Multimorbidity Among Persons Living with Human Immunodeficiency Virus in the United States

Food Insecurity Prevalence and Risk Factors among Persons with HIV in a Southeastern US Clinical Care Setting

Food insecurity (FI) is associated with adverse health outcomes for persons with HIV (PWH). Little is known about FI among PWH in southern or non-urban settings. We examined FI prevalence, risk factors, and access to services in a southeastern HIV clinic. Among PWH in the UNC CFAR HIV Clinical Cohort who were screened for FI as part of HIV care between 2021 and 2022, we estimated unadjusted prevalence ratios (PRs) comparing the probability of reporting FI by demographic and clinical characteristics. The 479 PWH screened for FI were 65% cisgender men, 62% non-Hispanic Black PWH, a median of 54 years old (IQR 41-62), and 93% with an HIV viral load (VL) < 200 copies/mL. FI prevalence was 36.3% (95% CI 32.3%-40.9%). Cisgender women and transgender adults were more likely to report FI than cisgender men (PRs 1.24 [95% CI 0.97-1.59] and 2.03 [1.32-3.12], respectively). Compared with White PWH, the PR was 1.71 (1.20-2.42) for Black and 2.44 (1.56-3.82) for Hispanic PWH. The PR was 1.42 (0.98-2.05) for PWH with VL ≥ 200 versus < 200 copies/mL. Having no or public versus private health insurance was also associated with FI. PWH with FI had a high prevalence of comorbidities including hypercholesterolemia (49%) and hypertension (48%), though these were not associated with FI. Almost half of PWH with FI were not accessing a food pantry or nutrition assistance program. Identifying FI in PWH is critical as FI is common and may contribute to viral non-suppression, poor comorbidity control, and gender and racial/ethnic health disparities in PWH.

Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states

Prostate cancer (PCa) incidence is reportedly lower in men with HIV compared to men without HIV for unknown reasons. We describe PCa incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare. Men (N = 15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and PCa were identified using non-drug claims. We estimated cause-specific (csHR) comparing incidence of PCa by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions, and stratified by age and race-ethnicity. Hazard of PCa was lower in men with HIV than men without HIV (csHR = 0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR = 0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR = 0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR = 1.17; 95% CI: 0.91, 1.50). Findings were similar in models restricted to men aged 50-64 and 40-49, but not in men aged 18-39. Reported deficits in PCa incidence by HIV status may be restricted to specific groups defined by age and race ethnicity.

Telehealth access and experiences of older adults with HIV during the COVID-19 pandemic: Lessons for the future

BACKGROUND

Telehealth services are proposed to improve access and retention to care for people with HIV (PWH). Yet the rapid uptake of telehealth services during the COVID-19 pandemic created equity concerns, especially for already vulnerable populations. Older PWH may face a combination of barriers to telehealth but also stand to benefit given social isolation and the need for multimorbidity management. Few studies have focused on this population, and we aimed to assess the telehealth capability and experiences of older PWH at an urban HIV clinic.

METHODS

We did this in two ways: (1) we contacted PWH aged ≥65 via telephone about telehealth capabilities and (2) we conducted focus groups with older PWH who transitioned from in-person to virtual classes affiliated with the clinic.

RESULTS

Among 179 PWH aged ≥65, 80 answered the telehealth questions. Among those who answered, 91% were male with a mean age of 69 (SD 3.0), and 55% were White. One-third did not have internet access or an email address. A total of 65% had at least one telehealth-capable device but 12.5% of respondents with a device did not know how to use it. Thirteen older PWH participated in focus groups with a mean age of 64 (SD 6.9) and 44% female. Themes were grouped into benefits (social/emotional connection and convenience) and challenges (technological barriers and missed in-person experience).

CONCLUSION

Participants preferred in-person classes but felt telehealth was a good alternative for mitigating isolation. Telehealth gave those with mobility and transportation issues improved access to supportive services. As the COVID-19 public health emergency ends, hybrid options should be considered to improve access for older PWH and address social isolation. Ensuring equitable access to devices and digital literacy training will be critical to ensure services can be utilized.

Antiretroviral Therapy Use and Disparities Among Medicare Beneficiaries with HIV

BACKGROUND

Antiretroviral therapy (ART) is recommended for all people with HIV. Understanding ART use among Medicare beneficiaries with HIV is therefore critically important for improving quality and equity of care among the growing population of older adults with HIV. However, a comprehensive national evaluation of filled ART prescriptions among Medicare beneficiaries is lacking.

OBJECTIVE

To examine trends in ART use among Medicare beneficiaries with HIV from 2013 to 2019 and to evaluate whether racial and ethnic disparities in ART use are narrowing over time.

DESIGN

Retrospective observational study.

SUBJECTS

Traditional Medicare beneficiaries with Part D living with HIV in 2013-2019.

MAIN MEASURES

Months of filled ART prescriptions each year.

KEY RESULTS

Compared with beneficiaries not on ART, beneficiaries on ART were younger, less likely to be Black (41.6% vs. 47.0%), and more likely to be Hispanic (13.1% vs. 9.7%). While the share of beneficiaries who filled ART prescriptions for 10 + months/year improved (+ 0.48 percentage points/year [p.p.y.], 95% CI 0.34-0.63, p < 0.001), 25.8% of beneficiaries did not fill ART for 10 + months in 2019. Between 2013 and 2019, the proportion of beneficiaries who filled ART for 10 + months improved for Black beneficiaries (65.8 to 70.3%, + 0.66 p.p.y., 95% CI 0.43-0.89, p < 0.001) and White beneficiaries (74.8 to 77.4%, + 0.38 p.p.y.; 95% CI 0.19-0.58, p < 0.001), while remaining stable for Hispanic beneficiaries (74.5 to 75.0%, + 0.12 p.p.y., 95% CI - 0.24-0.49, p = 0.51). Although Black-White disparities in ART use narrowed over time, the share of beneficiaries who filled ART prescriptions for 10 + months/year was significantly lower among Black beneficiaries relative to White beneficiaries each year.

CONCLUSIONS

ART use improved from 2013 to 2019 among Medicare beneficiaries with HIV. However, about 25% of beneficiaries did not consistently fill ART prescriptions within a given year. Despite declining differences between Black and White beneficiaries, concerning disparities in ART use persist.

Association between switching to integrase strand transfer inhibitors and incident diabetes in people with HIV

OBJECTIVE

Integrase strand transfer inhibitors (INSTI) are associated with weight gain in people with HIV (PWH), but their impact on diabetes is unclear. We evaluated the association between switching from nonnucleoside reverse-transcriptase inhibitors (NNRTI) or protease inhibitors (PI) to INSTI and incident diabetes.

DESIGN

Longitudinal cohort study.

METHODS

We included PWH aged ≥18 years from the Johns Hopkins HIV Clinical Cohort (2007-2023) without history of diabetes who had used NNRTI or PI for ≥180 days. We followed participants up to 10 years from HIV primary care visits where they switched to INSTI or continued NNRTI or PI. We estimated the hazard of incident diabetes associated with switching to INSTI using weighted Cox regression with robust variance estimator.

RESULTS

We included 2075 PWH who attended 22 116 visits where they continued NNRTI or PI and 631 visits where they switched to INSTI. Switching to INSTI was associated with a weighted hazard ratio (wHR) of 1.11 [95% confidence interval (CI), 0.77-1.59] for incident diabetes. The association if no weight gain occurred during the first two years was not qualitatively different (wHR 1.22; 95% CI, 0.82-1.80). In a posthoc analysis, switching to INSTI conferred a significant wHR of 1.79 (95% CI, 1.13-2.84) for diabetes within the first two years but not after.

CONCLUSIONS

Switching from NNRTI or PI to INSTI did not significantly increase overall diabetes incidence in PWH, although there may be elevated risk in the first two years. These findings can inform considerations when switching to INSTI-based regimens.

Adaptation of a Tailored Lung Cancer Screening Decision Aid for People With HIV

BACKGROUND

People with HIV are both at elevated risk of lung cancer and at high risk of multimorbidity, which makes shared decision-making (SDM) for lung cancer screening (LCS) in people with HIV complex. Currently no known tools have been adapted for SDM in people with HIV.

RESEARCH QUESTION

Can an SDM decision aid be adapted to include HIV-specific measures with input from both people with HIV and their providers?

STUDY DESIGN AND METHODS

This study used qualitative methods including focus groups of people with HIV and interviews with HIV care providers to adapt and iterate an SDM tool for people with HIV. Eligible participants were those with HIV enrolled in an HIV primary care clinic who met age and smoking eligibility criteria for LCS and HIV care providers at the clinic. Both the focus groups and interviews included semistructured discussions of SDM and decision aid elements for people with HIV. We used a framework-guided thematic analysis, mapping themes onto the Health Equity Implementation framework.

RESULTS

Forty-three people with HIV participated in eight focus groups; 10 providers were interviewed. Key themes from patients included broad interest in adapting LCS SDM specifically for people with HIV, a preference for clear LCS recommendations, and the need for positive framing emphasizing survival. Providers were enthusiastic about personalized LCS risk assessments and point-of-care tools. Both patients and providers gave mixed views on the usefulness of HIV-specific risk measures in patient-facing tools. Themes were used to adapt a personalized and flexible SDM tool for LCS in people with HIV.

INTERPRETATION

People with HIV and providers were enthusiastic about specific tools for SDM that are personalized and tailored for people with HIV, that make recommendations, and that inform LCS decision-making. Divergent views on presenting patient-facing quantitative risk assessments suggests that these elements could be optional but available for review. This tool may have usefulness in complex decision-making for LCS in this population and currently is being evaluated in a pilot prospective trial.

