1
|
Morton ZP, Christina Mehta C, Wang T, Palella FJ, Naggie S, Golub ET, Anastos K, French AL, Kassaye S, Taylor TN, Fischl MA, Adimora AA, Kempf MC, Tien PC, Ofotokun I, Sheth AN, Collins LF. Cumulative Human Immunodeficiency Virus (HIV)-1 Viremia Is Associated With Increased Risk of Multimorbidity Among US Women With HIV, 1997-2019. Open Forum Infect Dis 2023; 10:ofac702. [PMID: 36751648 PMCID: PMC9897021 DOI: 10.1093/ofid/ofac702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/26/2022] [Indexed: 12/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Zoey P Morton
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Christina Mehta
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tingyu Wang
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Frank J Palella
- Division of Infectious Diseases, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Susanna Naggie
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elizabeth T Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kathryn Anastos
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Audrey L French
- Division of Infectious Diseases, CORE Center, Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Seble Kassaye
- Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Tonya N Taylor
- SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Margaret A Fischl
- Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adaora A Adimora
- Gillings School of Global Public Health and the School of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mirjam-Colette Kempf
- Schools of Nursing, Public Health and Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Phyllis C Tien
- Division of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
- Medical Service, Department of Veterans Affairs, San Francisco, California, USA
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Anandi N Sheth
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Lauren F Collins
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Brummel SS, Van Dyke RB, Patel K, Purswani M, Seage GR, Yao TJ, Hazra R, Karalius B, Williams PL. Analyzing Longitudinally Collected Viral Load Measurements in Youth With Perinatally Acquired HIV Infection: Problems and Possible Remedies. Am J Epidemiol 2022; 191:1820-1830. [PMID: 35872591 PMCID: PMC9767869 DOI: 10.1093/aje/kwac125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/12/2022] [Accepted: 07/15/2022] [Indexed: 01/29/2023] Open
Abstract
Human immunodeficiency virus (HIV) viral load (VL) is an important quantitative marker of disease progression and treatment response in people living with HIV infection, including children with perinatally acquired HIV. Measures of VL are often used to predict different outcomes of interest in this population, such as HIV-associated neurocognitive disorder. One popular approach to summarizing historical viral burden is the area under a time-VL curve (AUC). However, alternative historical VL summaries (HVS) may better answer the research question of interest. In this article, we discuss and contrast the AUC with alternative HVS, including the time-averaged AUC, duration of viremia, percentage of time with suppressed VL, peak VL, and age at peak VL. Using data on youth with perinatally acquired HIV infection from the Pediatric HIV/AIDS Cohort Study Adolescent Master Protocol, we show that HVS and their associations with full-scale intelligence quotient depend on when the VLs were measured. When VL measurements are incomplete, as can be the case in observational studies, analysis results may be subject to selection bias. To alleviate bias, we detail an imputation strategy, and we present a simulation study demonstrating that unbiased estimation of a historical VL summary is possible with a correctly specified imputation model.
