Co-morbidities are common and rising among people with HIV in the US

People living with HIV are increasingly experiencing a range of non-AIDS-related co-morbidities as the population ages, including cardiovascular disease, kidney impairment and bone loss leading to fractures, according to research presented at the IDWeek 2016 meeting in New Orleans in October.

Thanks to effective antiretroviral therapy (ART), more HIV-positive people in the US and Europe are surviving to older ages. Estimates indicate that nearly half of people living with HIV in the US are aged 50 or older. While some research has found that HIV-positive people who were treated promptly with modern ART may have a life expectancy close to that of HIV-negative individuals, those who developed advanced immune deficiency or were treated with suboptimal therapy often have ongoing health problems.

Studies have shown that people with HIV are at higher risk for developing chronic non-AIDS conditions such as heart disease and cancer, and they may do so at younger ages. Some of these conditions have been linked to specific antiretroviral drugs, including kidney impairment and bone loss with tenofovir (Viread) and cardiovascular events with abacavir (Ziagen).

Xue Song of Truven Health Analytics and colleagues compared rates of co-morbid conditions and trends over time among HIV-positive and HIV-negative people.

Using Truven Health MarketScan Databases, the researchers selected more than 37,000 adults diagnosed with HIV and treated with ART from 2003 to 2013. The databases included more than 41 million people with commercial health coverage and about 8 million Medicaid enrollees from multiple states. HIV-positive people were matched with up to three HIV-negative control subjects based on demographic variables, region and type of health coverage.

The analysis included 21,180 HIV-positive people and 66,027 HIV-negative controls with commercial health coverage. Most (84%) were men, the mean age was approximately 48 years and 12% were over age 50. In addition, there were 16,431 people with HIV and 45,556 controls on Medicaid. In this group only about half (53%) were men and the mean age was about 50 years.

People with HIV were found to have significantly higher co-morbidity rates that HIV-negative people, and people on Medicaid generally had more health problems than those with commercial coverage.

Cardiovascular disease:

• Commercial cohort: 7% of HIV-positive vs 4% of HIV-negative people
• Medicaid cohort: 11% vs 8%, respectively.

Kidney disease:

• Commercial cohort: 9% vs 3%
• Medicaid cohort: 15% vs 6%.

Osteoporosis and fractures:

• Commercial cohort: 8% vs 6%
• Medicaid cohort: 13% vs 10%.

Other co-morbidities were more common, but occurred with similar frequency among people with and without HIV.

Hypertension:

• Commercial cohort: 31% of HIV-positive vs 30% of HIV-negative people
• Medicaid cohort: 37% vs 34%, respectively.

Hyperlipidaemia:

• Commercial cohort: 31% vs 30%
• Medicaid cohort: 22% vs 24%.

Endocrine disease:

• Commercial cohort: 21% vs 18%
• Medicaid cohort: 26% vs 25%.

People with HIV were much more likely than HIV-negative people to have hepatitis C, in the commercial cohort (5% vs 1%) and especially in the Medicaid cohort (23% vs 4%).

Between 2003 and 2013 the media age of ART-treated people with HIV rose in both the commercial (from 44 to 48 years) and Medicaid (from 42 to 48 years) cohorts.

Among people with HIV in the commercial cohort, the proportion with co-morbidities increased between 2003 and 2013 for diabetes (from 6% to 9%), hypertension (10% to 25%), hyperlipidaemia (10% to 23%), obesity (1% to 5%) and endocrine disease (10% to 16%).

Co-morbidities increased even more over time in the HIV-positive Medicaid cohort: diabetes (from 9% to 17%), hypertension (16% to 47%), hyperlipidaemia (8% to 29%), obesity (2% to 12%) and endocrine disease (14% to 24%).

Rates of cardiovascular events, kidney impairment and fractures rose from 2003 to 2013 in both the HIV-positive and HIV-negative groups with either commercial coverage or Medicaid, but the proportion with these three co-morbidities was consistently higher among HIV-positive people.

"HIV patients have multiple non-AIDS-related comorbidities, including risk factors for renal impairment, cardiovascular disease, and fracture/osteoporosis," the researchers concluded. "Among treated HIV patients, the prevalence of comorbidities is increasing over time, especially renal, bone and cardiovascular comorbidities."

Dr Song noted that commercially insured individuals are typically the healthiest population in the US with the best access to health care, so their data represents co-morbidities among the best-served patients with HIV.

Medicaid patients had higher rates of co-morbidities than commercial patients despite similar ages. In addition, the Medicaid population had more turn-over and had greater differences in co-morbidity rates between HIV-positive and HIV-negative people.

As a limitation, the researchers noted that these findings may not be generalisable to people with other types of health care coverage or with no insurance.