Elsevier

The Lancet

Volume 352, Issue 9142, 28 November 1998, Pages 1725-1730
The Lancet

Articles
Changing patterns of mortality across Europe in patients infected with HIV-1

https://doi.org/10.1016/S0140-6736(98)03201-2Get rights and content

Summary

Background

The introduction of combination antiretroviral therapy and protease inhibitors has led to reports of falling mortality rates among people infected with HIV-1. We examined the change in these mortality rates of HIV-1-infected patients across Europe during 1994-98, and assessed the extent to which changes can be explained by the use of new therapeutic regimens.

Methods

We analysed data from EuroSIDA, which is a prospective, observational, European, multicentre cohort of 4270 HIV-1-infected patients. We compared death rates in each 6 month period from September, 1994, to March, 1998.

Findings

By March, 1998, 1215 patients had died. The mortality rate from March to September, 1995, was 23·3 deaths per 100 person-years of follow-up (95% Cl 20·6–26·0), and fell to 4·1 per 100 person-years of follow-up (2·3–5·9) between September, 1997, and March, 1998. From March to September, 1997, the death rate was 65·4 per 100 person-years of follow-up for those on no treatment, 7·5 per 100 person-years of follow-up for patients on dual therapy, and 3·4 per 100 person-years of follow-up for patients on triple-combination therapy. Compared with patients who were followed up from September, 1994, to March, 1995, patients seen between September, 1997, and March, 1998, had a relative hazard of death of 0·16 (0·08–0·32), which rose to 0·90 (0·50–1·64) after adjustment for treatment.

Interpretation

Death rates across Europe among patients infected with HIV-1 have been falling since September, 1995, and at the begining of 1998 were less than a fifth of their previous level. A large proportion of the reduction in mortality could be explained by new treatments or combinations of treatments.

Introduction

AIDS is one of the leading causes of premature death worldwide1, 2, 3, 4, 5 and since the early 1980s such deaths have been steadily increasing in most countries.6 An estimated 30 million or more adults and children had HIV-1 infection or AIDS by the end of 1997, of whom almost 2% were from western Europe. Since the start of the epidemic, more than 11 million people have died. As the number of patients with AIDS continues to increase, future mortality from the disease will increase unless treatment of the disease improves and survival increases.5

Treatment of HIV-1 has changed rapidly since 1994, particularly as a result of combination therapy which reduces the risk of death.7, 8, 9, 10 The most recent class of drugs to be approved are protease inhibitors, which have been shown to increase survival in patients with advanced immunodeficiency.11, 12, 13, 14 Improvements in prophylaxis of opportunistic infections, better access to care, and changes in treatment options may all have contributed to the falling death rates.15, 16, 17, 18

We aimed to find out whether mortality rates had fallen between 1994 and 1998 across Europe in a group of prospectively followed patients infected with HIV-1. We also examined whether the changing mortality rates could be attributed to the introduction of new treatments.

Section snippets

Patients

The EuroSIDA study is a prospective, pan-European study of patients with HIV-1 in 50 centres across Europe (including Israel). Details of the study have been published elsewhere.19 In brief, centres provided data on consecutive patients seen in the outpatient clinic from May 2, 1994, until a predefined number of patients had been enrolled from each centre. This cohort of 3122 patients is the EuroSIDA I cohort. In December, 1995, a further 1369 patients were enrolled to the EuroSIDA II cohort.

Results

4270 patients with HIV-1 were included in this analysis. Among those who did not die, patients were lost to follow-up at a rate of about 5% per calendar year: the number of patients lost to follow-up was 168 (5·5%) by March, 1996, and 333 (10·9%) by March, 1997. During a median follow-up of 23 months (90% range 2·0–43·1), 1215 (28·5%) patients died. Table 1 shows the characteristics of the patients included in the study and the number of patients who died. The median age at recruitment to

Discussion

Our results show a substantial decrease in mortality associated with HIV-1 across Europe between September, 1995, and March, 1998, in a large cohort of patients. The statistical analyses showed that much of the reduction in mortality could be attributed to treatment changes. In addition, because the first cohort was established in 1994, we have been able to follow both the changes in mortality and the changes in treatment for HIV-1 infection.

There are differences in the recommendations for

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