Incidence of non-AIDS defining comorbidities among young adults with perinatally acquired HIV in North America

OBJECTIVE

The aim of this study is to describe the incidence of diabetes mellitus type 2 (T2DM), hypercholesterolemia, hypertriglyceridemia, hypertension, and chronic kidney disease (CKD) from 2000 to 2019 among North American adults with perinatally acquired HIV (PHIV) aged 18-30 years.

DESIGN

Description of outcomes based on electronic health records for a cohort of 375 young adults with PHIV enrolled in routine HIV care at clinics contributing data to the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

METHODS

We estimated overall, sex, and race-stratified cumulative incidences using Turnbull estimation, and incidence rates using quasi-Poisson regression. T2DM was defined as glycosylated hemoglobin more than 6.5% or based on clinical diagnosis and medication use. Hypercholesterolemia was based on medication use or total cholesterol at least 200 mg/dl. Hypertriglyceridemia was based on medication use or fasting triglyceride at least 150 mg/dl or nonfasting at least 200 mg/dl. Hypertension was based on clinical diagnosis. CKD was defined as estimated glomerular filtration rates less than 90 ml/mi|1.73 m 2 for at least 3 months.

RESULTS

Cumulative incidence by age 30 and incidence rates from age 18 to 30 (per 100 person-years) were T2DM: 19%, 2.9; hypercholesterolemia: 40%, 4.6; hypertriglyceridemia: 50%, 5.6; hypertension: 22%, 2.0; and CKD: 25%, 3.3. Non-Black women had the highest incidence of hypercholesterolemia and hypertriglyceridemia, Black adults had the highest hypertension incidence, and Black men had the highest CKD incidence.

CONCLUSION

There was a high incidence of five chronic comorbidities among people with PHIV. Earlier screening at younger ages might be considered for this unique population to strengthen prevention strategies and initiate treatment in a timely way.

The burden of secrecy in the management of multimorbidity in older people living with HIV aged 70 and over

The secrecy surrounding HIV continues to be a major concern for older people living with HIV (OPWH) despite their long-term experience of HIV and the presence of other chronic diseases. Our study aims to highlight how the secrecy surrounding HIV can affect the management of the other conditions. The results of this socio-anthropological sub-study of the ANRS EP66 SEPTAVIH study, which assesses frailty in OPWH, are based on in-depth interviews conducted with 20 OPWH with multimorbidities aged 70 years and over and 9 caregivers. Based on a cross-sectional thematic analysis, this study shows that HIV infection differs from other chronic diseases due to the secrecy and stigma associated with HIV. These specific issues associated with HIV complicate the lives of OPWH, depriving them of support from loved ones and forcing them to exclude their general practitioner from their care system. This then causes OPWH with multiple chronic diseases to become socially vulnerable and isolated. Interventions that support the sharing of information on HIV among OPWH and also among caregivers need to be identified as a matter of urgency in order to improve the lives and management of OPWH with multimorbidities.Trial Registration: ClinicalTrials.gov identifier: NCT03958786.

Determinants of receipt of prostate cancer screening among men living with HIV enrolled in an urban HIV Clinic in the United States over the period of 2000-2020

BACKGROUND

Prostate cancer is projected to account for the greatest proportion of cancer-related burden among men with HIV. However, incidence is reportedly lower than in men without HIV, potentially due to differences in screening. Factors influencing receipt of screening in men with HIV are unknown. We described receipt of prostate-specific antigen (PSA) testing and assessed factors for association with receipt of PSA test.

METHODS

Demographics, measures of HIV and related care, and non-HIV care were assessed for association with receipt of first PSA test in men ≥40 years old each calendar year in 2000-2020 using univariable and multivariable Poisson regression. Models were additionally stratified by calendar period to identify changes in determinants of PSA test as prostate cancer screening guidelines changed.

RESULTS

Men (n = 2,063) 72% Non-Hispanic Black, median age of 47 (IQR: 41, 53), contributed median of 4.7 years (IQR: 2.3, 10.0) of follow-up. Receipt of antiretroviral therapy (aIRR = 1.33; 95% CI: 1.14, 1.55), engagement in HIV care (aIRR = 2.09; 95% CI: 1.66, 2.62), history of testosterone-replacement therapy (aIRR = 1.34; 95% CI: 1.19, 1.50), urologist evaluation (aIRR = 1.66; 95% CI: 1.35, 2.05), and receipt of PSA test in preceding two years (no elevated PSA aIRR = 2.37; 95% CI: 2.16, 2.61; elevated PSA aIRR = 4.35; 95% CI: 3.24, 5.84) were associated with PSA testing in men aged 50 or older. Associations varied across calendar time.

CONCLUSION

Findings suggest men with greater interaction with healthcare are more likely to receive PSA test. Measures of control of HIV did not appear to influence the decision to screen.

Age-associated dementia among older people aging with HIV in the United States: a modeling study

OBJECTIVE

Almost 400 000 people with HIV (PWH) in the United States are over age 55 years and at risk for age-associated dementias (AAD), including Alzheimer's disease and vascular contributions to cognitive impairment and dementia (VCID). We projected the cumulative incidence and mortality associated with AAD among PWH at least 60 years in the United States compared with the general population.

DESIGN/METHODS

Integrating the CEPAC and AgeD-Pol models, we simulated two cohorts of 60-year-old male and female individuals: PWH, and the general US population. We estimated AAD incidence and AAD-associated mortality rates. Projected outcomes included AAD cumulative incidence, life expectancy, and quality-adjusted life-years (QALYs). We performed sensitivity and scenario analyses on AAD-specific (e.g. incidence) and HIV-specific (e.g. disengagement from HIV care) parameters, as well as premature aging among PWH.

RESULTS

We projected that 22.1%/16.3% of 60-year-old male individuals/female individuals with HIV would develop AAD by 80 years compared with 15.9%/13.3% of male individuals/female individuals in the general population. Accounting for age-associated and dementia-associated quality of life, 60-year-old PWH would have a lower life expectancy (QALYs): 17.4 years (14.1 QALYs) and 16.8 years (13.4 QALYs) for male and female individuals, respectively, compared with the general population [male individuals, 21.7 years (18.4 QALYs); female individuals, 24.7 years (20.2 QALYs)]. AAD cumulative incidence was most sensitive to non-HIV-related mortality, engagement in HIV care, and AAD incidence rates.

CONCLUSION

Projected estimates of AAD-associated morbidity, mortality, and quality of life can inform decision-makers and health systems planning as the population of PWH ages. Improved AAD prevention, treatment, and supportive care planning are critical for people aging with HIV.

An update on drug-drug interactions in older adults living with human immunodeficiency virus (HIV)

INTRODUCTION

People with HIV are living longer due to advances in antiretroviral therapy. With improved life expectancy comes an increased lifetime risk of comorbid conditions - such as cardiovascular disease and cancer - and polypharmacy. Older adults, particularly those living with HIV, are more vulnerable to drug interactions and adverse effects, resulting in negative health outcomes.

AREA COVERED

Antiretrovirals are involved in many potential drug interactions with medications used to treat common comorbidities and geriatric conditions in an aging population of people with HIV. We review the mechanisms and management of significant drug-drug interactions involving antiretroviral medications and non-antiretroviral medications commonly used among older people living with HIV. The management of these interactions may require dose adjustments, medication switches to alternatives, enhanced monitoring, and considerations of patient- and disease-specific factors.

EXPERT OPINION

Clinicians managing comorbid conditions among older people with HIV must be particularly vigilant to side effect profiles, drug-drug interactions, pill burden, and cost when optimizing treatment. To support healthier aging among people living with HIV, there is a growing need for antiretroviral stewardship, multidisciplinary care models, and advances that promote insight into the correlations between an individual, their conditions, and their medications.

Enhancing the delivery of comprehensive care for people living with HIV in Canada: insights from citizen panels and a national stakeholder dialogue

BACKGROUND

People living with human immunodeficiency virus (HIV) are living longer with health-related disability associated with ageing, including complex conditions. However, health systems in Canada have not adapted to meet these comprehensive care needs.

METHODS

We convened three citizen panels and a national stakeholder dialogue. The panels were informed by a plain-language citizen brief that outlined data and evidence about the challenge/problem, elements of an approach for addressing it and implementation considerations. The national dialogue was informed by a more detailed version of the same brief that included a thematic analysis of the findings from the panels.

RESULTS

The 31 citizen panel participants emphasized the need for more prevention, testing and social supports, increased public education to address stigma and access to more timely data to inform system changes. The 21 system leaders emphasized the need to enhance person-centred care and for implementing learning and improvement across provinces, territories and Indigenous communities. Citizens and system leaders highlighted that policy actions need to acknowledge that HIV remains unique among conditions faced by Canadians.

CONCLUSIONS

Action will require a national learning collaborative to support spread and scale of successful prevention, care and support initiatives. Such a collaborative should be grounded in a rapid-learning and improvement approach that is anchored on the needs, perspectives and aspirations of people living with HIV; driven by timely data and evidence; supported by appropriate decision supports and aligned governance, financial and delivery arrangements; and enabled with a culture of and competencies for rapid learning and improvement.

Incidence of prostate cancer in Medicaid beneficiaries with and without HIV in 2001-2015 in 14 states

Background

Prostate cancer is projected to be the most common cancer among people living with HIV; however, incidence of prostate cancer has been reported to be lower in men with HIV compared to men without HIV with little evidence to explain this difference. We describe prostate cancer incidence by HIV status in Medicaid beneficiaries, allowing for comparison of men with and without HIV who are similar with respect to socioeconomic characteristics and access to healthcare.

