Projecting changes in demographics and causes of death in people with HIV in western Europe from 2025 to 2050: a mathematical modelling study.
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BACKGROUND: Antiretroviral therapy (ART) scale-up in western Europe has reduced the incidence of AIDS-related conditions, increased life expectancies, and led to an ageing population of people with HIV. We aimed to project cause-specific mortality patterns in western Europe by 2050 in the context of changes in demographics and ART use. METHODS: We used a deterministic compartmental model calibrated in a Bayesian framework. From 2010 to 2023, the model was parameterised and calibrated using epidemiological data from the European Centre for Disease Prevention and Control, UNAIDS, and the Antiretroviral Therapy Cohort Collaboration, including information on rates of cause-specific mortality by demographics and CD4 cell counts. The number of deaths and mortality rates were modelled for a status quo scenario (where ART coverage and HIV incidence remained stable) from 2025 to 2050, as well as different scenarios in which various changes to ART coverage and HIV incidence were assumed. FINDINGS: By 2050, 839 761 (95% credible interval 789 451-860 875) people with HIV are projected to be living in western Europe, with 90% taking ART. The percentage of people with HIV older than 75 years is projected to increase from 8% in 2025 to 24% in 2050. The all-cause mortality rate is estimated to increase from 1·31 (1·25-1·36) per 100 person-years in 2025 to 2·04 (1·95-2·12) in 2050. Between 2010 and 2025, there was an estimated decline in AIDS-related deaths of 44·2% (37·7-50·1). From 2025 to 2050, projected AIDS-related mortality rates are estimated to remain constant at 0·21 per 100 person-years under a status quo scenario. Cardiovascular-related mortality rates are estimated to increase from 0·24 per 100 person-years (0·22-0·25) in 2025 to 0·50 (0·40-0·53) in 2050 and non-AIDS-defining cancers to increase from 0·31 per 100 person-years (0·30-0·32) in 2025 to 0·53 (0·50-0·56) in 2050, becoming the two leading causes of death by 2050 in people with HIV. Over the next 25 years, if there is an increase in ART coverage (reaching 94% in 2030) and a steady decrease in HIV incidence, there are projected to be 15 321 (14 124-16 743) fewer deaths in people with HIV in western Europe. INTERPRETATION: Non-AIDS-related deaths are projected to increase over time due to the ageing population of people with HIV offsetting the AIDS-related mortality reduction. Efforts are needed to promote comprehensive care for the ageing HIV population and focus on the health needs of people with HIV across their lifespan. FUNDING: US National Institute on Alcohol Abuse and Alcoholism and US National Institute of Allergy and Infectious Diseases.