Collapse
Affiliation(s)
- Sean S Brummel
- Correspondence to Dr. Sean S. Brummel, Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, François-Xavier Bagnoud Building, Room 507, 651 Huntington Avenue, Boston, MA 02115 (e-mail: )
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Palella FJ, Armon C, Cole SR, Hart R, Tedaldi E, Novak R, Battalora L, Purinton S, Li J, Buchacz K. HIV viral exposure and mortality in a multicenter ambulatory HIV adult cohort, United States, 1995-2016. Medicine (Baltimore) 2021; 100:e26285. [PMID: 34160393 PMCID: PMC8238313 DOI: 10.1097/md.0000000000026285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/20/2021] [Indexed: 01/04/2023] Open
Abstract
The aim of this study was to identify viral exposure (VE) measures and their relationship to mortality risk among persons with HIV.Prospective multicenter observational study to compare VE formulae.Eligible participants initiated first combination antiretroviral therapy (cART) between March 1, 1995 and June 30, 2015. We included 1645 participants followed for ≥6 months after starting first cART, with cART prescribed ≥75% of time, who underwent ≥2 plasma viral load (VL) and ≥1 CD4+ T-lymphocyte cell (CD4) measurement during observation. We evaluated all-cause mortality from 6 months after cART initiation until June 30, 2016. VE was quantified using 2 time-updated variables: viremia copy-years and percent of person-years (%PY) spent >200 or 50 copies/mL. Cox models were fit to estimate associations between VE and mortality.Participants contributed 10,453 person years [py], with median 14 VLs per patient. Median %PY >200 or >50 were 10% (interquartile range: 1%-47%) and 26% (interquartile range: 6%-72%), respectively. There were 115 deaths, for an overall mortality rate of 1.19 per 100 person years. In univariate models, each measure of VE was significantly associated with mortality risk, as were older age, public insurance, injection drug use HIV risk history, and lower pre-cART CD4. Based on model fit, most recent viral load and %PY >200 copies/mL provided the best combination of VE factors to predict mortality, although all VE combinations evaluated performed well.The combination of most recent VL and %PY >200 copies/mL best predicted mortality, although all evaluated VE measures performed well.
Collapse
Affiliation(s)
- Frank J. Palella
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Ellen Tedaldi
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | | | - Linda Battalora
- Cerner Corporation, Kansas City, MO
- Colorado School of Mines, Golden, CO
| | | | - Jun Li
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
4
|
Wang R, Haberlen SA, Palella FJ Jr, Mugavero MJ, Margolick JB, Macatangay BJC, Martínez-Maza O, Jacobson LP, Abraham AG. Viremia copy-years and mortality among combination antiretroviral therapy-initiating HIV-positive individuals: how much viral load history is enough? AIDS 2018; 32:2547-56. [PMID: 30379686 DOI: 10.1097/QAD.0000000000001986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Ongoing HIV replication while receiving combination antiretroviral therapy (cART) may reduce survival. Viremia copy-years (VCY) has shown improved mortality risk prediction over single time-point viral load measures. However, the timing of a patient's viral load history most associated with later mortality has not been studied. Here we determined the optimal duration and temporality of viral load history for predicting mortality. DESIGN Survival analysis among HIV-positive men who initiated cART in the Multicenter AIDS Cohort Study (1995-2015). METHODS VCY measures were derived from area-under-the-viral load-curve. The overall VCY based upon the complete post-cART viral load history was compared with 20 VCYs derived from viral loads assessed during different shorter time periods (the most recent 1-10 years and initial 1-10 years following cART initiation) for associations with mortality. RESULTS Each 10-fold increase in VCYs based on the most recent 3-8 years was significantly associated with 23-26% decrease in survival times, a magnitude of effect greater than that of the most recent viral load (16%). These associations were independent of CD4 cell count and single time-point viral loads. In addition, the degree of pre-cART immunodeficiency did not affect the mortality prognostic value of VCY based on viral loads in the most recent 3 years. Conversely, the overall VCY and VCYs based on viral loads immediately following cART initiation were not independent predictors of mortality. CONCLUSION Among cART-treated men, VCY based upon viral loads in the recent 3 years (six viral loads) has a mortality prognostic value greater than that of the overall VCY and single time-point viral loads, making the former a more feasible measure for use.
