Background
Antiretroviral therapy (ART) scale-up in Western Europe has reduced the incidence of AIDS, increased life expectancies, and led to an aging population of people with HIV (PWH). We aimed to predict cause-specific mortality patterns in Western Europe in the context of changes in demographics and ART use.
Methods
A deterministic, compartmental model was parameterised and calibrated using epidemiological data for 2010-2022 on Western Europe from the European Centre for Disease Prevention and Control and UNAIDS, including population sizes, new HIV cases, ART coverage, demographics, and migrants with HIV. Data on 147,698 PWH on ART in 8 European countries were taken from the Antiretroviral Therapy Cohort Collaboration, including cause-specific mortality rates by demographics and CD4 cell counts. The model accounted for age, sex at birth/mode of HIV acquisition, ART status, CD4 counts, and hepatitis C virus. We compared the status quo to a scenario where, from 2025, the ART start rate is 1.5x higher, the rate of stopping ART is halved, and HIV infections decrease by 1,000 each year from 2025 until reaching zero.
Results
By 2050, 1.1 million PWH are predicted to be living in Western Europe, up from 950,000 in 2025. Assuming current intervention coverage, 88% of PWH would be on ART in 2050. The percentage of PWH aged ≥76 years is predicted to rise from 10% in 2025 to 29% in 2050. The all-cause mortality rate is estimated to increase from 1.09 (95% Credibility Interval: 1.04-1.15) in 2025 to 1.53 (1.51-1.57) per 100 person-years in 2050. The estimated decline in the AIDS mortality rate between 2010 and 2025 is 80%. From 2025-2050, projected AIDS mortality rates remain at 0.27 per 100 person-years (Figure). Meanwhile, cardiovascular-related and non-AIDS defining cancer mortality rates would increase from 0.17 (0.16-0.18) to 0.33 (0.31-0.35), and 0.23 (0.22-0.24) to 0.37 (0.36-0.39) per 100 person-years, respectively, to be the two leading causes of death among PWH by 2050. In 2050, 42% of deaths among PWH would occur among PWH aged ≥76 years. Over the next 25 years, if there is an increase in ART coverage (reaching 91% in 2030) and a steady decrease in HIV incidence, there would be 32,387 (29,757-35,569) fewer deaths.
Conclusions
We estimate that by 2025 the UNAIDS target of reducing AIDS deaths by 75% from 2010 levels will be met in Western Europe. However, subsequently, non-AIDS-related deaths would increase over time due to the ageing population of PWH offsetting the AIDS mortality reduction.
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