Methods

Medicaid beneficiaries (N=15,167,636) aged 18-64 with ≥7 months of continuous enrollment during 2001-2015 in 14 US states were retained for analysis. Diagnoses of HIV and prostate cancer were identified using inpatient and other non-drug claims. We estimated cause-specific (csHR) and sub-distribution hazard ratios comparing incidence of prostate cancer by HIV status, adjusted for age, race-ethnicity, state of residence, year of enrollment, and comorbid conditions. Models were additionally stratified by age and race-ethnicity.

Results

There were 366 cases of prostate cancer observed over 299,976 person-years among beneficiaries with HIV and 17,224 cases over 22,298,914 person-years in beneficiaries without HIV. The hazard of prostate cancer was lower in men with HIV than men without HIV (csHR=0.89; 95% CI: 0.80, 0.99), but varied by race-ethnicity, with similar observations among non-Hispanic Black (csHR=0.79; 95% CI: 0.69, 0.91) and Hispanic (csHR=0.85; 95% CI: 0.67, 1.09), but not non-Hispanic white men (csHR=1.17; 95% CI: 0.91, 1.50). Results were similar in models restricted to ages 50-64 and 40-49, except for a higher hazard of prostate cancer in Hispanic men with HIV in their 40s, while the hazard of prostate cancer was higher in men with HIV across all models for men aged 18-39.

Conclusion

Reported deficits in prostate cancer incidence by HIV status may be restricted to specific groups defined by age and race-ethnicity.

Correlates of Breakthrough SARS-CoV-2 Infections in People with HIV: Results from the CIHR CTN 328 Study

COVID-19 breakthrough infection (BTI) can occur despite vaccination. Using a multi-centre, prospective, observational Canadian cohort of people with HIV (PWH) receiving ≥2 COVID-19 vaccines, we compared the SARS-CoV-2 spike (S) and receptor-binding domain (RBD)-specific IgG levels 3 and 6 months post second dose, as well as 1 month post third dose, in PWH with and without BTI. BTI was defined as positivity based on self-report measures (data up to last study visit) or IgG data (up to 1 month post dose 3). The self-report measures were based on their symptoms and either a positive PCR or rapid antigen test. The analysis was restricted to persons without previous COVID-19 infection. Persons without BTI remained COVID-19-naïve until ≥3 months following the third dose. Of 289 participants, 92 developed BTI (31.5 infections per 100 person-years). The median days between last vaccination and BTI was 128 (IQR 67, 176), with the most cases occurring between the third and fourth dose (n = 59), corresponding to the Omicron wave. In analyses adjusted for age, sex, race, multimorbidity, hypertension, chronic kidney disease, diabetes and obesity, a lower IgG S/RBD (log10 BAU/mL) at 1 month post dose 3 was significantly associated with BTI, suggesting that a lower IgG level at this time point may predict BTI in this cohort of PWH.

An overview of multimorbidity and polypharmacy in older people living with HIV

The availability of effective antiretroviral therapy (ART) has revolutionized the care of people living with HIV (PLHIV). As a result, PLHIV now have a life expectancy comparable with that of the general population. PLHIV are increasingly confronted with age-related comorbidities and geriatric syndromes, including frailty and polypharmacy, which occur at a higher prevalence and set in at an earlier age compared with their uninfected counterparts. The underlying pathophysiology for multimorbidity and polypharmacy are multifactorial, multidimensional and complex. Therefore, regular review and optimization of risk factors to maintain physical function, social and psychological health is of utmost importance. With an ever-growing population of older PLHIV, there is a pressing need to provide holistic care to address these emerging issues. Accelerated aging observed in PLHIV suggests that early involvement of a multidisciplinary team, including geriatricians, and implementation of integrated models of care can potentially improve the care of older PLHIV, who are at increased risk of frailty and complex multimorbidity. This article reviews the current global situation, discusses the challenges involved and suggests approaches to deliver comprehensive care for older PLHIV. Geriatr Gerontol Int 2024; 24: 49-59.

Combining Charlson comorbidity and VACS indices improves prognostic accuracy for all-cause mortality for patients with and without HIV in the Veterans Health Administration

Introduction

As people age with HIV (PWH), many comorbid diseases are more common than among age matched comparators without HIV (PWoH). While the Veterans Aging Cohort (VACS) Index 2.0 accurately predicts mortality in PWH using age and clinical biomarkers, the only included comorbidity is hepatitis C. We asked whether adding comorbid disease groupings from the Charlson Comorbidity Index (CCI) improves the accuracy of VACS Index.

Methods

To maximize our ability to model mortality among older age groups, we began with PWoH in Veterans Health Administration (VA) from 2007-2017, divided into development and validation samples. Baseline predictors included age, and components of CCI and VACS Index (excluding CD4 count and HIV RNA). Patients were followed until December 31, 2021. We used Cox models to develop the VACS-CCI score and estimated mortality using a parametric (gamma) survival model. We compared accuracy using C-statistics and calibration curves in validation overall and within subgroups (gender, age

Results

The analytic sample consisted of 6,588,688 PWoH and 30,539 PWH. Among PWoH/PWH, median age was 65/55 years; 6%/3% were women; 15%/48% were Black and 5%/7% Hispanic. VACS-CCI provided the best discrimination (C-statistic = 0.81) with excellent calibration (predicted and observed mortality largely overlapped) overall and within subgroups. When VACS-CCI was applied to PWH it demonstrated similar discrimination as VACS Index 2.0 (C-statistic = 0.77 for both) but superior calibration among those with CD4 < 200. Discrimination was improved when CD4 and HIV RNA were added VACS-CCI (C-statistic = 0.79). Liver and kidney disease, congestive heart failure, malignancy, and dementia were negatively associated with CD4 (p-trends all <0.0001).

Discussion

Among PWH and PWoH in VA care, age alone weakly discriminates risk of mortality. VACS Index 2.0, CCI, and VACS-CCI all provide better discrimination, but VACS-CCI is more consistently calibrated. The association of comorbid diseases with lower CD4 underscores the likely role of HIV in non-AIDS conditions. Future work will include adding CD4 and HIV RNA to VACS-CCI and validating it in independent data.

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Key Words

• Charlson Comorbidity Index
• HIV
• VACS Index
• mortality
• prediction

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MESH Headings Collapse

Grants

• P30 AI050409 NIAID NIH HHS
• P01 AA029545 NIAAA NIH HHS
• U01 AA020795 NIAAA NIH HHS
• U10 AA013566 NIAAA NIH HHS
• U01 AA020790 NIAAA NIH HHS
• U24 AA020794 NIAAA NIH HHS

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Affiliation(s)

Kathleen A. McGinnis VA Connecticut Healthcare System, West Haven, CT, United States
Amy C. Justice VA Connecticut Healthcare System, West Haven, CT, United States Yale School of Medicine, New Haven, CT, United States
Vincent C. Marconi The Atlanta Veterans Affairs Medical Center, Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, United States VA Medical Center, Decatur, GA, United States
Maria C. Rodriguez-Barradas Infectious Diseases Section, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, United States Department of Medicine, Baylor College of Medicine, Houston, TX, United States
Ronald G. Hauser VA Connecticut Healthcare System, West Haven, CT, United States Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States
Krisann K. Oursler Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States VA Salem Healthcare System, Salem, VA, United States
Sheldon T. Brown James J. Peters VA Medical Center, Bronx, NY, United States
Kendall J. Bryant National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, United States
Janet P. Tate VA Connecticut Healthcare System, West Haven, CT, United States Yale School of Medicine, New Haven, CT, United States
for the Veterans Aging Cohort Study

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The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study

BACKGROUND

Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030.

METHODS AND FINDINGS

Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts.

CONCLUSIONS

The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

Hospital Readmissions Among Persons With Human Immunodeficiency Virus in the United States and Canada, 2005-2018: A Collaboration of Cohort Studies

BACKGROUND

Hospital readmission trends for persons with human immunodeficiency virus (PWH) in North America in the context of policy changes, improved antiretroviral therapy (ART), and aging are not well-known. We examined readmissions during 2005-2018 among adult PWH in NA-ACCORD.

METHODS

Linear risk regression estimated calendar trends in 30-day readmissions, adjusted for demographics, CD4 count, AIDS history, virologic suppression (<400 copies/mL), and cohort.

RESULTS

We examined 20 189 hospitalizations among 8823 PWH (73% cisgender men, 38% White, 38% Black). PWH hospitalized in 2018 versus 2005 had higher median age (54 vs 44 years), CD4 count (469 vs 274 cells/μL), and virologic suppression (83% vs 49%). Unadjusted 30-day readmissions decreased from 20.1% (95% confidence interval [CI], 17.9%-22.3%) in 2005 to 16.3% (95% CI, 14.1%-18.5%) in 2018. Absolute annual trends were -0.34% (95% CI, -.48% to -.19%) in unadjusted and -0.19% (95% CI, -.35% to -.02%) in adjusted analyses. By index hospitalization reason, there were significant adjusted decreases only for cardiovascular and psychiatric hospitalizations. Readmission reason was most frequently in the same diagnostic category as the index hospitalization.

CONCLUSIONS

Readmissions decreased over 2005-2018 but remained higher than the general population's. Significant decreases after adjusting for CD4 count and virologic suppression suggest that factors alongside improved ART contributed to lower readmissions. Efforts are needed to further prevent readmissions in PWH.

