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Multimorbidity and Non-AIDS Rates Differ With HIV Duration in Older Adults
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4th International Workshop on HIV and Aging, October 30-31, 2013, Baltimore
Mark Mascolini
Rates of multimorbidity and non-AIDS conditions differed substantially in two groups of similarly aged HIV-positive Italians, depending on whether their infection lasted two decades or one, according to results of a large case-control study [1]. Compared with the more recently infected group, the group with longer HIV duration had 70% higher odds of multimorbidity.
HIV-positive people in their 30s or 40s comprise a heterogeneous melange marked by different racial and socioeconomic backgrounds, infection via different routes, different risks of cardiovascular disease or kidney dysfunction, and diagnosis and treatment at widely diverse CD4 counts. No one would think of considering middle-aged people with HIV as a monolithic cluster. Yet most studies of aging with HIV cannot split 50-and-older groups into innumerably discrete subgroups because numbers of older HIV-positive people--though growing rapidly--still represent minorities of HIV cohorts.
To begin addressing the diversity within older HIV cohorts, Giovanni Guaraldi in Modena and Julian Falutz in Montreal asked how two older groups differ--older people who picked up HIV in their youth or early middle age, and older people who became infected later in life [1]. To round out the comparison, they compared these two subsets with HIV-negative people matched to the HIV-positive people by age, gender, and region of origin.
The Modena-Montreal collaborators conducted a 1:1:3 case-control study with Modena Metabolic Clinic patients infected with HIV for 20.6 years or more making up group 1, Metabolic Clinic patients infected fewer than 11.3 years making up group 2, and HIV-negative general-population members of the Cineca Arno database (described in reference 2) making up group 3. The investigators called group 1 patients "aging patients" and group 2 patients "aged patients," but perhaps more descriptive terms (used in this report) are long-term infected patients and more-recently infected patients.
Modena's Metabolic Clinic cares for about 4000 HIV-positive people. Median age of clinic patients in 2003 was 40 years (interquartile range [IQR] 37 to 44); median age in 2012 jumped to 48 (IQR 45 to 53). Average age at estimated date of seroconversion climbed from 33 in 2003 to 43 in 2012.
Primary endpoints for this analysis were (1) HIV-associated non-AIDS conditions including cardiovascular disease, hypertension, type 2 diabetes mellitus, renal failure, and bone mineral density indicated by a T-score below -2 standard deviation, and (2) multimorbidity, defined as two or more non-AIDS conditions.
Because of age matching, median age of the 404 long-term infected patients and the 404 more recently infected patients was 46.7 (+/-6). Men made up 71% of both groups. The long-term group had a significantly higher proportion of current smokers than the more recently infected group (51% versus 40%, P = 0.017). Average body mass index was significantly lower in the long-term group (23.2 versus 24.6 kg/m(2) (P < 0.001), as was average waist circumference (87 versus 89.3 cm, P= 0.007). The long-term and more recently infected groups also differed significantly in total cholesterol (183 versus 199 mg/dL, P < 0.001), low-density lipoprotein cholesterol (106 versus 119 mg/dL, P < 0.001), and HOMA-measured insulin resistance (3.5 versus 2.6, P = 0.001).
Prevalence of multimorbidity was significantly higher in long-term infected patients than in more recently infected people (10.9% versus 8.7%, P < 0.01) and significantly higher in both these groups than in the HIV-negative controls (2.5%, P < 0.01 for both comparisons). At any age, long-term infected people had a 5-fold greater risk of multimorbidity than HIV-negative controls, while more recently infected people had a less accentuated risk compared with the control group.
Prevalence of individual non-AIDS conditions was nonsignificantly higher in the long-term infected group than in the more recently infected group for hypertension (36% versus 26%), diabetes (14% versus 13%), and low bone mineral density (23% versus 21%). Prevalence of chronic kidney disease was nonsignificantly higher in more recently infected people than in the long-term infected (3% versus 1%) but significantly higher than in HIV-negative controls (0%, P < 0.001). Rates of cardiovascular disease, hypertension, and diabetes were significantly higher in both HIV groups than in controls. Bone mineral density was not measured in controls.
Multivariate analysis determined that, compared with HIV-negative people, long-term HIV-infected people had 5 times higher odds of multimorbidity and more recently infected people had 3.8 times higher odds. In this analysis, men had more than doubled odds of multimorbidity. Focused solely on people with HIV, multivariate analysis figured that more recently infected people had 1.7 times higher odds of multimorbidity than long-term infected people, each year of age raised the odds of multimorbidity 1.1 times, and male gender raised chances 4.7 times.
The researchers concluded that older people with HIV are a heterogeneous group, with duration of HIV infection and host factors affecting the risk of multimorbidity. Guaraldi agreed that duration of infection was not precisely known for either HIV group. But he observed that median ages of people who met the long-term and more-recent infection cutoffs in this analysis have changed substantially in the Modena Metabolic Clinic from 2003 (41 years with long-term infection versus 39 years with more recent infection) to 2012 (50 years with long-term infection versus 44 years for more recent infection), and the gap between the long-term and recent groups widened substantially.
References
1. Guaraldi G, Zona S, Stentarelli C, et al. Aging with HIV vs HIV seroconversion at older age: a diverse population with distinct comorbidity profiles. 4th International Workshop on HIV and Aging, October 30-31, 2013, Baltimore. Abstract 12.
2. Guaraldi G, Orlando G, Zona S, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis. 2011;53:1120-1126. http://cid.oxfordjournals.org/content/53/11/1120.long
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