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50% Polypharmacy Rates in HIV MACS >5 Comoedications / Prevalence and trends of polypharmacy among HIV-positive and -negative men in the Multicenter AIDS Cohort Study from 2004 to 2016
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Polypharmacy was defined as taking 5 or more non-HIV medications since the last health care visit.
Of note the averages were quite young at 36-56 only, so for PLWH over 65 we can expect much hgher polypharmacy rates.
Among the 50 years and older age group, HIV-positive and HIV-negative participants had increases in polypharmacy over the observation period, from 38.4% to 46.8% (P = .0081) and from 16.7% to 46.0% (P < .0001), respectively.
Among participants younger than 50, polypharmacy among HIV-positive participants remained stable (18.9% in 2004 to 17.3% in 2016; P = .5374) but increased among HIV-negative men (5.6% to 20.4%; P < .0001).
we found that use of medications used to treat these diseases (diabetes, dyslipidemia, and hypertension) was slightly greater among HIV-positive participants.
In this study, the overall prevalence of polypharmacy increased among MACS participants over a 12-year period and was driven by increases in the use of medications to treat aging-related chronic comorbidities, prominently including antihypertensive and cholesterol-lowering drugs. As expected, HIV-positive and older participants (≥50 years) carried the greatest burden of polypharmacy, with HIV-positive participants 50 years and older having the highest rates. Having medication insurance coverage was associated with increased polypharmacy. Participants who were non-Hispanic black and other race were less likely to experience polypharmacy than non-Hispanic white participants. Earlier MACS enrollment was also positively associated with polypharmacy. Participants enrolled during the earlier recruitment period were on average older and reported higher rates of medication insurance, therefore greater rates of polypharmacy were expected, regardless of HIV status. HIV-related clinical factors (viral load and CD4 cell count) and self-reported ART adherence among HIV-positive participants did not demonstrate a statistically significant association with polypharmacy.
Among HIV-positive participants at their index visit, 48.2% had an undetectable viral load, 62.3% were at least 95% adherent to their ART medications, 47.9% had a CD4 count of greater than or equal to 500 cells/mm3, and were prescribed a median of 3 (IQR, 0 to 3) ART medications. Nearly one-third of HIV-positive participants (28.8%) reported no ART use (Table 1).
Several risk factors for polypharmacy were identified. HIV-positive status (aPR, 1.36; 95% CI, 1.26 to 1.46), age 50 or older (aPR, 1.61......
Adjusted prevalence of Non-HIV medications
Overall, the adjusted prevalence rates of antidepressant, antihypertensive, cholesterol-lowering, and steroid medication use were 22.1%, 30.6%, 29.2%, and 14.5%, respectively. HIV-positive participants reported more antidepressant (25.5% vs 18.6%; P < .0001), cholesterol-lowering (31.0% vs 27.4%; P < .0001), and steroid (19.1% vs 9.7%; P < .0001) use than HIV-negative persons. There were similar prevalence rates of antihypertensive medication use between HIV-positive and -negative participants (30.6% vs 30.6%; P = .8760). Other differences were observed by age and by HIV status (Fig 1).
Participants older than 50 and HIV-positive participants had higher prevalence of use of the aforementioned medications than persons younger than 50 and HIV negative. Overall, the use of antihypertensive, cholesterol-lowering, and steroid medications increased over time (P < .0001), while antidepressant use remained relatively stable. The changes in prevalence of use of these medications from 2004 to 2016 are graphically represented in Fig 1.
Prevalence of select medications by age, HIV status, and visit.
Figure shows adjusted prevalence of antidepressant, antihypertensive, cholesterol-lowering, and steroid medication use among those 50 years and older (A, C, E, and G, respectively), and among those younger than 50 years old (B, D, F, and H, respectively).
Fig 1. Prevalence of select medications by age, HIV status, and visit. Figure shows adjusted prevalence of antidepressant, antihypertensive, cholesterol lowering, and steroid medication use among those 50 years and older (A, C, E, and G, respectively), and among those younger than 50 years old (B, D, F, and H, respectively).