Examining the Association Between a Modified Quan-Charlson Comorbidity Index and HIV Viral Suppression: A Cross-Sectional Analysis of DC Cohort Participants

With the advancement of effective antiretroviral therapy, people with HIV live longer, and many are developing non-AIDS comorbidities. It is important to assess how comorbidities are associated with HIV-related health outcomes, such as viral suppression (VS). The aim of this study was to analyze the association between comorbidity burden, measured using a modified Quan-Charlson Comorbidity Index (QCCI), and VS (viral load result of <200 copies/mL). We hypothesized that an increase in QCCI score, indicating a higher risk for mortality, would correlate with lower likelihood of VS because of the burden of comorbidity treatment, possibly leading to worse antiretroviral adherence. Our analysis included participants from the DC Cohort Longitudinal HIV Study in Washington, DC. Eligible participants were aged ≥18 years and enrolled in the cohort as of January 1, 2018 (n = 2,471). A modified QCCI score, which weighs selected comorbidities (not including HIV/AIDS) and predicts mortality, was calculated using International Classification of Disease-9/10 codes from electronic health records. Multivariable logistic regressions were used to characterize the association between QCCI composite scores and VS. Participants were predominantly virally suppressed (89.6%), male (73.9%), non-Hispanic Black (74.7%), and between 18 and 55 years (59.3%). The median QCCI score was 1 (range = 1-12, interquartile range = 0-2), demonstrating predominately low mortality risk. We did not establish a statistically significant association between QCCI score and VS (adjusted odds ratio = 1.06, 95% confidence interval 0.96-1.17). Our findings suggest that a higher QCCI score was not associated with lower VS in this population, which may be partly due to the high retention in care among cohort participants.

Considerations for long-acting antiretroviral therapy in older persons with HIV

People with HIV (PWH) can now enjoy longer, healthier lives due to safe and highly effective antiretroviral therapy (ART), and improved care and prevention strategies. New drug formulations such as long-acting injectables (LAI) may overcome some limitations and issues with oral antiretroviral therapy and strengthen medication adherence. However, challenges and questions remain regarding their use in aging populations. Here, we review unique considerations for LAI-ART for the treatment of HIV in older PWH, including benefits, risks, pharmacological considerations, implementation challenges, knowledge gaps, and identify factors that may facilitate uptake of LA-ART in this population.

Impaired gut microbiota-mediated short-chain fatty acid production precedes morbidity and mortality in people with HIV

Antiretroviral therapy (ART) has dramatically lengthened lifespan among people with HIV (PWH), but this population experiences heightened rates of inflammation-related comorbidities. HIV-associated inflammation is linked with an altered microbiome; whether such alterations precede inflammation-related comorbidities or occur as their consequence remains unknown. We find that ART-treated PWH exhibit depletion of gut-resident bacteria that produce short-chain fatty acids (SCFAs)-crucial microbial metabolites with anti-inflammatory properties. Prior reports establish that fecal SCFA concentrations are not depleted in PWH. We find that gut-microbiota-mediated SCFA production capacity is better reflected in serum than in feces and that PWH exhibit reduced serum SCFA, which associates with inflammatory markers. Leveraging stool and serum samples collected prior to comorbidity onset, we find that HIV-specific microbiome alterations precede morbidity and mortality in ART-treated PWH. Among these microbiome alterations, reduced microbiome-mediated conversion of lactate to propionate precedes mortality in PWH. Thus, gut microbial fiber/lactate conversion to SCFAs may modulate HIV-associated comorbidity risk.

Cardiovascular health among persons with HIV without existing atherosclerotic cardiovascular disease

OBJECTIVES

We sought to characterize atherosclerotic cardiovascular disease (ASCVD) risk and metrics of cardiovascular health in persons with HIV (PWH) eligible for primary prevention of ASCVD.

DESIGN

A cross-sectional study of PWH 40 years and older without documented ASCVD who received care at three HIV clinics in San Francisco from 2019 to 2022.

METHODS

We used ICD-10 codes and electronic health record data to assess ASCVD risk and cardiovascular health, as defined by the American Heart Association's Life's Essential 8 (LE8) metrics for nicotine exposure, BMI, lipids, glucose, and blood pressure (BP).

RESULTS

Among 2567 PWH eligible for primary prevention of ASCVD, the median age was 55 years, 14% were women, and 95% were on antiretroviral therapy. Seventy-seven percent had undergone complete assessment of ASCVD risk factors, and 50% of these patients had intermediate-high ASCVD risk (≥7.5%). Of those with hypertension, 39% were prescribed an antihypertensive. Among those eligible, 43% were prescribed a statin. The mean LE8 cardiovascular health score [0--100 (best health)] was 55.1 for nicotine exposure, 71.3 for BMI, 70.4 for lipids, 81.2 for blood glucose, 56.0 for BP, with an average score of 66.2 across the five metrics. Patients with Medicare insurance, black patients, and those with sleep apnea and chronic kidney disease had on average lower cardiovascular health scores; patients with undetectable viral loads had higher cardiovascular health scores.

CONCLUSION

We highlight opportunities for improving primary prevention of ASCVD among PWH, especially in the areas of guideline-based therapy, nicotine exposure, and BP control.

The prevalence of multimorbidity in virally suppressed HIV-positive patients in Limpopo

Background

Non-communicable diseases (NCDs) are an emerging global public health problem.

Objectives

To assess the prevalence of NCDs and their risk factors among adults on antiretroviral therapy (ART).

Method

This was a cross-sectional study (July 2019 - January 2020) in Limpopo, South Africa. Patients were enrolled if they were ≥ 40 years, HIV-positive, and virologically suppressed on ART. Data were analysed descriptively, and a binomial regression model was used to identify risk factors for NCDs.

Results

The majority of participants (65%; 319/488) were women. Most (83%; 405/488) were aged 40-59 years; 60% (285/472) were overweight or obese. Based on self-report, 22% (107/488) were currently smokers. Almost half (44%) 213/488) reported daily consumption of vegetables and 65% (319/488) exercised regularly and 39% (190/488) reported treatment for another chronic disease. The leading comorbid conditions were hypertension (32%; 158/488) and diabetes mellitus (5%; 24/488). Risk factors for hypertension included age 60 years and older (relative risk [RR]: 1.72; 95% confidence interval [CI]: 1.29-2.30) diabetes (RR: 1.42; 95% CI: 1.08-1.87), overweight (RR: 1.32; 95% CI: 1.03-1.69) and obesity (RR: 1.69; 95% CI: 1.32-2.17).

Conclusion

There is a high prevalence, both of risk factors for NCDs and multimorbidity (> 1 chronic disease) in patients who are ≥ 40 years and virologically suppressed on ART.

Evaluation of Glomerular Filtration Rate Trends in People Living With HIV Corrected by the Baseline Glomerular Filtration Rate

BACKGROUND

Chronic kidney disease, for which estimated glomerular filtration rate (eGFR) trajectories are early markers, is frequent in people living with HIV.

SETTING

Identify eGFR trajectory patterns according to kidney function and assess associated factors over a 13-year follow-up period.

METHODS

We evaluated longitudinal changes and its associated factors in eGFR of 3366 participants according to kidney function with a 2-level, linear, mixed model.

RESULTS

Participants with initial kidney dysfunction experienced a slight eGFR increase, whereas others showed a slight decrease. A weak relationship was observed between baseline eGFR and its variation over time. Baseline eGFR was affected by age, CD4 + count, viral load, hypertension, hyperlipidemia, AIDS-defining illness and tenofovir (TDF) with integrase inhibitor (INSTI) or efavirenz. Significant factors for eGFR change included the following: in kidney dysfunction, CD4 + cell count of >350 cells per cubic millimeter and undetectable viral load increased eGFR, whereas TDF + protease inhibitor decreased eGFR; in mildly decreased kidney function, CD4 + cell count of >350 cells per cubic millimeter, AIDS-defining illness, and TDF + efavirenz increased eGFR, whereas age, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR; in normal kidney function, age, CD4 + cell count of > 350 cells per cubic millimeter, undetectable viral load, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR, whereas TDF + efavirenz increased eGFR (all P value for interaction < 0.05).

CONCLUSION

Our findings suggest that eGFR trajectories varied widely between individuals in people living with HIV. In the lower eGFR group, virus-related factors were more relevant, whereas traditional risk factors for renal dysfunction were more prominent in the highest eGFR group.

What are the predictors of change in multimorbidity among people with HIV? A longitudinal observational cohort study

INTRODUCTION

Multimorbidity is common among people living with HIV (PLWH), with numerous cross-sectional studies demonstrating associations with older age and past immunosuppression. Little is known about the progression of multimorbidity, particularly in the setting of long-term access to antiretrovirals. This study aims to determine factors predictive of change in multimorbidity in PLWH.

METHODS

People living with HIV who attended a regional HIV service were recruited to a consented observational cohort between September 2016 and March 2020. Demographic data, laboratory results and a Cumulative Illness Rating Scale (CIRS) were collected at enrolment and first clinical review of every subsequent year. Change in CIRS score was calculated from enrolment to February 2021. Associations with change were determined through univariate and multivariate linear regression.

RESULTS

Of 253 people, median age was 58.9 [interquartile range (IQR): 51.9-64.4] years, 91.3% were male, and HIV was diagnosed a median of 22.16 years (IQR: 12.1-30.9) beforehand. Length of time in the study was a median of 134 weeks (IQR: 89.0-179.0), in which a mean CIRS score change of 1.21 (SD 2.60) was observed. Being older (p < 0.001) and having a higher body mass index (p = 0.008) and diabetes (p = 0.014) were associated with an increased likelihood of worsening multimorbidity. PLWH with a higher level of multimorbidity at baseline were less likely to worsen over time (p < 0.001).

CONCLUSION

As diabetes and weight predict worsening multimorbidity, routine diabetes screening, body mass index measurement, and multimorbidity status awareness are recommended.

