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Multiple non-AIDS Diseases More Frequent in
Aging IDUs With Versus Without HIV
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First International Workshop on HIV and Aging, October 4-5, 2010, Baltimore
Mark Mascolini
Injection drug users (IDUs) with HIV were significantly less likely than IDUs without HIV to have none of the seven non-AIDS conditions studied, according to a 1261-person ALIVE cohort analysis [1]. IDUs with HIV proved significantly more likely than HIV-negative IDUs to have multiple comorbid conditions. Median age in the study population was 49 years.
The study involved members of the prospective ALIVE cohort, all of whom are at least 18 years old, have a history of injection drug use, and have a confirmed HIV test. This cross-sectional analysis focused on 1261 cohort members who had results on tests for at least five of seven non-AIDS conditions: obesity (body mass index at or above 30 kg/m(2)), hypertension (systolic pressure at or above 140 mm Hg, diastolic pressure at or above 90 mm Hg, or self-reported antihypertensive therapy), diabetes (hemoglobin A1c above 6.5% or self-reported diabetes treatment), kidney dysfunction (urine protein-creatinine ratio below 60 mL/min per 1.73 m(2)), anemia (hemoglobin below 13 g/dL for men and below 12 g/dL for women), liver fibrosis/cirrhosis (stiffness at or above 9.3 kPa on transient elastography or Metavir score at or above F2 or significant fibrosis), and obstructive lung disease (FEV1/FVC below 70% on portable spirometry).
The study group included 900 people without HIV and 362 with HIV, who were similar in median age (49.1 versus 48.7), proportion of men (65.4% versus 64.1%), proportion homeless at cohort entry (14.8% versus 13.7%), cigarette smoking prevalence at cohort entry (83.7% versus 82.3%), and proportion with depressive symptoms (21.4% versus 21.9%). The HIV group had a significantly higher proportion of African Americans (93.4% versus 85.2%), a significantly lower proportion of people currently working (15.0% versus 26.4%), a significantly lower proportion of alcohol users at cohort entry (42.0% versus 54.9%), a significantly lower proportion of drug injectors at cohort entry (33.7% versus 41.7%), and a significantly lower proportion of noninjection drug users at cohort entry (33.1% versus 47.7%).
Proportions of study participants with none of the seven comorbidities were higher among HIV-negative people under 50 than HIV-positive people under 50 (27% versus 18%) and among HIV-negative people over 50 (15% versus 9%). The HIV-positive group under 50 had higher proportions with two comorbid conditions (30% versus 25%), three such conditions (18% versus 9%), and four or five such conditions. Compared with the HIV-negative over-50 group, HIV-infected IDUs over 50 had higher proportions with two comorbid conditions (32% versus 27%), three comorbid conditions (19% versus 16%), four comorbid conditions (14% versus 7%), or five comorbid conditions (3.2% versus 2.4%).
In the HIV-positive group, three comorbid conditions were significantly more likely in people 50 or older than in younger people:
kidney dysfunction (54.8% versus 42.9%, P = 0.026),
hypertension (46.2% versus 28.9%, P = 0.001), and obstructive lung disease (23.5% versus 14.7%, P = 0.042). There was a trend to higher prevalence of anemia in the younger HIV group than in the older HIV group (47.6% versus 38.0%, P = 0.068).
Multivariate analysis established that the following variables independently raised the risk of increased multiple comorbidity:
-- HIV infection with at least 200 CD4s (versus HIV-negative): odds ratio (OR): 1.47, P = 0.004
-- HIV infection with under 200 CD4s (versus HIV-negative): OR 3.59, P = 0.000
-- Older age (per year): OR 1.06, P = 0.000
-- Female gender: OR 1.51, P = 0.000
-- Depressive symptoms: OR 1.40, P = 0.008
In this analysis cigarette smoking (OR 0.669, P = 0.004) and nonintravenous drug use (OR 0.735, P = 0.005) lowered the risk of increasing multiple non-AIDS conditions. The investigators speculated that those counterintuitive findings could reflect the lower body mass index and lower blood pressure found in smokers and drug users.
Use of antiretroviral therapy did not affect the risk of increasing multiple comorbidities, but the researchers suggested that a look at individual antiretroviral classes might be more revealing.
Among IDUs with HIV, high proportions of people with kidney disease (83.8%), cirrhosis (83.9%), and obstructive lung disease (43.6%) said their physician never told them they had those conditions. Such negative reports were less frequent among people with hypertension (37.4%) and diabetes (23.1%). Those findings led the investigators to conclude that a "high proportion of conditions are unrecognized and untreated based on self-report."
The researchers noted that their analysis did not include such important conditions as cardiovascular disease, cancer, and bone disease (all of which are affected by smoking). They cautioned that diabetes may be underestimated in HIV-infected people because their analysis defined diabetes by hemoglobin A1c, which may underestimate glycemia in people with HIV [2]. Finally, they noted that the findings may apply only to urban African-American IDU populations.
References
1.Salter ML, Ahmed M, Mehta SH, Kirk GD. HIV infection and immune suppression are associated with higher burden of multimorbidity among aging IDUs in Baltimore, MD. First International Workshop on HIV and Aging. October 4-5, 2010. Baltimore. Abstract O_14.
2. Kim PS, Woods C, Georgoff P, et al. A1C underestimates glycemia in HIV infection. Diabetes Care. 2009;32:1591-1593.
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