Collapse
|
5
|
Sempa JB, Dushoff J, Daniels MJ, Castelnuovo B, Kiragga AN, Nieuwoudt M, Bellan SE. Reevaluating Cumulative HIV-1 Viral Load as a Prognostic Predictor: Predicting Opportunistic Infection Incidence and Mortality in a Ugandan Cohort. Am J Epidemiol 2016; 184:67-77. [PMID: 27188943 DOI: 10.1093/aje/kwv303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 10/29/2015] [Indexed: 11/12/2022] Open
Abstract
Recent studies have evaluated cumulative human immunodeficiency virus type 1 (HIV-1) viral load (cVL) for predicting disease outcomes, with discrepant results. We reviewed the disparate methodological approaches taken and evaluated the prognostic utility of cVL in a resource-limited setting. Using data on the Infectious Diseases Institute (Makerere University, Kampala, Uganda) cohort, who initiated antiretroviral therapy in 2004-2005 and were followed up for 9 years, we calculated patients' time-updated cVL by summing the area under their viral load curves on either a linear scale (cVL1) or a logarithmic scale (cVL2). Using Cox proportional hazards models, we evaluated both metrics as predictors of incident opportunistic infections and mortality. Among 489 patients analyzed, neither cVL measure was a statistically significant predictor of opportunistic infection risk. In contrast, cVL2 (but not cVL1) was a statistically significant predictor of mortality, with each log10 increase corresponding to a 1.63-fold (95% confidence interval: 1.02, 2.60) elevation in mortality risk when cVL2 was accumulated from baseline. However, whether cVL is predictive or not hinges on difficult choices surrounding the cVL metric and statistical model employed. Previous studies may have suffered from confounding bias due to their focus on cVL1, which strongly correlates with other variables. Further methodological development is needed to illuminate whether the inconsistent predictive utility of cVL arises from causal relationships or from statistical artifacts.
Collapse
|
6
|
Wright ST, Hoy J, Mulhall B, O’Connor CC, Petoumenos K, Read T, Smith D, Woolley I, Boyd MA. Determinants of viremia copy-years in people with HIV/AIDS after initiation of antiretroviral therapy. J Acquir Immune Defic Syndr 2014; 66:55-64. [PMID: 24463783 PMCID: PMC3981928 DOI: 10.1097/qai.0000000000000125] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Recent studies suggest higher cumulative HIV viremia exposure measured as viremia copy-years (VCY) is associated with increased all-cause mortality. The objectives of this study are (1) report the association between VCY and all-cause mortality and (2) assess associations between common patient characteristics and VCY. METHODS Analyses were based on patients recruited to the Australian HIV Observational Database (AHOD) who had received ≥24 weeks of antiretroviral therapy (ART). We established VCY after 1, 3, 5, and 10 years of ART by calculating the area under the plasma viral load time series. We used survival methods to determine the association between high VCY and all-cause mortality. We used multivariable mixed-effect models to determine predictors of VCY. We compared a baseline information model with a time-updated model to evaluate discrimination of patients with high VCY. RESULTS Of the 3021 AHOD participants who initiated ART, 2073 (69%), 1667 (55%), 1267 (42%), and 638 (21%) were eligible for analysis at 1, 3, 5, and 10 years of ART, respectively. Multivariable-adjusted hazard ratio association between all-cause mortality and high VCY was statistically significant, hazard ratio 1.52 (1.09, 2.13), P = 0.01. Predicting high VCY after 1 year of ART for a time-updated model compared with a baseline information model, the area under the sensitivity/specificity curve was 0.92 vs. 0.84; and at 10 years of ART, area under the sensitivity/specificity curve was 0.87 vs. 0.61, respectively. CONCLUSION A high cumulative measure of viral load after initiating ART is associated with increased risk of all-cause mortality. Identifying patients with high VCY is improved by incorporating time-updated information.
Collapse
Affiliation(s)
- Stephen T Wright
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Jennifer Hoy
- Department of Medicine, Monash University, Melbourne, Australia
- Infectious Diseases Unit, The Alfred Hospital, Melbourne, Australia
| | - Brian Mulhall
- The Kirby Institute, University of New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Catherine C O’Connor
- The Kirby Institute, University of New South Wales, Sydney, Australia
- RPA Sexual Health, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Kathy Petoumenos
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - Timothy Read
- Melbourne Sexual Health Centre, The Alfred Hospital, Melbourne, Australia
| | - Don Smith
- The Albion Centre, Sydney, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Ian Woolley
- Department of Medicine, Monash University, Melbourne, Australia
- Infectious Diseases, Monash Medical Centre, Melbourne, Australia
| | - Mark A Boyd
- The Kirby Institute, University of New South Wales, Sydney, Australia
| |
Collapse
|