averaging 3.91 years per-person. Racial/ethnic minority women had greater survival losses compared to their White counterparts (26% and 83% more in Blacks and Hispanics). Data on delayed presentation to care for Hispanic and Black women have repeatedly shown that rates of HIV-related OIs are disproportionately high in both groups [7
]. These differences remain, despite recent data suggesting a narrowing of the survival gap between White and Black HIV-infected persons in the US over the past decade [46
The estimated life expectancy for HIV-infected individuals in the US who initiate ART very late (CD4 <50/μl) was 8.83 years lower than for patients who initiate ART according to current guidelines [6
]. Major survival losses were also due to inadequate retention in care. For White women, the group that presented to care earliest, the survival losses due to late presentation and early discontinuation averaged 2.06 years. These results further emphasize the gap between guideline-concordant and actual care [47
This study underscores the importance of developing interventions focused on better linkage to and retention in care, especially for racial/ethnic minorities. The US Department of Health and Human Services has implemented several HIV prevention programs that target minority women [48
]. Recent efforts to expand routine HIV testing in the US may also begin to address the problem of earlier diagnosis [49
]. Special attention to linkage to care after HIV testing will be critical [52
This study also demonstrates that treatment discontinuation adds substantially to survival losses from HIV. Findings from two large European cohorts report discontinuation rates ranging from 7% at 1 year to 18% at 2 years [8
]. Data from the US show even higher treatment discontinuation rates, ranging from 7% to 40% over 2 to 7 months [9
], with the highest rates among racial/ethnic minority women [3
]. Since average ART initiation occurs at lower CD4 counts for men, especially among minorities, late initiation results in larger life expectancy losses for Hispanic and Black men than women. These results are consistent with the findings of Giordano et al.
, showing clear survival benefits for HIV-infected patients receiving consistent care, compared to irregular care, despite the observation that those who received consistent care presented with more advanced disease [57
This study has several limitations. First, patients who entered the HIV Research Network with HIV RNA levels >400 copies/ml and not on ART were assumed to be initiating therapy for the first time, since information on previous ART was unavailable. However, a sensitivity analysis using gender and race/ethnicity data on CD4 count at the time of presentation from another study [15
] showed similar results, with even greater survival losses for Hispanics. Second, while we used data from only seven sites in the HIV Research Network, the demographic characteristics of persons receiving care in those sites were similar to those from CDC HIV surveillance reports [43
]. Third, the high-risk definition included in our SMR calculations did not explicitly include tobacco use, but since a majority of HIV-infected individuals smoke at least one cigarette per day, this has been indirectly accounted for in the SMR calculations [59
]. Fourth, we estimated the survival losses due to high-risk behavior and HIV-infection independently; however, the biological and social impact of HIV disease may amplify survival losses due to high-risk behavior.
Using currently available data on HIV care in the US, mean survival losses in HIV-infected patients were 23.55 years per-person compared to the general US population and 15.22 years compared to those without HIV infection but with a similar risk profile. Of these 15.22 years, 11.92 years were attributable to HIV infection itself; an additional 3.30 years were lost due to late presentation and early discontinuation of care. Improving access to medical and social services could address the additional risk factors for early mortality [60
]. Survival losses for racial/ethnic minority women with HIV were higher than for Whites by as much as 83%, and these disparities were greatest for Hispanics. Future studies should focus on earlier testing, linkage to and retention in care for all HIV-infected persons, with an emphasis on women as well as racial and ethnic minorities.