Women’s Death Rates After Starting HIV Treatment Vary Widely Between Geographical Regions

NIAID Now | February 01, 2020

Women make up more than half of all adults with HIV worldwide and up to 60 percent of adults with HIV from low- and middle-income countries. Access to health care and treatment for HIV varies greatly across the world, and delays in diagnosing HIV and connecting people to care are major barriers to potentially life-saving antiretroviral therapy (ART).

A large collaborative study sponsored by NIAID examined death rates of women on HIV treatment in 56 countries in Europe, the Americas, and sub-Saharan Africa. Investigators pooled data on more than 190,000 women 18 years old or older with HIV from two large international consortia: the International Epidemiology Databases to Evaluate AIDS (IeDEA) Cohort Consortium and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE). They examined deaths from any cause in the first 4 years after starting ART between 2000 and 2014.

For all regions analyzed, death rates were highest in the first 3 months after starting ART and leveled off after 6–12 months. Women in Central America, the Caribbean, and sub-Saharan Africa (East, West, and South Africa) had the highest death rates of all regions studied. These women had lower levels of CD4+ T cells—infection-fighting white blood cells that are targeted and killed by HIV—when they started treatment, indicating that their HIV disease was more advanced at the time it was diagnosed. Conversely, death rates were markedly lower in women from Europe and North America than those from all other regions. 

Women in Europe and North America had the highest levels of CD4+ T cells when starting ART. Although initial CD4+ T-cell levels were similar among women in North America and Europe, death rates of women in Europe were lower than those of women in North America. Data on deaths in North American study populations, or cohorts, is generally more complete than in European cohorts, but this does not fully explain the higher death rates in North American cohorts. Instead, factors such as better access to HIV care in Europe and the higher proportion of North American women with underlying health disparities are more important causes of this difference.

Numerous factors likely contribute to the global health inequalities highlighted in this study for women with HIV. Earlier diagnosis and timely use of healthcare services for HIV are known to improve survival. More robust healthcare systems in Europe and North America likely contribute to earlier testing and initiation of therapy when HIV/AIDS is less advanced. Most European countries included in this study have nationalized healthcare systems that provide free access to HIV testing and treatment. Furthermore, lower death rates overall in Northern Hemisphere countries underlie the HIV-specific death rates. The findings from this study could help in developing region-specific approaches aimed at improving the life expectancies of women with HIV worldwide.

Reference: IeDEA and COHERE in EuroCoord Cohort Collaboration. All-cause mortality after antiretroviral therapy initiation in HIV-positive women from Europe, Sub-Saharan Africa and the Americas. AIDS. 2020 Feb 1;34(2):277-289.

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