Age increases multimorbidity risk in people with HIV in Brazil
The number of people living with HIV experiencing more than one non-communicable disease (NCD) increased as they got older, with metabolic diseases being the biggest contributor.
The number of people living with HIV and with multimorbidity, defined as having two or more unique non-communicable diseases (NCDs), increased in Brazil over 10 years from 3% to 11%. This increase was mirrored with the rising age of this cohort of patients, revealing that those aged over 50 were at an increased risk of multimorbidity.
The analysis also revealed that females, those with low CD4 counts at HIV diagnosis, and those who already had a morbidity were at a greater risk of having multiple NCDs. Metabolic diagnosis were also found to be the most frequent causes of multimorbidity.
Multimorbidity is associated with poorer health outcomes, loss of quality of life, polypharmacy and increased frailty and mortality. We know from research in high-income countries that people living with HIV experience high levels of co-morbidity and that multimorbidity is rising as they age with HIV, but little is known about the experience and trends in low- and middle-income countries, like Brazil.
Brazil provides an excellent opportunity using a middle-income country with a large, long-running and free antiretroviral treatment programme to understand trends or predictors of NCD multimorbidity in this context.
In this observational cohort study, data from 6,206 patients starting antiretroviral treatment between 2003 and 2014 from multiple sites across Brazil was analysed. NCDs were categorised as cardiovascular artery disease, hyperlipidemia (HLD), diabetes, chronic kidney disease, cirrhosis, osteoporosis, osteonecrosis, venous thromboembolism and non-AIDS-defining cancer.
For those with multimorbidity, the most frequent NCD diagnosis was HLD (having a high level of fat proteins in the blood), which accounted for 40% in men and 35% in women. Diabetes was the second most frequent NCD in people with multimorbidity, accounting for a quarter (25%) of diagnoses. Women then had significantly higher levels of osteoporosis compared to men – 15% of all NCDs in women compared to 7% in men.
Of note, the researchers found no significant association to increased multimorbidity risk relating to race, education, hepatitis C virus infection, calendar year, or specific antiretrovirals.
At baseline, the most common NCD diagnoses were high-grade HLD and osteoporosis in the overall cohort of people living with HIV. Over time, rates of cardiovascular disease, non-AIDS-defining cancers, diabetes, kidney disease and cirrhosis remained statistically unchanged over the study period. But the rate of high-grade HLD decreased, while the rate of osteoporosis increased.
In their discussion, the authors note that decreased levels of HLD could be the result of less frequent use of lopinavir/ ritonavir, protease inhibitors which have been associated with increased risk of HLD. Osteoporosis increases may be the result of increased implementations of screening programmes over the time period, but also increased implementation of tenofovir, which has been associated with increased osteoporosis risk.
The authors note that their study is limited by the non-inclusion of all possible NCDs, such as pulmonary disease (data of which was not collected) and mental health disorders (which are difficult to classify and validate). Screening for a number of NCDs also remains limited in some parts of Brazil, meaning the results could be underestimated.
Going forward, understanding better the role metabolic disorders play in increased risk of NCD multimorbidity in Brazil could help inform trends, outcomes and future policy in the country.