Mortality Associated with Chronic Comorbidities among HIV-infected Persons in the United States

Combination antiretroviral therapy (cART) has substantially reduced HIV-related morbidity and mortality in the United States. HIV-infected persons today are living healthier and longer lives with expected lifespans near equal to those of uninfected person if the infection is effectively treated [1]. CDC estimates that by year 2020, over half of the HIV-infected persons in the United States will be aged 50 years or older [2]. With increased longevity, HIV-infected patients increasingly experience a variety of age-related chronic diseases [3] common in the general population, such as cardiovascular disease, liver disease, diabetes, and non-AIDS related cancers.

HIV-infected persons may experience similar or even higher rates of some of these comorbidities than HIV-uninfected persons. Reasons include the high prevalence of behavioral risk factors (e.g., tobacco use, alcohol use) and side effects of HIV-related treatments (e.g., kidney toxicity, unhealthy elevations in cholesterol). Emerging data suggest HIV itself may more directly increase risk for conditions such as atherosclerosis, low bone mineral density, and chronic obstructive pulmonary disease by stimulating a state of chronic inflammation that favors these outcomes. As a result, deaths among cART-treated persons in the United States are increasingly likely to result from non-AIDS-related causes [4,5].

Since 1993, The Centers for Disease Control and Prevention (CDC) have funded a multi-site study of HIV-infected patients cared for at HIV-specialty clinics: the HIV Outpatient Study (HOPS). In recent years, the HOPS investigators have shown that:

  • Most HOPS patients suffer from multiple chronic conditions in addition to HIV. In recent years, approximately two-thirds of HOPS patients had two or more chronic conditions in addition to HIV [3].
  • In 2004, among HOPS patients who died, 43% died solely from non-AIDS-related causes. In 1996, that percentage was 13% [4].
  • Despite persistent reductions in mortality among cART-treated HOPS patients (rates currently average at 1.6% percent per 100 persons per year, down from about 10% before 1996) disparities in mortality remain [6]. These sociodemographic disparities appear at least in part attributable to differences in the burden of chronic conditions not directly related to HIV infection. Among HOPS participants who died, comorbid conditions which may be prevented by lifestyle changes (e.g., tobacco smoking cessation, dietary changes) were often more prevalent among blacks/African Americans and Hispanics/Latinos than whites, and among publicly than privately insured participants [6].
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As HIV-infected patients age and experience multiple comorbidities, the integration of HIV care and primary care is ever more important. HIV providers should be comfortable with standard chronic disease management and coordinate care with specialists as needed (e.g., cardiologists, nephrologists, hepatologists) while primary care providers will need to become more comfortable with the basic management of HIV infection. Because HIV-infected patients see their doctors for HIV care typically twice or more annually, HIV providers have repeated opportunities for brief messages related to chronic HIV disease prevention (e.g., including smoking cessation, exercise and weight loss) to reduce illness and death due to chronic conditions.

References:

1. Samji H, Cescon A, Hogg RS, et al for the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) of IeDEA. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One. 2013; 8(12):e81355.

2. Brooks JT, Buchacz K, Gebo KA, Mermin J. HIV infection and older Americans: the public health perspective. Am J Public Health. 2012;102(8):1516-26.

3. Buchacz K, Baker RK, Palella FJ Jr, et al for the HIV Outpatient Study Investigators. Disparities in prevalence of key chronic diseases by gender and race/ethnicity among antiretroviral-treated HIV-infected adults in the US. Antivir Ther. 2013;18(1):65-75.

4. Palella FJ Jr, Baker RK, Moorman AC, et al for the HIV Outpatient Study Investigators. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. J Acquir Immune Defic Syndr. 2006;43(1):27-34.

5. Adih WK, Selik RM, Hu X. Trends in Diseases Reported on US Death Certificates That Mentioned HIV Infection, 1996-2006. J Int Assoc Physicians AIDS Care. 2011;10(1):5-11.

6. Palella FJ Jr, Baker RK, Buchacz K, et al for the HOPS Investigators. Increased mortality among publicly insured participants in the HIV Outpatient Study despite HAART treatment. AIDS. 2011;25(15):1865-76.

Disclaimer: The findings and conclusions of this report are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

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