DISCUSSION
In this study, the overall prevalence of polypharmacy increased among MACS participants over a 12-year period and was driven by increases in the use of medications to treat aging-related chronic comorbidities, prominently including antihypertensive and cholesterol-lowering drugs. As expected, HIV-positive and older participants (≥50 years) carried the greatest burden of polypharmacy, with HIV-positive participants 50 years and older having the highest rates. Having medication insurance coverage was associated with increased polypharmacy. Participants who were non-Hispanic black and other race were less likely to experience polypharmacy than non-Hispanic white participants. Earlier MACS enrollment was also positively associated with polypharmacy. Participants enrolled during the earlier recruitment period were on average older and reported higher rates of medication insurance, therefore greater rates of polypharmacy were expected, regardless of HIV status. HIV-related clinical factors (viral load and CD4 cell count) and self-reported ART adherence among HIV-positive participants did not demonstrate a statistically significant association with polypharmacy. However, ART medication use itself was positively associated with increased polypharmacy.
Unexpectedly, polypharmacy prevalence by HIV status was similar in both age groups toward the end of the observation period.
Our findings corroborate the trend of increased polypharmacy among HIV-positive and -negative populations [14-18]. Recently, Justice et al reported that polypharmacy was common in both HIV-positive and -negative individuals, and they found similar factors associated with polypharmacy, such as older age, white race, and HIV-positive status [17]. Since the introduction of effective ART, HIV-positive individuals experience markedly extended survival [24], and hence experience non-HIV chronic comorbidities. These comorbidities often occur at higher rates and earlier ages than among HIV-negative persons [8]. Our data revealed conflicting results regarding selected aging-related comorbidity rates by HIV status. HIV-negative participants more often reported diabetes, dyslipidemia, and high blood pressure than HIV-positive persons; however, this could have been in part due to HIV-negative participants having been older. Nevertheless, we found that use of medications used to treat these diseases (diabetes, dyslipidemia, and hypertension) was slightly greater among HIV-positive participants. This could be due, in part, to HIV-negative participants reporting lower rates of medication insurance coverage and health care visits overall. However, polypharmacy rates converged between HIV-positive and -negative participants at the end of the observation period. HIV-negative participants had a lower number of health care visits in 2004 compared with HIV-positive participants. By 2016, the numbers of health care visits by HIV status were similar. In analyses restricted to HIV-positive participants, we found that having a detectable viral load, CD4 less than 500, and ART adherence were not associated with a greater likelihood of polypharmacy, while ART use was associated with polypharmacy; this finding could be related to increased dyslipidemia and cardiovascular disease reported in association with ART use among HIV-positive persons [25-26].
Our study was subject to several limitations. We relied on self-reported medication use, which presented the possibility of recall bias. Short-term medication use, such as antibiotics, may have been underreported, especially if taken for short periods of time. Finally, this study used a nonrandom convenience sample and was restricted to HIV-positive and -negative MSM in 4 major metropolitan regions. Therefore, these results may not be generalizable to other MSM in the general population. Despite these limitations, there were some important strengths in this analysis including the ability to evaluate the long-term characterization of polypharmacy in a cohort for which standardized collection of medication use was semiannually recorded, in contrast to previously published polypharmacy studies, which were cross-sectional.
Conclusion
In the MACS, polypharmacy was more prevalent among participants who were HIV positive, 50 years and older, enrolled during the earlier recruitment period, and had medication insurance coverage. Increased rates of comorbidities among the participants drove the main finding of increasing rates of polypharmacy over time. We also observed a convergence of polypharmacy prevalence between HIV-positive and -negative participants by the end of the observation period, which could be explained by increasing health care visits by HIV-negative participants. Further research will be needed to elucidate determinants of increased polypharmacy and to explore the appropriateness of prescribing practices that may contribute to polypharmacy among PLWH.
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