- A B.C. study measured life expectancy trends among more than 14,000 people living with HIV
- People living with HIV had shorter life expectancies if they had been assigned female at birth
- The gap persisted even after ruling out differences in HIV treatment and social determinants
When taken as directed, HIV treatment (antiretroviral therapy; ART) is highly effective. As a result, many studies in Canada and other high-income countries project that most ART users will have near-normal life expectancy.
In 2020, researchers found that the distribution of people with HIV in British Columbia was as follows:
- 94% of people were diagnosed with HIV
- 92% of people diagnosed with HIV were taking ART
- 95% of people taking ART had a suppressed viral load
However, the B.C. researchers noted that among participants taking ART, 98% of those assigned male at birth had a suppressed viral load, while the figure among those assigned female at birth was 81%. This finding spurred a team of researchers to find out more about life expectancy in males and females with HIV.
A note about terminology. The authors of this study analyzed data based on sex assigned at birth because gender data were not systematically collected over the entire study period, which extended back to 1996. This means the category “male” could include transgender women and nonbinary people, and the category “female” could include transgender men and nonbinary people. Categorizing participants in this way has limitations, but allowed the researchers to measure sex-related differences and inequities accurately with the data they had. CATIE has used the terms “assigned male at birth” (AMAB) and “assigned female at birth” (AFAB) in this summary to make the composition of these categories clear.
A team of researchers at the BC Centre for Excellence in HIV/AIDS, Simon Fraser University, the University of British Columbia and elsewhere analyzed databases in that province to understand trends in survival among people with HIV. They reviewed information from several databases that collect information from people with HIV about their health, lab test results, medication use, and so on. The data were stripped of identifying information prior to analysis. The research team reviewed information collected between 1996 and 2020.
The researchers focused on 14,272 people with HIV (82% AMAB, 18% AFAB) whose average profile upon entering the study was as follows:
- age – 38 years
- injection drug use – 26% AMAB, 44% AFAB
- living in a low-income neighbourhood – 31% AMAB, 39% AFAB
- initiated ART with advanced immune deficiency (less than 200 CD4+ cells/mm3) – 26% of AMAB participants and 44% of AFAB participants
On average, participants were monitored for about 10 years.
Results
Researchers found that life expectancy increased tremendously for people with HIV assigned male at birth from the period 1996-2001 to the period 2012-2020. They had a life expectancy at age 20 of 48 additional years (to live to age 68), whereas for people with HIV assigned female at birth, the equivalent figure was 41 additional years at age 20 (to live to age 61).
What’s more, over the course of the study the gap in life expectancy persisted based on sex assigned at birth. This difference in life expectancy was statistically significant; that is, not likely due to chance alone. It remained significant, even when researchers took into account CD4+ cell counts when ART was initiated and social and structural factors that play a role in health.
Why the gap?
The researchers found that the following issues only partially explained the poorer survival prospects of people with HIV assigned female at birth—living in a low-income neighbourhood, living in a rural area, having a history of injecting drugs.
In the study, participants assigned female at birth were not more likely to die from complications arising from cardiovascular disease or cancer. Rather, they were significantly more likely to perish from complications linked to any of the following:
- kidney disease
- liver disease
- chronic lung disease
The researchers noted that among people without HIV, in general, other studies have found that people assigned female at birth have a longer life expectancy than people assigned male at birth.
The present study of people with HIV was not designed to uncover the reasons behind this difference in life expectancy. However, the B.C. researchers noted the following points obtained from other studies that are likely relevant to the findings from their study:
- People assigned female at birth are more likely than people assigned male at birth to engage in cigarette smoking.
- Co-infection with hepatitis B virus and/or hepatitis C virus is relatively common among people who inject drugs; if left untreated, these viral infections could contribute to reduced survival by inciting liver injury and liver cancer. Hepatitis C virus is also associated with an increased risk of kidney injury.
Thus, screening for these issues and providing relevant care could help reduce complications and deaths from smoking, injection drug use, and liver and kidney injury.
What to do?
The researchers stated that their findings underscore the importance of “further prioritizing women with HIV and [who are] at risk for HIV” for social and health services. The researchers called for public health strategies to address “structural factors negatively affecting the health of women with (or at risk for) HIV, including access to care, unemployment, poverty, unstable housing, stigma and discrimination.”
Additionally, the researchers argued for the provision of “low-barrier person-centred care models for women with HIV, providing integrated multidisciplinary care and addressing the unique needs of women with HIV, including specific barriers that women experience accessing care.”
For the future
The B.C. study is a good first step in documenting trends in life expectancy based on sex and gender in the current era. Additional research and interventional studies are needed to address this finding.
—Sean R. Hosein
Resources
BC Centre for Excellence in HIV/AIDS
Canadian HIV Women’s Sexual and Reproductive Health Cohort Study
REFERENCES:
- 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. 2025 Feb 6:S2468-2667(24)00304-9.
- Shokoohi M, Bauer GR, Kaida A, et al. Social determinants of health and self-rated health status: A comparison between women with HIV and women without HIV from the general population in Canada. PLoS One. 2019 Mar 21;14(3):e0213901.
- Corouge M, Vallet-Pichard A, Pol S. HCV and the kidney. Liver International. 2016 Jan;36 Supplement 1:28-33.