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Chow FC, Nance RM, Becker K, Ho EL, Huffer A, Kalani R, Marra CM, Zunt JR, Bamford L, Burkholder GA, Cachay E, Eron JJ, Keruly J, Kitahata MM, Napravnik S, Saag MS, Willig AL, Moore RD, Tirschwell DL, Delaney JA, Crane HM. Sex Differences in the Risk of Stroke Associated With Traditional and Non-Traditional Factors in a US Cohort of People With HIV Infection. Neurology 2024; 103:e209726. [PMID: 39088772 DOI: 10.1212/wnl.0000000000209726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Although stroke risk associated with HIV may be greater for women than men, little is known about whether the impact of different factors on cerebrovascular risk varies by sex in people with HIV (PWH) and contributes to stroke risk disparities in this population. The primary objective of this study was to examine whether sex modifies the effect of demographics, cardiometabolic factors, health-related behaviors, and HIV-specific variables on stroke risk in PWH from the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort. METHODS In this observational cohort study, we analyzed data from clinical encounters for PWH followed at 5 CNICS sites from approximately 2005 to 2020. All potential stroke events were adjudicated by neurologists. Patient-reported outcomes collected at clinic visits, including substance use and depression, were also available. We used Cox proportional hazards models to determine whether sex modified the association of predictors of interest with incident stroke. RESULTS Among 13,573 PWH (19% female sex at birth, mean age 44 years, mean follow-up 5.6 years), female sex was associated with a higher risk of stroke only among individuals aged 50 years or younger (hazard ratio [HR] 2.01 at age 40 [1.25-3.21] vs HR 0.60 at age 60 [0.34-1.06]; p = 0.001 for the interaction). Younger female participants who developed a stroke were more likely to have treated hypertension, a higher cardiovascular risk score, and detectable HIV than younger male participants whereas these factors were comparable by sex among older participants who developed a stroke. Sex modified the effect of detectable HIV (HR 4.66 for female participants [2.48-8.74] vs HR 1.30 for male participants [0.83-2.03]; p = 0.001 for the interaction), methamphetamine use (HR 4.78 for female participants [1.47-15.56] vs HR 1.19 for male participants [0.62-2.29]; p = 0.04 for the interaction), and treated hypertension (HR 3.44 for female participants [1.74-6.81] vs HR 1.66 for male participants [1.14-2.41]; p = 0.06 for the interaction) on stroke risk. DISCUSSION Younger female participants with HIV were at elevated cerebrovascular risk compared with younger male participants. Several risk factors had a greater adverse effect on stroke risk in female participants than in male participants, including HIV viremia, methamphetamine use, and treated hypertension. These findings underscore the importance of a personalized approach to predict and prevent cerebrovascular risk among PWH.
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Affiliation(s)
- Felicia C Chow
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Robin M Nance
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Kyra Becker
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Emily L Ho
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Andrew Huffer
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Rizwan Kalani
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Christina M Marra
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Joseph R Zunt
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Laura Bamford
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Greer A Burkholder
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Edward Cachay
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Joseph J Eron
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Jeanne Keruly
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Mari M Kitahata
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Sonia Napravnik
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Michael S Saag
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Amanda L Willig
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Richard D Moore
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - David L Tirschwell
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Joseph A Delaney
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
| | - Heidi M Crane
- From the Departments of Neurology (F.C.C.) and Medicine (Infectious Diseases) (F.C.C.), University of California, San Francisco; Departments of Medicine (R.M.N., C.M.M., J.R.Z., M.M.K., H.M.C.), Neurology (K.B., E.L.H., A.H., R.K., C.M.M., J.R.Z., D.L.T.), and Global Health (J.R.Z.), University of Washington, Seattle; Swedish Neuroscience Institute (E.L.H.), Swedish Medical Center, Seattle, Washington; Department of Epidemiology (J.R.Z., J.A.D.), University of Washington, Seattle; Department of Medicine (L.B., E.C.), University of California, San Diego; Department of Medicine (G.A.B., M.S.S., A.L.W.), University of Alabama, Birmingham; Department of Medicine (J.J.E., S.N.), University of North Carolina, Chapel Hill; Department of Medicine (J.K., R.D.M.), Johns Hopkins University; and University of Manitoba (J.A.D.), Winnipeg, Canada
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