Survival after long-term ART exposure: findings from an Asian patient population retained in care beyond 5 years on ART.

BACKGROUND: This study investigated survival in people living with HIV being followed-up from five and ten years after antiretroviral therapy (ART) initiation in a multi-country Asian cohort. METHODS: We included patients in follow-up >5 years after ART initiation. Factors associated with mortality beyond five and ten years on ART were analysed using competing risk regression with time-updated variables. RESULTS: Of 13,495 patients retained after five years on ART, 279 subsequently died (0.56/100 person-years). Increased mortality was associated with age >50 years (sub-hazard ratio [sHR] 2.24, 95% confidence interval [95%CI] 1.58-3.15, compared to ≤40 years), HIV exposure through injecting drug use (sHR 2.17, 95%CI 1.32-3.56), HIV viral load ≥1000 copies/mL: sHR 1.52, 95%CI 1.05-2.21, compared to <400), regimen (second-line regimen: sHR 2.11, 95%CI 1.52-2.94, and third-line regimen: sHR 2.82, 95%CI 2.00-3.98, compared to first-line regimen), HBV co-infection (sHR 2.23, 95%CI 1.49-3.33), fasting plasma glucose ≥126 mg/dL (sHR 1.98, 95%CI 1.22-3.21, compared to <100 mg/dL), and estimated glomerular filtration rate <60 mg/min/1.73m2 (sHR 2.57, 95%CI 1.56-4.22). Decreased mortality was associated with transmission through male-to-male sexual contact (sHR 0.44, 95%CI 0.22-0.88, compared to heterosexual transmission) and higher CD4 count (200-349 cells/µL: sHR 0.27, 95%CI 0.20-0.38, 350-499 cells/µL: sHR 0.10, 95%CI 0.07-0.16, and ≥500 cells/µL: sHR 0.09, 95%CI 0.06-0.13, compared to <200 cells/µL). Results after ten years were similar, but most associations were weaker due to limited power. CONCLUSIONS: Next to preventing ART failure, HIV programs should carefully monitor and treat comorbidities, including hepatitis, kidney disease and diabetes, to optimise survival after long-term ART exposure.