SciELO - Scientific Electronic Library Online

 
vol.23 suppl.1Evaluation and management of cardiovascualr risk in VIH infection: Expert consensus of ACIN (Colombian Association of Infectious Diseases)Identification of mutations associated with resistance to Integrase Strand Transfer Inhibitors (INSTI) in ART-naïve HIV- 1 patients in Medellin, Colombia author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

Related links

  • On index processCited by Google
  • Have no similar articlesSimilars in SciELO
  • On index processSimilars in Google

Share


Infectio

Print version ISSN 0123-9392

Infect. vol.23  supl.1 Bogotá Dec. 2019

http://dx.doi.org/10.22354/in.v23i1.763 

ARTICULOS ORIGINALES

Comorbidities among adults living with hiv from two healthcare centers in Colombia

Comorbilidad entre adultos viviendo con VIH en dos centros de atención en Colombia

Pedro Luis Martinez-Iglesias1  , Jaime Enrique Ruiz-Sternberg2  , Sebastian León-Leiva2  , Claudia Catalina Beltran-Rodriguez2  , Mónica María Rojas-Rojas2  , José Moreno2  , William Lenis-Quintero3 

1 Sociedad integral de especialistas en Salud SAS, SIES.

2 MSD, Bogota, Colombia.

3 Centro de medicina física y Rehabilitación Recuperar SA IPS, Valle del Cauca, Cali, Colombia

Abstract

Objective:

To determine the prevalence of comorbidities among adults living with HIV from two healthcare centers in Colombia, and to identify factors associated with comorbidity-free years.

Methods:

Observational, retrospective medical chart review study. Summary statistics for demographic and clinical characteristics were developed and relationship between comorbidity-free years were analyzed through Kaplan-Meier analysis and Cox regression.

Results:

669 clinical charts were included, 71.7% were male and 16.1% were 50 years or older, 69.96% had at least one comorbidity. The most frequent comorbidities were dislipidemia(15.06%), hypertension(5.67%), risk factors were tobacco use(15.33%), alcohol intake(24.36%) and drugs abuse (14.66%).

Discussion:

These findings are consistent with previous reports showing the underlying processes of patients, producing multiple comorbidities.

Conclusions:

Significant proportion of patients have comorbidities that may increase risk of other complications or reduced comorbidity-free years. Poly-pharmacy among HIV+ adults need to be addressed to ensure adherence and minimize drug-drug interactions.

Key words: HIV; Comorbidity; Adult

Resumen

Objetivo:

Determinar la prevalencia de comorbilidades entre adultos viviendo con VIH en dos centros de atención en Colombia e identificar los factores asociados con años libres de comorbilidad .

Metodos:

Revisión observacional retrospectiva de historias clínicas. Resumen de estadísticas de características demográficas y clínicas y análisis de correlación entre características clínicas a través de pruebas de Kaplan-Meier y regresión de Cox.

Resultados:

Se analizaron 669 historias clínicas, 71.7% fueron hombres y 16.1% tuvieron 50 años o más, 69.96% tuvieron al menos una comorbilidad. Las comorbilidades más frecuentes fueron dislipidemia(15.06%), hipertensión (5.67%), los factores de riesgo fueron el uso de tabaco (15.33%), ingesta de alcohol (24.36%) y abuso de drogas (14.66%).

Discusión:

Estos hallazgos son consistentes con reportes previos que evidencian los procesos subyacentes que llevan a múltiples comorbilidades.

Conclusiones:

Una proporción significativa de pacientes tiene comorbilidades que pueden aumentar el riesgo de otras condiciones o los años libres de comorbilidad. La polifarmacia en pacientes HIV+ debe hacerse de manera que se asegure la adherencia y se minimicen las interacciones entre medicamentos.

Palabras-clave: VIH; co-morbilidad; Colombia

Background

Widespread use of combined highly active antirretroviral therapy (HAART), has improved HIV positive(HIV+) patients survival over the last decade1,2. Life expectancy has grown at least fifteen years in people living with HIV3, increasing patients lifespan4. In developed countries, almost half of deaths in HIV+ individuals with HAART therapy have a closer relationship to external factors than HIV infection itself5. For low-middle income countries where HAART coverage also is increasing, stemmed from a mix of chronic immune activation, medication side effects, coinfections, and the aging process itself, pose many challenges for addressing HIV as a public health problem6.