Prevalence and Correlates of Cardiovascular, Pulmonary, Cancer, and Mental Health Comorbidities Among Adults With HIV Who Smoke

ABSTRACT

Using data from the D.C. Cohort Longitudinal HIV Study, we examined (a) diagnosed mental health and (b) cardiovascular, pulmonary, or cancer (CPC) comorbidity among adults with HIV who smoked. Among 8,581 adults, 4,273 (50%) smoked; 49% of smokers had mental health, and 13% of smokers had a CPC comorbidity. Among smokers, non-Hispanic Black participants had a lower risk for mental health (prevalence ratio [PR]: 0.69; 95% confidence interval [CI] [0.62-0.76]) but a higher risk for CPC (PR: 1.17; 95% CI [0.84-1.62]) comorbidity. Male participants had a lower risk for mental health (PR: 0.88; 95% CI [0.81-0.94]) and CPC (PR: 0.68; 95% CI [0.57-0.81]) comorbidity. All metrics of socioeconomic status were associated with a mental health comorbidity, but only housing status was associated with a CPC comorbidity. We did not find any association with substance use. Gender, socioeconomic factors, and race/ethnicity should inform clinical care and the development of smoking cessation strategies for this population.

Perceptions of multiple chronic conditions and coping strategies among migrants from Sub-Saharan Africa living in France with diabetes mellitus and HIV: An interview-based qualitative study

Although diabetes is common among people living with HIV/AIDS (PLWHA), few data exists on how migrants from Sub-Saharan Africa (SSA) experience living with these two coexisting conditions in France. The objective of this study was to analyze perception of polypathology among PLWHA from SSA with type 2 diabetes and identify barriers and facilitators to their self-management. A qualitative study was conducted using semi-structured interviews from November 2019 to April 2020 with participants selected from a cohort of PLWHA and diabetes at Avicenne University Hospital. A total of 12 semi-structured interviews were conducted and analyzed using thematic analysis with inductive approach. Stigma remained a major issue in self-managing HIV, and some participants did not consider themselves as having a polypathology, as HIV has always been considered as a distinct condition. In general, emotion-based resources (e.g spirituality, trust in the medical discourse) and social support were mobilized more than problem-solving resources (e.g perception of medication as life-saving). Participants used the same main resource in self-management of HIV and diabetes, and resources used differed from participant to participant. This study highlighted challenges in self-management of diabetes and HIV in this population and complexity related to the socioeconomic and cultural specificities. Self-management could be more successful if patients and carers move in the same direction, having identified the individual coping resources to reach objectives.

Sleep disturbances and their correlation with cardiovascular risk, obesity, and mood disorders in people with HIV

BACKGROUND

The relationship between sleep disorders (SDs), cardiovascular risk (CVR), and mood disorders (MDs) has been studied in detail in the general population, but far less in people with HIV (PWH).

METHODS

Cross-sectional analysis in single centre cohort of PWH. Sleep quality was assessed using by Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Berlin Questionnaire (BQ), Pittsburgh Sleep Quality Index (PSQI); anxiety and depression were evaluated by the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9. Demographic, clinical and HIV-related data were collected, and Framingham and Data collection on Adverse effects of anti-HIV Drugs (DAD)-10 scores were computed in modelling associations with each SDs scale.

RESULTS

Data were collected for 721 PWH on stable combination antiretroviral therapy (cART) (median age of 53 years, 71.8% males, 96% with undetectable HIV RNA, 50.3% on cART potentially affecting sleep, and 20.4% on hypno-inducing drugs), 76.9% had SDs 60.3, 31.3, 31.1, and 7.9% at PSQI, BQ, ISI, and ESS, respectively. Anxiety and depression were detected in 28.3 and 16.1% participants, respectively. BQ score was independently associated with high BMI ( P  < 0.001), Framingham risk >10% ( P  < 0.001), and both DAD-10R and -10F score >10% ( P  < 0.001 and P  = 0.031). PSQI and ISI scores were independently associated with depression and anxiety ( P  < 0.001). No association between SDs and specific antiretroviral regimens, nor HIV-related parameters was detected.

CONCLUSIONS

In our cohort of PWH on stable ART, despite the alarmingly higher prevalence, SDs were associated with the same determinants (cardiovascular risk factors and MDs) observed in the general population.

Risk factors associated with 30-day hospital readmissions among persons living with HIV in Nantong, China

OBJECTIVE

To estimate 30-day hospital readmission rates among persons living with HIV (PLWH) at the Nantong Infectious Disease Hospital in China and analyse the related risk factors.

METHODS

A single-centre retrospective cohort study was conducted. There were 894 PLWH records obtained from the electronic medical record (EMR) system at the Nantong Infectious Disease Hospital in China, from October 2013 to February 2018. The 30-day readmission rates were calculated, and the risk factors were analysed by generalised estimating equations (GEEs).

RESULTS

A total of 1153 hospitalizations from 894 patients were recorded between October 2013 and February 2018. The median time of 30-day readmissions was 13 days (interquartile range (IQR), 6-23). The reasons for all causes, acquired immunodeficiency syndrome (AIDS)-defining illnesses (ADIs), and non-AIDS-defining infections (non-ADIs) were 9.08, 13.52, and 7.91%, respectively. The results from the GEE analysis demonstrated that the risk factors associated with 30-days readmissions were as follows: no antiretroviral therapy (ART) prior to hospitalisations (odds ratio (OR) = 1.90, 95% confidence interval (CI): 1.21-3.00), low CD4 counts (OR = 2.17, 95% CI: 1.33-3.54), and multiple comorbidities (OR = 6.45, 95% CI: 1.62-25.73).

CONCLUSION

Early detection of HIV infection and early initiation of ART treatment are the keys to controlling 30-day readmissions.

Cardiometabolic Diseases and Quality-of-Life Outcomes in Adults With HIV in the Deep South: A Cross-sectional Study

ABSTRACT

The role of cardiometabolic diseases (CMDs) on physical health-related quality of life (P-HRQoL) and quality of sleep was examined among 261 PLWH ≥40 years, recruited from a university-affiliated HIV clinic in the Deep U.S. South. Using a cross-sectional study design, participants completed the Medical Outcomes Study HIV Health Survey (MOS-HIV; P-HRQoL) and Pittsburgh Sleep Quality Index. The overall prevalence of self-reporting ≥1 CMD was 64.4%. P-HRQoL scores were lower in PLWH with ≥1 CMD compared with those with no CMDs (45.53 ± 11.54 vs. 49.67 ± 10.77, p <.01). Poor sleep quality was higher among participants with ≥1 CMD compared with those with no CMDs (9.28 ± 4.42 vs. 7.26 ± 4.17, p <.01). Each additional CMD resulted in a 1.83-point decrease in P-HRQoL and 0.74-point increase in poor sleep quality scores. Interventions that focus on targeting these quality-of-life domains in PLWH with CMDs are needed.

Defining multimorbidity in people with HIV - what matters most?

PURPOSE OF REVIEW

Although multimorbidity (defined as the coexistence of multiple conditions) presents significant health challenges to people with HIV, there is currently no consensus on how it should be defined among this population. This review aimed to examine the definition of multimorbidity in existing studies among people with HIV ( n  = 22).

RECENT FINDINGS

Variation in the definition of multimorbidity (in terms of the number and nature of conditions included) across studies among people with HIV was observed, with less than half (45%) reporting a selection criteria for conditions. The number of conditions considered ranged from 4 to 65. Certain conditions (e.g. stroke, myocardial infarction and chronic kidney disease) and risk factors (e.g. hypertension) were more frequently included, while other symptoms (e.g. joint pain, peripheral neuropathy and sleeping problems) and mental health conditions (e.g. anxiety and panic attacks) were rarely included in the definition of multimorbidity.

SUMMARY

The definition of multimorbidity among people with HIV is highly variable, with certain conditions overlooked. We propose recommendations that researchers should consider when defining multimorbidity among this population to not only enable comparisons between studies/settings but also to ensure studies consider a person-centred approach that can accurately capture multimorbidity among people with HIV.

New onset type 2 diabetes mellitus risks with integrase strand transfer inhibitors-based regimens: A systematic review and meta-analysis

Objectives

The development of diabetes mellitus (DM) in patients taking integrase strand transfer inhibitors (INSTIs) has raised concerns. It's critical because, in most guidelines, INSTIs are the preferred third agent at first-line regimens. This study investigates the excess risk of developing DM among people living with HIV (PWH) on INSTIs-based regimens compared to those with other combination antiretroviral therapies (cART).

Methods

A search from PubMed, clinicaltrials.gov, Latin America and Caribbean health sciences literature, Cochrane, and google scholar to retrieve case-control and cohort studies were done. The literature search was performed for studies from January 2007 to January 2021. Data were extracted from studies and pooled as risk ratios (RR) with a 95% confidence interval (CI) using Stata 14 software. The protocol was registered in PROSPERO, ID: CRD42021230282.

Results

This review included ten studies, resulting in 62 400 participants. There was no significant difference in the incidence of DM between participants receiving INSTIs-based regimens versus other cARTs (RR 0.97, 95% CI: 0.92-1.03; participants = 50 958; studies = 4; I² = 86.8%, chi-square = 22.67). There is no statistically significant difference in DM among people treated with INSTIs-based regimens compared to those treated with boosted protease inhibitors (PIs)-based regimens (RR 0.97, 95% CI 0.92-1.03; participants = 49 840; studies = 3; I² = 89.3%, chi-square = 18.65). DM incidence was lower in INSTIs-based regimens than in those using non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based regimens (RR 0.80, 95% CI 0.69-0.91; participants = 42 346; studies = 2; I² = 0%, chi-square = 0.18).

Conclusion

The present review shows a nonsignificant difference in the incidence of DM in patients receiving INSTIs-based regimens compared to other regimens. However, there was a lower incidence of DM in the INSTIs group compared to the NNRTIs-based and PIs compared to the NNRTIs-based. When the INSTIs drugs dolutegravir, raltegravir, and elvitegravir were compared, there was a lower incidence of DM in raltegravir compared with elvitegravir.

