Wednesday, April 26, 2017

Life Expectancy and HIV

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The number of people living with HIV (PLHIVs) globally has been growing as well as people that are newly infected. The Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2015 estimated a total of 36.7 million people living with HIV (31.8 million adults, 16.0 million women, and 3.2 million children). While there are around 2.1 million people that are newly infected (1.9 million adults and 240,000 children) in the same year, AIDS-related deaths were estimated to be around 1.1 million in total (1.0 million adults and 190,000 children).

Despite the increasing number of people living with HIV globally, the World Health Organization (WHO) reported that the global life expectancy increased by five years between 2000 and 2015 – the fastest increase since the 1960s and during the full implementation of the Millennium Development Goals (MDGs) – reversing the declines during the 1990s when global life expectancy fell in Africa due to the AIDS epidemic and in Eastern Europe following the collapse of the Soviet Union (WHO, 2015).

The World Health Statistics (2016) revealed that the global life expectancy at birth in 2015 was 71.4 years (73.8 years for females; 69.1 years for males) with females living longer than males all around the world. There was no significant difference in the gap in life expectancy between the sexes in 1990 and 2015. 

The UNAIDS global figures reflect both increase in the number of new infections but as well as access to antiretroviral treatment (ART) which impacted and reduced mortality and morbidity related to AIDS complications. The Global Health Observatory data of the WHO and the 2016 World Health Statistics highlighted the WHO African region to have shown the greatest increase, by 9.4 years to 60 years, mainly due to the enhancement in child survival strategies and in the expanded access of antiretroviral treatment for people living with HIV.

This paper will explore the link between HIV and the AIDS epidemic to the global life expectancy and its effects in several world regions. This paper will also look into the life expectancy of people living with HIV and the impact of such in the society and public health.

And though the world has committed to end the AIDS epidemic by 2030, reaching this bold target, now within the framework of the Sustainable Development Goals, would be the central question. However, the extraordinary accomplishments in reducing and halting HIV & AIDS globally in the last fifteen years have ignited confidence globally that this target can be achieved.

HIV as a global epidemic
The World Health Organization and the Joint United Nations Programme on HIV/AIDS conducted estimates on 2010 and 2015 on the global HIV epidemic and registered 33.3 million and 36.7 million people living with HIV (at all ages) respectively. Eastern and Southern Africa ranked with the highest increase of 1.8 million (2010: 17.2 million; 2015: 19.0 million), followed by Eastern Europe & Central Asia with 0.5 million (2010: 1.0 million; 2015: 1.5 million), and Asia and Pacific with 0.4 million (2010: 4.7 million; 2015: 5.1 million) (UNAIDS, 2015).

New HIV infections were estimated in 2010 and 2015 and registered 2.2 million and 2.1 million respectively with a decrease of 0.1 million globally. The greatest number of decrease in new cases were from Eastern and southern Africa with 0.14 million (2010: 1.1 million; 2015: 960,000), followed by Western and Central Africa with 40,000 (2010: 450,000; 2015: 410,000), and Asia and Pacific with 10,000 (2010: 310,000; 2015: 300,000). However, Eastern Europe and Central Asia increased their number of new HIV infections by 70,000 (2010: 120,000; 2015: 190,000).

The Lancet published a systematic analysis for the Global Burden of Disease Study (2013) on global, regional, and national age-sex-specific all-cause and cause-specific mortality for 240 causes of death from 1990 to 2013 – the leading causes of death globally (with the number of deaths) in 2013 are:
1.      Ischemic heart disease (8,139,900)
2.      Stroke (6,446,900)
3.      Chronic obstructive pulmonary disease (2,931,200)
4.      Pneumonia (2,652,600)
5.      Alzheimer’s disease (1,655,100)
6.      Lung cancer (1,639,600)
7.      Road injuries (1,395,800)
8.      HIV/AIDS (1,341,000)
9.      Diabetes (1,299,400)
10.  Tuberculosis (1,290,300)

The Lancet analysis also revealed that the gender gap in death rates for adults aged 20 to 44 is widening with HIV & AIDS (together with interpersonal violence, road injury, and maternal mortality) is one of the key conditions responsible. The lowest income regions had made significant progress in combating maternal mortality, HIV & AIDS, tuberculosis, and malaria but also showed that greater attention and effort are needed. HIV & AIDS remained a major cause of mortality in Southern and sub-Saharan Africa and to a smaller extent in Western and Eastern sub-Saharan Africa (Lancet, 2014). 

