Is having HIV 'like a death sentence'?

This is an amended version of a blog entry originally entitled 'Canada: Expert doctor defends his statements on HIV life expectancy'. I was forced to remove the original posting to which this entry refers due to a threat of legal action.

I have now included the news article from the original posting (about the Owen Antoine case in St. Thomas, Ontario, Canada) in this fuller entry on Mr Antoine's trial.

The offending post dealt with the reported statements of Dr Anurag Markanday, the expert witness for the Crown in an article on the case from the St Thomas Times Journal, with which I strongly disagree.

Dr Anurag Markanday told the jury there’s no cure for HIV, but drugs do slow the process of the disease. "It’s like a death sentence ... while we can keep the virus suppressed, we are going to run out of options." Once diagnosed, the average lifespan of a person is eight to 10 years, he testified.

For someone with access to HIV treatment – as is the case in Canada – HIV is now a chronic, manageable condition.

In subsequent email correspondence, Dr Markanday again asserted his opinion that, “in the absence of a cure, I would still label it as "death sentence" for someone not on therapy (when clinically indicted) [sic] or in heavily treatment experienced patients with multiple drug mutations and limited options.”

Of course if someone is not on treatment when they should be (in most cases when they have a CD4 count below 350 cells/mm³) then they are more likely to get sick and die. But that is focusing on the exception and not the rule.

And yes, if someone was diagnosed in the 80s or 90s and burned through every class of drug they may well have multiple drug mutations, but there are now many options for what used to be known as ‘salvage therapy’, including the amazing new drugs and new drug classes that Dr Markanday says he is working with.

Consequently, I really must question his focus on worse-case scenarios and his use of the emotive phrase, ‘death sentence’.

Dr Markanday then points out “the effects from other co-morbidities such as hepatitis co-infection with early cirrhosis and mortality, hyperlipidemia/CV events have also increased. (In terms of number of years one could safely say at least ten years since the diagnosis).”

Again, I wonder why Dr Markanday focuses on hepatitis coinfection – which certainly does increase the likelihood of illness and death in someone with HIV? I have no idea whether the complainant was already infected with viral hepatitis before she was allegedly infected with HIV, but if this is not the case, how is it relevant?

As for lipid increase and cardiovascular events, the latest word from the D:A:D study, which looks at these events, is that “there does not seem to be an epidemic on the horizon – simply a risk that needs to be managed.”

So, yes, remaining on suppressive anti-HIV treatment, giving up smoking, exercising and eating well, and taking lipid-lowering drugs if indicated, may be necessary to reduce the risk of an HIV-positive person succumbing to a heart attack, but the increased risk of treated HIV infection itself is not considered something that dramatically alters life-expectancy.

Why could Dr Markanday not have said that with treatment, someone diagnosed with HIV infection today is expected to have, more or less, a normal lifespan? That is what Italy’s Dr Stefano Vella – one of the most respected HIV clinicians in the world – said at the 2006 International AIDS Conference in Toronto, and many expert HIV clinicians agree.

Solid data backs up Dr Vella’s assertion. In 2006, researchers from the United States calculated that someone who was provided with anti-HIV drug combinations according to 2004’s US treatment guidelines would benefit from these treatments for between 21 and 25 years before they finally stopped working. Their estimate included four separate attempts at suppressing HIV to ‘undetectable’ levels, from first-line therapy to ‘salvage’ therapy. (Schackman BR et al. The lifetime cost of current HIV care in the United States. Medical Care 44(11); 990=997, 2006.)

Last year, a large Danish study concluded that a 25 year-old diagnosed with HIV and treated with the anti-HIV drugs available then could expect to live well into their mid-sixties . The Danish study found that the average 25 year-old who remained HIV-negative could expect to live until they were in their mid-seventies. Consequently, successfully treated HIV infection appears to reduce life-expectancy by about ten years. (Lohse N et al. Survival of persons with and without HIV infection in Denmark, 1995-2005. Annals of Internal Medicine:146: 87-95, 2007.)

However, anti-HIV treatments – and knowledge about how to best use them – continue to advance at a rapid pace. As time goes on, experts believe that is very likely that other ways of treating HIV will be discovered that will mean that successful outcomes from the use of anti-HIV treatment could last even longer.

Certainly, HIV can lead to some serious illnesses if untreated. In 2006, around 100 out of the 400 deaths reported in HIV-positive people in the UK were due to their being diagnosed with HIV too late for effective anti-HIV treatment, highlighting the importance of HIV testing in order to make the most of the latest advances in anti-HIV therapy.

Another third of these 400 deaths were not considered related to HIV at all. Consequently, most HIV-related deaths are preventable if HIV is diagnosed early enough and treated succesfully. (Johnson M et al. BHIVA Mortality Audit. BHIVA Autumn Conference, London, 2006.)

Ultimately, anti-HIV treatments have greatly improved the life expectancy of people with HIV, as long as they:

• Know their HIV status early enough to get timely and effective treatment
• Have access to good quality HIV treatment and care
• And take anti-HIV drugs regularly and on time.

Finally, as for life expectancy for someone not on treatment, there are new data from UNAIDS and WHO which finds that, as a result of a better understanding of the natural history of untreated HIV infection, the average number of years that people living with HIV are estimated to survive without treatment has been increased from nine to eleven years.