Resistance to Prostaglandin E2 Promotes Monocyte Activation During Chronic HIV Infection

BACKGROUND

Monocyte activation is a driver of inflammation in the course of chronic HIV infection. Prostaglandin E2 (PGE2) is known to mediate anti-inflammatory effects, notably the inhibition of tumor necrosis factor- (TNF-) production by monocytes. We aim to investigate the effects of PGE2 on activation of monocytes in chronic HIV infection and the mechanisms through which PGE2 modulates their inflammatory signature.

METHODS

We recruited a group of people with HIV (PWH) and matched healthy uninfected persons. We compared plasma levels of PGE2, monocyte activation, and sensitivity of monocytes to the inhibitory actions mediated by PGE2.

RESULTS

We found increased plasma levels of PGE2 in PWH, and an activated phenotype in circulating monocytes, compared with uninfected individuals. Monocytes from PWH showed a significant resistance to the inhibitory actions mediated by PGE2; the concentration of PGE2 able to inhibit 50 of the production of TNF- by lipopolysaccharide-stimulated monocytes was 10 times higher in PWH compared with uninfected controls. Furthermore, the expression of phosphodiesterase 4B, a negative regulator of PGE2 activity, was significantly increased in monocytes from PWH.

CONCLUSIONS

Resistance to the inhibitory actions mediated by PGE2 could account, at least in part, for the inflammatory profile of circulating monocytes in PWH.

Cumulative Human Immunodeficiency Virus (HIV)-1 Viremia Is Associated With Increased Risk of Multimorbidity Among US Women With HIV, 1997-2019

Background

To evaluate the effect of cumulative human immunodeficiency virus (HIV)-1 viremia on aging-related multimorbidity among women with HIV (WWH), we analyzed data collected prospectively among women who achieved viral suppression after antiretroviral therapy (ART) initiation (1997-2019).

Methods

We included WWH with ≥2 plasma HIV-1 viral loads (VL) <200 copies/mL within a 2-year period (baseline) following self-reported ART use. Primary outcome was multimorbidity (≥2 nonacquired immune deficiency syndrome comorbidities [NACM] of 5 total assessed). The trapezoidal rule calculated viremia copy-years (VCY) as area-under-the-VL-curve. Cox proportional hazard models estimated the association of time-updated cumulative VCY with incident multimorbidity and with incidence of each NACM, adjusting for important covariates (eg, age, CD4 count, etc).

Results

Eight hundred six WWH contributed 6368 women-years, with median 12 (Q1-Q3, 7-23) VL per participant. At baseline, median age was 39 years, 56% were Black, and median CD4 was 534 cells/mm3. Median time-updated cumulative VCY was 5.4 (Q1-Q3, 4.7-6.9) log10 copy-years/mL. Of 211 (26%) WWH who developed multimorbidity, 162 (77%) had incident hypertension, 133 (63%) had dyslipidemia, 60 (28%) had diabetes, 52 (25%) had cardiovascular disease, and 32 (15%) had kidney disease. Compared with WWH who had time-updated cumulative VCY <5 log10, the adjusted hazard ratio of multimorbidity was 1.99 (95% confidence interval [CI], 1.29-3.08) and 3.78 (95% CI, 2.17-6.58) for those with VCY 5-6.9 and ≥7 log10 copy-years/mL, respectively (P < .0001). Higher time-updated cumulative VCY increased the risk of each NACM.

Conclusions

Among ART-treated WWH, greater cumulative viremia increased the risk of multimorbidity and of developing each NACM, and hence this may be a prognostically useful biomarker for NACM risk assessment in this population.

A Growing Number of Men Who Have Sex With Men Aging With HIV (20212031): A Comparison of Two Microsimulation Models

BACKGROUND

Men who have sex with men (MSM) on antiretroviral therapy (ART) are at risk for multimorbidity as life expectancy increases. Simulation models can project population sizes and age distributions to assist with health policy planning.

METHODS

We populated the CEPAC-US model with CDC data to project the HIV epidemic among MSM in the United States. The PEARL model was predominantly informed by NA-ACCORD data (20092017). We compared projected population sizes and age distributions of MSM receiving ART (20212031) and investigated how parameters and assumptions affected results.

RESULTS

We projected an aging and increasing population of MSM on ART: CEPAC-US, mean age 48.6 (SD 13.7) years in 2021 versus 53.9 (SD 15.0) years in 2031; PEARL, 46.7 (SD 13.2) years versus 49.2 (SD 14.6) years. We projected 548 800 MSM on ART (147 020 65 years) in 2031 (CEPAC-US) and 599 410 (113 400 65 years) (PEARL). Compared with PEARL, CEPAC-US projected a smaller population of MSM on ART by 2031 and a slower increase in population size, driven by higher estimates of disengagement in care and mortality.

CONCLUSIONS

Findings from two structurally distinct microsimulation models suggest that the MSM population receiving ART in the United States will increase and age over the next decade. Subgroup-specific data regarding engagement in care and mortality can improve projections and inform health care policy planning.

Ageing with HIV in the United States: Changing trends in inpatient hospital stays and comorbidities, 2003-2015

INTRODUCTION

As people with HIV (PWH) age, they experience prolonged exposure to HIV and antiretroviral therapy, increased risks of developing age-related HIV-associated non-AIDS (HANA) comorbidities and higher rates of hospitalization. Few studies have explored the ageing of PWH and its impact on hospital stays in the US. This study examined trends, characteristics and comorbidities associated with hospital stays with HIV (HSWH) as compared with hospital stays without HIV (HSWOH).

METHODS

Thirteen years of pooled National Inpatient Sample (NIS) data from 2003 through 2015 were analysed to describe yearly trends. Trends were evaluated for eight major HANA conditions (cardiovascular disease, cancer, diabetes, liver disease, bone loss, kidney disease, pulmonary disease and neurological disease) across four age groups (18-34, 35-49, 50-64, 65+ years).

RESULTS

Although overall rates of hospitalization reduced across all age groups, the proportion of HIV-related hospitalization increased among older Americans. The average number of chronic conditions was higher for HSWH among all age groups and disproportionately increased for older PWH. Although age-adjusted rates of cardiovascular disease, cancer, bone loss and pulmonary disease were lower for HSWH relative to HSWOH, rates increased disproportionately over the study period. The prevalence of all major HANA conditions except cancer and diabetes increased among the elderly (65+), and the prevalence of cardiovascular disease, cancer, bone loss, kidney disease and pulmonary disease also increased among patients aged 50-64 years.

CONCLUSIONS

Higher rates of hospitalizations and HANA comorbidities were observed among older HIV patients. The ageing of PWH suggests increased future hospital resource utilization for HSWH. Appropriate training of healthcare providers is essential to managing increased comorbidity burdens of older PWH during hospital stays in the US.

Frailty and Aging in HIV- Status Post 13 Years of National Awareness

The People aged 50 years and above comprise over 50% of people living with HIV (PLWH) in the US. Despite the advances made with anti-retroviral therapy in increasing their life span, PLWH are plagued with non-AIDS associated conditions which increase their risk for morbidity and mortality. Frailty, a decline in physical and functional reserve, is one of the manifestations of aging, has a prevalence of 5-30%, and occurs up to 2 decades earlier in people aging with HIV (PAWH). The majority of providers for PAWH have minimal experience with the concept of gerontology, frailty, and aging. Hence, there is a gap in clinicians' knowledge on how to address frailty and aging in PAWH. This review will focus on the clinical interventions that mitigate frailty and aging in PAWH as well as highlight areas of investigation towards achieving these mediations. Beyond the identification of the roles of exercise and nutrition, more studies are needed on the pragmatic approach to apply these resources to routine care. There should be continued reinforcement of the proven strategy of combination antiretroviral therapy as well as treatment of co-infections and age-appropriate health and cancer screening in PAWH.

Access to and quality of care for sexual and gender minority women living with HIV in Metro Vancouver, Canada: Results from a longitudinal cohort study

BACKGROUND

While scarce, literature suggests that women at the intersection of HIV status and gender and/or sexual minority identities experience heightened social and health disparities within health care systems.

OBJECTIVES

This study examines the association between sexual and/or gender minority identities and: (1) experiences of poor treatment by health professionals and (2) being unable to access health services among a cohort of women living with HIV in Metro Vancouver, Canada.

DESIGN

Data were drawn from a longitudinal community-based cohort of women living with HIV (Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment).

METHODS

We examined associations between sexual and/or gender minority identities and the two outcomes. We drew on explanatory variables to measure sexual minority and gender minority identities independently and a combined variable measuring sexual and/or gender minority identities. The associations between each of these three variables and each outcome were analysed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios and 95% confidence intervals are reported.

RESULTS

The study sample included 1460 observations on 315 participants over 4.5 years (September 2014 to February 2019). Overall, 125 (39.7%) reported poor treatment by health professionals and 102 (32.4%) reported being unable to access health care services when needed at least once over the study period. A total of 110 (34.9%) of participants reported sexual and/or gender minority identities, 106 (33.7%) reporting sexual minority identities, with 29 (9.2%) reporting gender minority identities. In multivariable analysis, adjusting for confounders, sexual minority identities, and combined sexual and/or gender minority identities were significantly associated with increased odds of experiencing poor treatment by health professionals (sexual minority adjusted odds ratio = 1.39 (0.94-2.05); sexual and/or gender minority adjusted odds ratio = 1.48 (1.00-2.18)) and being unable to access health services (sexual minority adjusted odds ratio = 1.89 (1.20-2.97); sexual and/or gender minority adjusted odds ratio = 1.91 (1.23-2.98)). In multivariable analysis, gender minority identities were not significantly associated with increased odds of experiencing poor treatment by health professionals (gender minority adjusted odds ratio = 1.38; 95% CI = 0.76-2.52) and being unable to access health services (gender minority adjusted odds ratio = 1.72; 95% CI = 0.89-3.31) possibly due to low sample size among women with gender minority identities.

