The Burden of Non-Communicable Diseases and Mortality in People Living With HIV (PLHIV) in the Pre-, Early- and Late-HAART Era

NA Jespersen; F Axelsen; J Dollerup; M Nørgaard; CS Larsen


HIV Medicine. 2021;22(6):478-490. 

In This Article

Abstract and Introduction


Objectives: To estimate the burden of non-communicable diseases (NCDs) and mortality among PLHIV in the pre-, early- and late-HAART (highly active antiretroviral therapy) era.

Methods: We conducted a cohort study using population-based Danish medical registries including all adult HIV-infected residents of the Central Denmark Region during 1985–2017. For each HIV patient, we selected 10 comparisons from the background population matched by age, sex and municipality of residence. Based on hospital-related diagnoses we estimated the prevalence and incidence of specific NCD at diagnosis and at 5 and 10 years.

Results: We identified 1043 PLHIV and 10 430 matched comparisons. PLHIV had lower socioeconomic status and more were born outside western Europe. At HIV diagnosis, 21.9% of PHLIV vs. 18.2% of non-HIV individuals had at least one NCD, increasing to 42.2% vs. 25.9% after 10 years. PLHIV had higher prevalence and cumulative incidence of alcohol abuse, chronic obstructive pulmonary disease (COPD), ischaemic heart disease, mental disorders, renal and liver disease, but no increased risk of diabetes mellitus. Only PLHIV in the age groups 41–50 and > 51 years had an increased incidence of osteoporosis. From the pre- to the late-HAART era, 10-year mortality among PLHIV decreased from 45.5% to 9.4% but continued at more than twice that of uninfected comparisons. However, in the late-HAART era, the mortality of PLHIV who were alive 2 years after HIV diagnosis was approaching that of comparisons.

Conclusions: Even in the late-HAART era, PLHIV have an excess mortality, which may be attributable to several NCDs being more prevalent among PLHIV. The prevalence rates of ischaemic heart disease, diabetes, osteoporosis and renal disease tend to increase over calendar time. Therefore, improvement of survival and quality of life of PLHIV neets strategies to reduce the risk of developing NCDs, including avoiding toxic antiretroviral therapy and lifestyle changes.


Antiretroviral therapy (ART) has resulted in HIV infection becoming a chronic medical condition. The life expectancy of people living with HIV (PLHIV) has gradually improved, approaching that of the general population.[1,2] Consequently, PLHIV are surviving to older age and requiring lifelong care and treatment. The proportion of PLHIV > 50 years old is predicted to increase to 73% in 2030.[3]

Despite a dramatic decrease in HIV/AIDS-related mortality, even well-treated PLHIV have a decreased life expectancy compared with individuals without HIV.[4,5] HIV/AIDS-related deaths remain high in the first year after HIV diagnosis, primarily among late presenters. However, after the first year of ART, the excess mortality is primarily caused by non-communicable diseases (NCDs).[6,7]

Across all age groups, PLHIV have a disproportionate risk of NCDs, mental disorders, and alcohol- and substance-use disorders.[1,8–10] This may be caused by a higher prevalence of traditional risk factors for chronic diseases such as tobacco and alcohol use, risk behaviour related to HIV transmission, intrinsic to HIV or ART-related toxicities.[11] Unhealthy lifestyle has been shown to be more frequent among PLHIV than among the general population.[12–14] Chronic inflammation has been associated with premature ageing and may predispose to NCDs.[15] The prevalence of NCDs in PLHIV may correspond to that observed in HIV-uninfected people who are 10 years older.[16] Also, antiretroviral drugs have been implicated in the development of cardiovascular disease (CVD), diabetes, osteoporosis and nephrotoxicity.[12]

The aim of this study was to describe the prevalence of NCDs among PLHIV at the time of diagnosis, and the mortality and occurrence of NCDs over calendar time and by age compared with the background population, with a focus on the changes during the pre-, early- and late-HAART (highly active antiretroviral therapy) era.