Effect of HIV and AIDS on life expectancy
Mortality surge and life expectancy drops were experienced by countries that were greatly affected by the AIDS epidemic in the previous decades such as in the sub-Saharan Africa. Populations in countries such as Botswana, Lesotho, and South Africa have slowed dramatically or have stopped due to AIDS, but overall growth in the region surpassed that of other world regions (Ashford, 2006).
People living with HIV have compromised immune system and response and therefore are susceptible to develop diseases and contract infections (called opportunistic infections). Infections that are most common among people living with HIV are pneumonia and tuberculosis and therefore advance HIV infection have increased cases on these diseases in many regions of the world. Current trends show that HIV & AIDS undercuts human security and derails development leading to remarkable lowering in life expectancy of affected countries due to incapacitation or death of adults in their prime (Angelo, 2003).

United Nations representative and humanitarian co-ordinator in Zimbabwe, Angelo Victor, studied the demographic impact and the magnitude of HIV & AIDS in Africa in 2003 as published in Cadernos de Estudos Africanos and stated that HIV & AIDS has made “considerable and sometimes dramatic impact” on life expectancy as well as mortality and population growth rates.

The Human Development Report in 2003 made a comparison of life expectancy within the context of HIV & AIDS to the expected life expectancy without AIDS illustrating that in countries with high prevalence among the young population (15-24), majority of them would die before they reach their thirties (UNDP, 2001). Several countries with high prevalence (such as Zimbabwe, Botswana, Swaziland, and Lesotho) shown a loss of life expectancy by more than two decades and were greatly affected by the epidemic from 2000-2005 (UNDP, 2001). 

Regional impact
Generally, male adult mortality worsens as HIV prevalence increases and apparent that differentials in male adult mortality levels are caused by the AIDS epidemic in Sub-Saharan Africa (Ngom and Clark, 2003).

The AIDS epidemic severely affected the sub-Saharan Africa’s population and became the top leading cause of mortality in the region in 2005. The region’s Under Five mortality rates were substantially higher than they would be without HIV. Lamptey, Johnson, and Khan (2006) stressed that without access to antiretroviral treatment, one-third of children infected via mother-to-child transmission would die before reaching their first year and about 60% will die before reaching the age of five.   

The Caribbean is the second most affected region in the world on AIDS prevalence with an estimated 2.4% of the adult population ranking after Sub-Saharan Africa and the number of adults and children living with HIV in the Americas represent seven per cent of the world total and the number of adults and children newly infected with HIV is at five per cent of the world total (UNAIDS/WHO, 2002)

Life expectancy of people living with HIV
The life expectancy of people living with HIV has improved significantly increased since the introduction and availability of the antiretroviral therapy (ART) and since then has contributed greatly to the survival of people living with HIV.

People living HIV can expect to have a life expectancy that is as nearly the same as that of HIV- individuals if they were diagnosed in time and were able to access antiretroviral drugs, developed a lifelong adherence to medication and treatment (Nakagawa, May, and Phillips, 2013), maintaining a low rate of virologic failure & relatively preserved CD4 counts (Nakagawa, et al, 2012), and a sustained viral load suppression enhancing the durability of the antiretroviral treatment to prevent the development of ART resistance (Richman, et al, 2004).

However in 2016 at the Conference on Retroviruses and Opportunistic Infections in the United States, a study was presented comparing the life expectancies of HIV-positive and HIV-negative individuals within the Kaiser Permanente health insurance system and found that although life expectancy among people living with HIV has improved, life expectancy at age 20 remains 13 years behind that of HIV-negative individuals and this gap did not improve between 2008 and 2011 in the cohort study (Marcus, et al, 2016).

The Marcus study also compared the life expectancies in both HIV-positive and HIV-negative individuals in the Kaiser system with the life expectancies in the US general population and found that HIV-positive individuals’ life expectancy is lower by two years in the US general population than that of the HIV-negative individuals group in the Kaiser system. Interestingly, some have greater results in some groups with notably five years in males. This, according to Marcus might be accountable to HIV and to the difference in the HIV-positive individual’s health coverage. 