CONCLUSION

Our findings suggest the need for access to inclusive, affirming, trauma-informed health care services tailored specifically for and by women living with HIV with sexual and/or gender minority identities.

HIV-1 tropism in low-level viral load HIV-1 infections during HAART in Guangdong, China

Background

Since only a few studies have been conducted on the factors associated with different HIV-1 tropisms in low-level viral load HIV-1 infections in China, we investigated the sequences of HIV-1 V3 loop in prevalent HIV-1 subtypes and factors related to HIV-1 tropism and immune recovery in HIV-1 infections after 6 months of highly active antiretroviral therapy (HAART) in Guangdong, China.

Methods

Plasma samples with HIV-1 RNA of 400-999 copies/mL were collected. We analyzed the amino acid sequence of the V3 loop by in silico prediction algorithms. Mann-Whitney and Chi-square tests were used for statistical comparison. Furthermore, logistic regression and multiple linear regression were used, respectively, for factors associated with 351 HIV-1 tropism and immune recovery of 67 cases with continued CD4⁺ T cell count during HAART.

Results

There was a lower percentage of HIV-1 R5-tropic virus in CRF01_AE (66.3%) (p < 0.0001) and CRF55_01B (52.6%) (p < 0.0001) compared with both CRF07_BC (96.1%) and CRF08_BC (97.4%), respectively. Compared with the R5-tropic virus, higher proportions of IIe8/Val8, Arg11/Lys11, and Arg18/His18/Lys18 were observed in the X4-tropic virus of CRF01_AE and CRF07_BC (p < 0.0001). The baseline CD4⁺ T cell count (p < 0.0001) and baseline CD4⁺ T/CD8⁺ T ratio (p = 0.0006) of all R5-tropic infections were higher than those in the X4-tropic infection. The baseline CD4⁺ T cell count (odds ratio [OR] 0.9963, p = 0.0097), CRF07_BC (OR 0.1283, p = 0.0002), and CRF08_BC (OR 0.1124, p = 0.0381) were associated with less HIV-1 X4-tropism. The baseline CD4⁺ T cell count was a positive factor (p < 0.0001) in the recovery of CD4⁺ T cell count during HAART.

Conclusion

R5-tropism represented the majority in low-level viral load HIV-1 infections receiving HAART for more than 6 months in Guangdong, China. The baseline immune level in the HIV-1 R5-tropic infections was higher than that in the X4-tropic infections. The amino acids of the 8th, 11th, and 18th of the HIV-1 V3 loop were more variable in the X4-tropic HIV-1. CRF01_AE, CRF55_01B, and lower baseline CD4⁺ T cell count were associated with more HIV-1 X4-tropism. The immune recovery during HAART was positively related to baseline CD4⁺ T cell count.

A Retrospective Study of the Safety and Immunogenicity of MVC-COV1901 Vaccine for People Living with HIV

BACKGROUND

This study aimed to assess the safety and immunogenicity of MVC-COV1901, a recombinant COVID-19 protein vaccine, containing S-2P protein adjuvanted with CpG 1018 and aluminum hydroxide, for people living with HIV (PWH).

METHODS

A total of 57 PWH of ≥20 years of age who are on stable antiretroviral therapy were compared with 882 HIV-negative participants. Participants received two doses of MVC-COV1901 28 days apart.

RESULTS

No vaccine-related serious adverse events (SAEs) were recorded. Seroconversion rates (SCRs) of 100% and 99.8% were achieved in PWH and comparators, respectively, 28 days after the second dose. After adjusting for sex, age, BMI category, and comorbidity, the adjusted GMT ratio of comparator/PWH was 3.2 (95% CI 2.5-4). A higher CD4/CD8 ratio was associated with a higher GMT (R = 0.27, p = 0.039). MVC-COV1901 has shown robust safety but elicited weaker immune responses in PWH.

CONCLUSIONS

Further investigations may be needed to determine whether PWH require distinct immunization strategies with improved immunogenicity. The main study is registered at ClinicalTrials.gov (NCT04695652).

Weight Gain Among Treatment-Naïve Persons With HIV Receiving Dolutegravir in Kenya

BACKGROUND

Several recent studies have linked integrase strand transfer inhibitors (INSTI) with increased weight gain.

SETTING

The effects of sex on weight gain with dolutegravir (DTG)-based antiretroviral therapy (ART) among treatment-naïve participants in a lower-income, sub-Saharan population with high rates of pre-ART underweight and tuberculosis (TB) coinfection are unknown.

METHODS

Our analysis included treatment-naïve participants in Kenya and starting their first treatment regimen between January 1, 2015, and September 30, 2018. Participants were grouped into 2 cohorts based on the initial treatment regimen [DTG vs. nonnucleoside reverse transcriptase inhibitors (NNRTI)]. We modelled weight changes over time using a multivariable nonlinear mixed-effect model, with participant as a random effect. Logistic regression models were constructed to evaluate the association between different variables with extreme increase in body mass index (≥10% increase).

RESULTS

Seventeen thousand forty-four participants met our inclusion criteria. Sixty-two percent of participants were women, 6% were receiving active TB therapy, and 97% were on NNRTI-based regimens. Participants starting DTG-based regimens were more likely to gain weight when compared with participants starting NNRTI-based regimens. Female participants starting DTG-based regimens experienced the highest weight gain compared with other participants (mean gain of 6.1 kgs at 18 months). Female participants receiving DTG-based regimens, along with participants with lower CD4 cell counts, underweight at baseline, and those receiving active TB therapy were also at higher risk for extreme body mass index increase.

CONCLUSIONS

Our study in a lower-income sub-Saharan African population confirms higher weight gain with DTG-based regimens compared with traditional ART for treatment-naïve patients.

Racial Differences in the Effect of HIV Status on Motor and Pulmonary Function and Mobility Disability in Older Adults

BACKGROUND

Older Black adults face a disproportionate burden of HIV prevalence, but less is known about racial disparities in age-related outcomes in HIV. We assessed the effect of HIV status and race on motor and pulmonary function, as well as how they contribute to mobility disability.

SETTING

Community-based study; Chicago, IL METHODS: Participants were 363 community-dwelling adults age ≥ 50 years, 48% living with HIV, and 68% Black. Participants with HIV were recruited from a specialty HIV clinic, and participants without HIV (comparable on key demographic, lifestyle, and behavioral characteristics) were recruited from the community. Measures included motor function summarized by 10 motor performance measures, pulmonary function summarized by 3 measures assessed using handheld spirometry, and self-reported mobility disability.

RESULTS

In fully adjusted linear models, HIV was associated with better motor (β = 9.35, p < 0.001) and pulmonary function (β = 16.34, p < 0.001). For pulmonary function, the effect of HIV status was moderated by race (interaction between Black race and HIV status: β =  - 11.66, p = 0.02), indicating that better pulmonary function among participants with HIV was less evident among Black participants. In fully adjusted models, odds of mobility disability did not differ by race, HIV status, or pulmonary function; better motor function was associated with lower odds of mobility disability (OR = 0.91 per 1-point higher, 95% CI 0.88-0.93).

CONCLUSION

Better motor and pulmonary function exhibited by participants with HIV could reflect access to medical care. Racial differences in lung function among participants with HIV indicate potential disparities in prevention or treatment of pulmonary disease or underlying risk factors.

Risk Factors Attributable to Hypertension among HIV-Infected Patients on Antiretroviral Therapy in Selected Rural Districts of the Eastern Cape Province, South Africa

BACKGROUND

Antiretroviral therapy has improved HIV patients' quality of life and life expectancy. However, complications have emerged in the form of hypertension. In the rural Eastern Cape, there is minimal information about HIV-infected people. The current study intended to evaluate the factors associated with hypertension in HIV-infected individuals receiving antiretroviral therapy in rural areas of South Africa's Eastern Cape.

METHODS

For this cohort study, HIV-positive people taking antiretroviral therapy aged 15 and up were recruited at random from several rural locations in the Eastern Cape. Using Cox univariate and multivariate analyses, the key predictors of hypertension were found.

RESULTS

Of the total participants (n = 361), 53% of individuals had hypertension. In the Cox multivariate model, patients that had hypertension heredity, BMI ≥ 25 kg/m2, eGFR < 60 mL/min/1.73 m2, advanced and severe CD4 counts, 1TFE and 1T3E regimens, and the male gender were found to be at greater risk of hypertension.

CONCLUSIONS

The findings of this study indicate that hypertension is a prevalent concern among HIV patients receiving antiretroviral therapy. HIV patients should have their blood pressure checked regularly, and they should be screened for high blood pressure and given treatment for it.

Discrimination and Calibration of the Veterans Aging Cohort Study Index 2.0 for Predicting Mortality Among People With Human Immunodeficiency Virus in North America

BACKGROUND

The updated Veterans Aging Cohort Study (VACS) Index 2.0 combines general and human immunodeficiency virus (HIV)-specific biomarkers to generate a continuous score that accurately discriminates risk of mortality in diverse cohorts of persons with HIV (PWH), but a score alone is difficult to interpret. Using data from the North American AIDS Cohort Collaboration (NA-ACCORD), we translate VACS Index 2.0 scores into validated probability estimates of mortality.

METHODS

Because complete mortality ascertainment is essential for accurate calibration, we restricted analyses to cohorts with mortality from the National Death Index or equivalent sources. VACS Index 2.0 components were ascertained from October 1999 to April 2018. Mortality was observed up to March 2019. Calibration curves compared predicted (estimated by fitting a gamma model to the score) to observed mortality overall and within subgroups: cohort (VACS/NA-ACCORD subset), sex, age <50 or ≥50 years, race/ethnicity, HIV-1 RNA ≤500 or >500 copies/mL, CD4 count <350 or ≥350 cells/µL, and years 1999-2009 or 2010-2018. Because mortality rates have decreased over time, the final model was limited to 2010-2018.

