Decreasing Excess Mortality of HIV-infected Patients Initiating Antiretroviral Therapy: Comparison with Mortality in General Population in China, 2003 – 2009

OBJECTIVE: To evaluate excess mortality across calendar time comparing HIV-infected patients receiving combination antiretroviral therapy (cART) with the general Chinese population. METHODS: Patients receiving free cART through the National Free Antiretroviral Therapy Program (NFATP) between January 1 2003 and December 31 2009 were included. Observed mortality rates excess mortality rates and standardized mortality ratios were calculated by calendar periods. Factors associated with excess mortality across calendar time were evaluated in multivariable Poisson regression models. RESULTS: Among 64836 HIV-infected patients the observed and excess mortality rates in 2003-2004 were 9.5 deaths per 100 person-years [95% confidence interval (CI): 8.8 to 10.2] and 9.1 (95% CI: 8.5 to 9.8); in 2008-2009 these decreased to 5.6 (95% CI: 5.4 to 5.8) and 5.2 (95% CI: 5.0 to 5.4) respectively. The adjusted excess hazard ratio (eHR) for 2003-2004 in comparison to 2008-2009 was 1.27 (95% CI: 1.11 to 1.45). Patients initiating cART at CD4 cell counts /=350 cells per microliter had an adjusted eHR of 9.92 (95% CI: 8.59 to 11.44). Patients starting cART at older ages also had greater excess mortality with an eHR of 1.63 (95% CI: 1.47 to 1.82) comparing ages >/=45 to 18-29 years. Standardized mortality ratio results were consistent with those for excess mortality. CONCLUSIONS: Substantial decreases in excess mortality were observed from 2003 to 2009 in China among HIV-infected patients receiving free cART. However mortality among HIV-infected patients remained higher than the general Chinese population. As more efficacious first- and second-line cART regimens become increasingly available to Chinese HIV-infected patients further reductions in overall and excess mortality are likely.