Implications of longer life expectancy of PLHIVs
According to the Global AIDS Response Progress Report (GARPR) in 2016 and UNAIDS estimates, there were 7.5 million people living with HIV on antiretroviral treatment (all ages) in 2010 and in 2015 the number grew at 17 million (all ages) with the highest increase in Eastern and Southern Africa and in Asia and Pacific at almost 40% each. This growth is remarkable as it surpassed the 2015 achievement of extending access to antiretroviral treatment to more than 15 million people living with HIV in 2015 but expressing grave concern that despite efforts to expand access to ART, more than half of all PLHIVs still are not aware of their HIV status and about 22 million of them remain without ART (United Nations, 2016).

While for the AIDS-related deaths, the numbers went down from 1.5 million in 2010 to 1.1 million in 2015. Eastern and Southern Africa showed the greatest number of reduction of AIDS-related deaths of around 290,000 (2010: 760,000 and 2015: 470,000). Eastern Europe & Central Asia and Middle East & North Africa regions showed increased in AIDS-related deaths with 38,000 to 47,000 and 9,500 to 12,000 cases respectively.

The UNAIDS and WHO estimates the global number of people being newly infected with HIV is lowering – from 3.2 million in 2000, 2.5 million in 2005, 2.2 million in 2010, and 2.1 million in 2015. Global targets sets lesser than 500,000 new HIV infections in 2020 and less 200,000 further in 2030. Similarly for AIDS-related deaths, UNAIDS and WHO estimates a continuous decrease over time – from 2.0 million in 2005, 1.5 million in 2000/2010, and 1.1 million in 2015. The global targets for AIDS-related deaths are set at less than 500,000 in 2020 and less than 400,000 in 2030.

With studies now confirming that early diagnosis, initiation and access to antiretroviral treatment, and development of lifelong adherence have indeed estimated increases in the life expectancies of HIV-positive individuals comparing to HIV-negative individuals one implication to that is an expectation that younger patients who are detected early will be on treatment longer – at least about three to four decades. And with an estimate of 7.5 million people on ART and increasing over time, a large proportion of individuals will be in lifetime treatment and that shall incur costs in antiretroviral drugs. Such costs will be shouldered by the government and would need increasing budgetary allocations for HIV treatment, care, and support programs.

Another aspect with the increasing estimates of life expectancies among people living with HIV is the management of HIV-related co-infections and opportunistic infections. HIV-positive patients must regularly be screened for tuberculosis and hepatitis among others to prevent such opportunistic infections to occur. Regular testing for CD4 cell counts and viral load are also necessary.

Another implication to a higher life expectancy among people living with HIV is the occurrence of HIV in ageing. Treatment and management of chronic diseases which can be aggravated with the presence of HIV, and management of treatment regimen are imperative for chronic care among ageing people living with HIV. An increase in interest in this field of study is recommended because of the further implications it will have in the lives of people, related policies and programs including the development of age-specific guidelines, and support services.

Prevention measures and services will be a very important component in HIV care – prevention for the development of co-morbidities and opportunistic infection among people living with HIV and prevention for contracting the virus among HIV-negative people. Another implication is seen in enhancing the global HIV treatment, care, and support programs including access of people living with HIV to health insurance covering their medication, vaccination, other laboratory processes, access to cheaper antiretroviral drugs especially for those who have developed drug to drug interaction and support services to long-term ART usage. 

As it is shown that as the percentage of 15-49 year-old males with HIV increases, the global life expectancy of males decreases, recent studies proved that early detection, access to retroviral treatment, and a lifelong adherence to ART increases life expectancy of people living with HIV. Gender norms and HIV should also be looked closely as it may be one of the causes of late detection and adherence to treatment regimen.

Finally, the global effort to ensure that people are regularly screened and detected early for HIV, those screened know their HIV status and can access to ART as soon as possible, and to sustain their adherence to their treatment regimen are all imperative but challenging at the same time for governments, policy-makers, healthcare providers, researchers, and other support groups in not just achieving national and international targets but in shaping a future for people living with HIV, their families, and other vulnerable populations.

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