RESULTS

Among 37230 PWH in VACS and 8061 PWH in the NA-ACCORD subset, median age was 53 and 44 years; 3% and 19% were women; and 48% and 39% were black. Discrimination in NA-ACCORD (C-statistic = 0.842 [95% confidence interval {CI}, .830-.854]) was better than in VACS (C-statistic = 0.813 [95% CI, .809-.817]). Predicted and observed mortality largely overlapped in VACS and the NA-ACCORD subset, overall and within subgroups.

CONCLUSIONS

Based on this validation, VACS Index 2.0 can reliably estimate probability of all-cause mortality, at various follow-up times, among PWH in North America.

Degree of Polypharmacy and Cognitive Function in Older Women with HIV

The number of people with HIV (PWH) experiencing age-associated comorbidities including those treated with medications and cognitive impairment is increasing. We examined associations between polypharmacy and cognition in older women with HIV (WWH) given their vulnerability to this comorbidity. Cross-sectional analysis capitalizing on Women's Interagency HIV Study data collected between 2014 and 2017. WWH meeting the following criteria were analyzed: age ≥50 years; availability of self-reported non-antiretroviral therapy (ART) medications data; and neuropsychological data. The number of non-ART medications used regularly in the prior 6 months was summed. Polypharmacy was categorized as none/low (0-4), moderate (5-9), or severe (≥10). Multivariable linear regression analyses examined polypharmacy-cognition (T-score) associations in the total sample and among virally suppressed (VS; < 20 copies/mL)-WWH after covariate adjustment for enrollment site, income, depressive symptoms, substance use (smoking, heavy alcohol, marijuana, crack, cocaine, and/or heroin), the Veterans Aging Cohort Study index (indicators of HIV disease and organ system function, hepatitis C virus serostatus), ART use, nadir CD4 count, and specific ART drugs (efavirenz, integrase inhibitors). We included 637 women (median age = 55 years; 72% Black). Ninety-four percent reported ART use in the past 6 months and 75% had HIV RNA <20 copies/mL. Comorbidity prevalence was high (61% hypertension; 26% diabetes). Moderate and severe polypharmacy in WWH were 34% and 24%. In WWH, severe polypharmacy was associated with poorer executive function (p = .007) and processing speed (p = .01). The same pattern of findings remained among VS-WWH. Moderate polypharmacy was not associated with cognition. Moderate and severe polypharmacy were common and associated with poorer executive function and processing speed in WWH. Severe polypharmacy may be a major contributor to the persistence of domain-specific cognitive complications in older WWH above and beyond the conditions that these medications are used to treat.

Comorbidity and life expectancy in shared decision making for lung cancer screening

Shared decision making (SDM) is an important part of lung cancer screening (LCS) that includes discussing the risks and benefits of screening, potential outcomes, patient eligibility and willingness to participate, tobacco cessation, and tailoring a strategy to an individual patient. More than other cancer screening tests, eligibility for LCS is nuanced, incorporating the patient's age as well as tobacco use history and overall health status. Since comorbidities and multimorbidity (ie, 2 or more comorbidities) impact the risks and benefits of LCS, these topics are a fundamental part of decision-making. However, there is currently little evidence available to guide clinicians in addressing comorbidities and an individual's "appropriateness" for LCS during SDM visits. Therefore, this literature review investigates the impact of comorbidities and multimorbidity among patients undergoing LCS. Based on available evidence and guideline recommendations, we identify comorbidities that should be considered during SDM conversations and review best practices for navigating SDM conversations in the context of LCS. Three conditions are highlighted since they concomitantly portend higher risk of developing lung cancer, potentially increase risk of screening-related evaluation and treatment complications and can be associated with limited life expectancy: chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and human immunodeficiency virus infection.

Biopsychosocial Health Outcomes and Experienced Intersectional Stigma in a Mixed HIV Serostatus Longitudinal Cohort of Aging Sexual Minority Men, United States, 2008‒2019

Objectives. To determine whether intersectional stigma is longitudinally associated with biopsychosocial outcomes. Methods. We measured experienced intersectional stigma (EIS; ≥ 2 identity-related attributions) among sexual minority men (SMM) in the United States participating in the Multicenter AIDS Cohort Study. We assessed longitudinal associations between EIS (2008‒2009) and concurrent and future hypertension, diabetes, dyslipidemia, antiretroviral therapy adherence, HIV viremia, health care underutilization, and depression symptoms (2008‒2019). We conducted causal mediation to assess the contribution of intersectional stigma to the relationship between self-identified Black race and persistently uncontrolled outcomes. Results. The mean age (n = 1806) was 51.8 years (range = 22-84 years). Of participants, 23.1% self-identified as Black; 48.3% were living with HIV. Participants reporting EIS (30.8%) had higher odds of hypertension, dyslipidemia, diabetes, depression symptoms, health care underutilization, and suboptimal antiretroviral therapy adherence compared with participants who did not report EIS. EIS mediated the relationship between self-identified Black race and uncontrolled outcomes. Conclusions. Our findings demonstrate that EIS is a durable driver of biopsychosocial health outcomes over the life course. Public Health Implications. There is a critical need for interventions to reduce intersectional stigma, help SMM cope with intersectional stigma, and enact policies protecting minoritized people from discriminatory acts. (Am J Public Health. 2022;112(S4):S452-S462. https://doi.org/10.2105/AJPH.2022.306735).

A Heavy Burden: Preexisting Physical and Psychiatric Comorbidities and Differential Increases Among Male and Female Participants After Initiating Antiretroviral Therapy in the HIV Outpatient Study, 2008-2018

Attention to non-AIDS comorbidities is increasingly important in the HIV care and management in the United States. We sought to assess comorbidities before and after antiretroviral therapy (ART) initiation among persons with HIV (PWH). Using the 2008-2018 HIV Outpatient Study (HOPS) data, we assessed changes in prevalence of physical and psychiatric comorbidities, by sex, among participants initiating ART. Cox proportional hazards models were fit to investigate factors associated with the first documented occurrence of key comorbidities, adjusting for demographics and other covariates, including insurance type, CD4⁺ cell count, ART regimen, and smoking status. Among 1,236 participants who initiated ART (median age 36 years, CD4 cell count 375 cells/mm³), 79% were male, 66% non-white, 44% publicly insured, 53% ever smoked, 33% had substance use history, and 22% had body mass index ≥30 kg/m². Among females, the percentages with at least one condition were: at ART start, 72% had a physical and 42% a psychiatric comorbidity, and after a median of 6.1 years of follow-up, these were 87% and 63%, respectively. Among males, the percentages with at least one condition were: at ART start, 61% had a physical and 32% a psychiatric comorbidity, and after a median of 4.6 years of follow-up, these were 82% and 53%, respectively. In multivariable Cox proportional hazards analyses, increasing age and higher viral loads (VL) were associated with most physical comorbidities, and being a current/former smoker and higher VL were associated with all psychiatric comorbidities analyzed. HOPS participants already had a substantial burden of physical and psychiatric comorbidities at the time of ART initiation. With advancing age, PWH who initiate ART experience a clinically significant increase in the burden of chronic non-HIV comorbidities that warrants continued surveillance, prevention, and treatment.

Could a Dolutegravir-Based Antiretroviral Therapy Lead to Clinical Obesity? A Retrospective Cohort Study Conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Sidama, Ethiopia

Background

As of April 2019, the dolutegravir (DTG)-based regimen is replacing the efavirenz-based regimen in Ethiopia, mainly due to its superiority in viral load suppression. However, there is a growing concern about this medication-based regimen, the most serious of which is excessive weight gain. In this study, we looked at weight gain disparities among human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients on antiretroviral therapy (ART) who have been shifted to tenofovir/lamivudine/dolutegravir (TLD) from a tenofovir/lamivudine/efavirenz (TLE)-based regimen versus those who are maintained on a tenofovir/lamivudine/efavirenz-based regimen.

Methods

A facility-based retrospective observational cohort study was conducted in pursuit of weight change disparities between tenofovir/lamivudine/dolutegravir and tenofovir/lamivudine/efavirenz-based regimens among patients who have attained optimal viral suppression at Hawassa University Comprehensive Specialized Hospital antiretroviral clinic. Chi-square and logistic regression were used as appropriate using an SPSS version 21 program to test the association of specific variables to outcome variables, and a P value <0.05 was considered statistically significant.

Results

This study included 422 patients, 211 of whom were switched from tenofovir/lamivudine/efavirenz to tenofovir/lamivudine/dolutegravir and the remaining were who kept on a tenofovir/lamivudine/efavirenz-based regimen. Patients on a tenofovir/lamivudine/dolutegravir-based regimen had a mean weight gain of 3.88 ± 2.021 kg in one year compared to those on TLE (2.26 ± 2.39). In a bivariate analysis, being male was found to protect against unwanted weight gain at COR 0.531 (0.345, 0.816). A current CD4 count of more than 500 has been found to be strongly correlated with weight gain in multivariate analysis at an AOR of 0.315 (0.188, 0.527) at a P value ≤0.001.

Conclusion

According to this study, tenofovir/lamivudine/dolutegravir (TLD)-based antiretroviral medication (ART) users are more likely to gain weight, and clinicians should advise them of the risks of weight gain as well as cost-effective ways to prevent weight gain linked to poor health outcomes in these patients. Future investigations should confirm the findings of this study, and more research into the effects of weight gain in these people is required.