Despite Increases, Gender Disparities in Life Expectancy Persist Among People With HIV

Women living with HIV had a lower life expectancy compared with their male counterparts, even as life expectancy increased overall between 1996 and 2020. Additioanlly. this disparity was found to increase over time, which could be explained due to immune status, according to a study published in Lancet Public Health.1

Life expectancy has improved exponentially in individuals living with HIV since the introduction of antiretroviral therapy (ART), with most individuals living with HIV having similar life expectancy compared with those who do not have HIV.2 Life expectancy between sexes has been previously studied, with results finding that women have lower life expectancy, which is different than life expectancy of women without HIV. This study aimed to evaluate differences in life expectancy between men and women living with HIV, specifically in those living in British Columbia, Canada, from 1996 to 2020.

The present study used data from the Comparative Outcomes and Service Utlization Trends (COAST) study that compared health outcomes in patients with HIV. Data from this study was collected from Population Data BC and the BC Centre for Excellence in HIV/AIDS’s Drug Treatment Program. Data on patient demographics, billing information, clinical administration, hospital discharges and transfers, drug dispensations, and deaths were included.

Women with HIV had shorter life expectancy compared with men | Image credit: RAJCREATIONZS - stock.adobe.com

Individuals were included if they were aged 20 years and older and had at least 1 day of follow up between April 1, 1996, and March 31, 2020. The latest of 20th birthday, record of positive HIV status, or April 1, 1996, were used as a baseline. Individuals were followed until whichever came first between the end of follow-up, death, or March 31, 2020. There were 3 periods considered based on types of ART available: 1996 to 2001, 2002 to 2011, and 2012 to 2020.

Data were also collected about self-reported HIV transmission risk category, history of ART, and CD4 counts. Income quintile and rurality was also collected.

Overall, 14,272 individuals were included in the analysis, with women making up 17.8% of the population. A median (IQR) of 9.9 person years (3.9-17.9) in men and 10.0 person-years (4.2-16.8) in women equaled the median follow-up time. Median age was 38 (32-46) years in men and 34 (28-42) years in women. Injection drug use was recorded as an HIV transmission risk factor in 26.0% of men and 43.5% of women. A total of 30.9% of men lived in the lowest income quintile compared with 38.6% of women.

Life expectancy increased from 1996 to 2001 to 2012 to 2020 from 24.46 years to 48.00 years in men aged 20 years. Women’s life expectancy increased from 22.13 years to 40.94 years in that same period, with men’s life expectancy increasing by 23.54 years compared with women’s 18.81 years. This pattern continued throughout the course of the patients’ lives. Life expectancy at 40 years was 33.37 in men and 28.10 years in women; men had higher life expectancy at 55 years as well with 23.89 years for men and 21.13 years for women.

An increase in the gap of life expectancy between men and women was found between being aged 20 years in 1996 to 2001 (2.33 years; 95% CI, –0.78 to 5.44) and in 2012 to 2020 (7.05 years; 95% CI, 3.10-11.0). This same gap was also seen in those aged 40 years from 1996 to 2001 (3.21 years; 95% CI, 1.41-4.98) to 2012 to 2020 (5.26 years; 95% CI, 3.17-7.35). This gap was significant in those aged 55 across both time periods.

An increase in hazard all-cause mortality was associated with the female sex (adjusted hazard ratio [aHR], 1.37; 95% CI, 1.27-1.48) compared with male sex. Female sex was associated with non-communicable mortality (aHR, 1.33; 95% CI, 1.14-1.54) in the fully adjusted model. Sensitivity and main analyses did not have significantly different life expectancy estimates.

Women had a higher hazard for all-cause mortality if they had a first record of an HIV infection around 1996 (aHR, 1.20; 95% CI, 1.10-1.31). Women were statistically significantly associated with all-cause mortalityeven after adjusting for socioeconomic status but not associated with mortality from cardiovascular disease or cancer when adjusting for sociostructural factors and CD4 count when starting ART. Mortality from renal disease, liver disease, and chronic respiratory disease were all associated with women (aHR, 2.30; 95% CI, 1.66-3.21).

There were some limitations to this study. This study may not be generalizable to those who have not yet been diagnosed with HIV who do not know that they have been infected. There were no data on gender or gender roles among the participants. There were a small number of deaths which did not allow for a model on mortality that covered individual causes of death. The HIV risk transmission category had missing values. Individual-level information was harder to capture due to using administrative health data.

The authors concluded that life expectancy in women was significantly behind men, even as ART remained free and available to obtain in those living with HIV. Social determinants of health could be a reason for this discrepancy.

"Together, we believe these findings demonstrate the need for the provincial government, health care providers, and other HIV-related organizations to urgently prioritize their focus on women who are living with, or who are at risk of contracting, HIV by developing public health initiatives that address the systemic challenges facing women who are affected by, or are vulnerable to, HIV and stressing the importance of screening and preventative measures for non-communicable diseases among females with HIV," Katherine Kooij, PhD, co-author of the study, said in a statement to The American Journal of Managed Care®.

References

1. Kooij KW, Zhang W, Trigg J, et al. Life expectancy and mortality among males and females with HIV in British Columbia in 1996-2020: a population-based cohort study. Lancet Public Health. Published online February 6, 2025. doi:10.1016/s2468-2667(24)00304-9
2. Trickey A, Sabin CA, Burkholder G, et al. Life expectancy after 2015 of adults with HIV on long-term antiretroviral therapy in Europe and North America: a collaborative analysis of cohort studies. Lancet HIV. 2023;10(5):E295-E307. Doi:10.1016/S2352-3018(23)00028-0