Increase in chronic health conditions in people with HIV hospitalized in Canada and the US

In Canada and other high-income countries, the widespread availability of effective HIV treatment (antiretroviral therapy; ART) since 1996 has led to improved health in many people with HIV who take ART as directed. The power of ART is so transformative that researchers project that many ART users will live well into their senior years.

Despite improvements in life expectancy among ART users, some studies have found that, in general, ART users are at increased risk of hospitalization compared to people without HIV, even those in similar age groups. To explore the factors that might be driving hospitalizations in ART users, a team of researchers in Canada and the U.S. pooled anonymized data from more than 28,000 people with HIV, nearly 7,000 of whom were hospitalized. They explored the data for trends in time that occurred between 2008 and 2018.

The researchers found that, over time, the proportion of ART users who had one or more hospitalizations decreased. However, hospitalized people tended to have significantly increased rates of one of the following comorbidities:

• high cholesterol
• high blood pressure
• type 2 diabetes
• chronic kidney disease

What’s more, some hospitalized people had two, three or even more comorbidities—this is called multimorbidity.

The researchers drew attention to the need for hospital staff to “include efforts to ensure that chronic conditions are adequately managed” in people with HIV once they leave the hospital.

Study details

Researchers focused on 28,381 people who were receiving care over the course of the study. About 90% of all participants were from the U.S.

The average profile of participants at the time they entered the study was as follows:

• age – 43 years
• cisgender males – 82%; cisgender females – 17%; transgender – 1%
• major ethno-racial groups: White – 39%; Black – 32%; Hispanic – 17%
• CD4+ count – 457 cells/mm³
• proportion with a suppressed viral load (in this case, less than 200 copies/mL) – 54%
• history of AIDS-related illness – 13%

A subgroup of 6,781 people was hospitalized over the course of the study. Their characteristics were broadly similar to the larger non-hospitalized group of participants.

Results

Over the course of the study, the researchers found the following trends among hospitalized people:

• there were proportionally fewer people who injected drugs (from 27% to 18%)
• the proportion of people with hepatitis C virus decreased
• the proportion of people with hepatitis B virus remained stable
• the average age of hospitalization increased from 47 years to 54 years
• the average CD4+ count increased from nearly 300 cells/mm³ to 463 cells/mm³
• the proportion of people with a suppressed viral load because they were taking ART rose from 47% to 79%
• the proportion of obese participants rose from 18% to 26%

Increasing comorbidities

According to the researchers, hospitalized people with HIV had “a high burden of non-AIDS conditions.” What’s more, the researchers found that the proportion of people with the following non-AIDS conditions increased over time: high cholesterol levels, type 2 diabetes, chronic kidney disease. They also found that 50% of participants who were hospitalized in 2018 had high blood pressure (drugs were prescribed to treat it). The researchers did not assess whether these drugs resolved high blood pressure.

In addition, the researchers found that the proportion of hospitalized people with multimorbidity increased over time.

The increase in comorbidities in hospitalized people over the course of the study was higher than expected, even considering people’s age. It is plausible that the excess inflammation and immune activation that is a feature of chronic HIV infection could have played a role in the development of comorbidities. However, the present study was not designed to investigate this issue.

Bear in mind

According to the researchers, their findings underscore the importance of hospital staff preparing patients for care when they leave the hospital. Such efforts should include access to healthcare and medicines for management of comorbidities.

As mentioned, the researchers found that 50% of hospitalized patients in 2018 had high blood pressure. The researchers noted that perhaps “better outpatient chronic disease management could also potentially prevent hospitalizations. For instance, the prevalence of hypertension, hyperlipidemia, diabetes, and chronic kidney disease was particularly high in people with HIV hospitalized for conditions that are sensitive to the poor control of these comorbidities, such as cardiovascular and renal/genitourinary conditions.”

The researchers also drew attention to the rates of obesity, which increased over time. They stated that obesity “could have contributed to [some cases of] hospitalizations.”

Unfortunately, the researchers were unable to assess the level of control of comorbidities (for example, whether participants took drugs for blood pressure and if they were effective in lowering blood pressure). They also did not have data about socioeconomic factors that could have affected hospitalization. Also absent from the study was information about mental health and problematic substance use.

Multimorbidity 

The researchers drew attention to multiple simultaneous comorbidities—multimorbidity—in hospitalized people. They found that multimorbidity increased over the course of the study. Furthermore, other studies project that people with HIV are at increased risk for multimorbidity as they age. The researchers stated: “Complex clinical profiles with multiple conditions can complicate [hospitalization] and lead to worse outcomes, including longer hospital stays and readmission. Strategies are needed to improve the care of people with HIV who have multimorbidity, such as coordinated or integrated care with different specialists.”

For the future

The analysis of a large dataset by the researchers is a good first step toward improving care for people with HIV. It is possible that some hospitalizations could have been avoided if certain chronic conditions—blood pressure, blood sugar, cholesterol levels, and so on—were well controlled. Future studies are needed to assess how well patients who are hospitalized have these conditions under control. People who have problems managing comorbidities should be offered counselling by nurses in the community after hospitalization to help them overcome barriers to control chronic conditions.

By Sean R. Hosein

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