Longtime exposure to HAART may increase the risk of metabolic complications7, cardiovascular diseases8, hypertension9, hyperlipidemia10, renal disease11, reduced bone mineral density12 and drug-drug Interactions13. Comorbidities can occur not only related to HIV therapy and concomitant medications but to the infection itself; indirect causal relationships may appear because of risk factors shared among diseases14. In parallel, with survival increase of HIV+ patients, there has been a rise in the burden of AIDS and non-AIDS comorbidities, including overrepresentation of traditional risk factors15, and chronic immune activation and inflammation16.

Therefore, there is a need for a change in the clinical management and treatment of HIV infection, a situation that will put new demands on the health care system to evaluate the burden of disease and risk factors involved among people living with HIV17. The goal of this study was to determine the prevalence of comorbidities in a group of HIV+ patients attending two urban-based clinics in Colombia, as well as identify risk factors associated to variation in comorbidity-free years of this population, according to their age and whether they receive treatment or not for those comorbidities.

Material and methods

This was an observational, retrospective medical chart review study of adult HIV+ patients. A convinience sample of 669 medical charts were selected from HIV+ adults 18 years and older during the reference period (from July1, 2014-July30 2015), who were receiving medical care in two HIV clinical facilities: Recuperar: (“Centro de Medicina Física y Rehabilitación Recuperar SA IPS”), located in Cali, and SIES: (“Sociedad Integral de Especialistas en Salud SAS), that serves patients from Bogotá; Armenia and Medellin. The following patient data were collected from each clinical chart: sex, age, weight(Kgs), Body Mass Index (BMI) and documented diagnosis of one of the following conditions (clinical diagnosis previously reported by the health care professional in the clinical chart): type 2 diabetes mellitus(T2DM), dyslipidemia, high blood pressure, overweight, depression, lipodystrophy and use of tobacco, drugs and alcohol. In adittion, past or current use of prescription or over the counter drugs related to comorbidities were recorded from the same source. Score on the Framingham risk scale was also included 10. The study was submitted to the local institutional ethics committee “CAIMED” and approved in 2016.

Inclusion Criteria

Active charts of adult HIV+ patients, who were 18 years or older at the beginning of the reference period who had been receiving health care at that clinic for at least six months or longer.

Exclusion Criteria

Medical charts with incomplete information.

Outcomes

Comorbidities according to age and time since HIV diagnosis.

Statistical analysis

Summary statistics for demographic and clinical characteristics, considering those patients who received or not treatment for their comorbidities and were under or over 50 years old. We examined the relationship between comorbidity-free years (time to diagnosis once entered to the cohort) through Kaplan-Meier bivariate analysis18 and Cox regression19. Potential confounders in the multivariate analyses were: age, sex, tobacco or alcohol use. The statistical package used for the analysis was STATA V.14.020.

Results

A total of 669 medical records were reviewed, 16.14% were 50 years or older and 476 (71.15%;95%CI:67.59%-74.46%) were males. 337 patients (50.37%) and 332 (49.63%) (p=0.846) were from Recuperar and SIES, respectively. Of the patients, 2.55% (95%CI:1.59%-4.07%) were overweight. Table 1 shows the percent distribution for the most common comorbidities. The most common comorbidity was dyslipidemia, followed by hypertension and T2DM. Table 2 shows information of patient characteristics by age (50±), receiving treatment for any comorbidity and center. Patients 50 years or older were more likely to have dyslipidemia, hypertension and T2DM than those under 50 years old. They were also more likely to have any comorbidity, and to have more years since HIV diagnosis and since starting treatment for HIV.

Table 1 Most frequent comorbidities and risk factors 

Table 2 Patient characteristics by age group (50±) and receiving treatment for any comorbidity. Variable Age Group Receiving T 

Regarding Framingham scale, the average score was 4.62(95%CI:3.91-5.34low risk). About medication use, 0.91%(95%CI:0.4-2.01%) of patients used anti-hyperglycemic agents, 5.77%(95%CI:4.22-7.84%) lipid lowering therapy, 3.95%(95%CI:2.7-5.74%) antihypertensive medication, 2.58%(95%CI:1.61-4.12%) proton-pump inhibitor, 0.6%(95%CI:0.22-1.61%) H2 blockers, 0.75%(95%CI:0.31- 1.81%) antacids, 0.91%(95%CI:0.4-2.01%) asthma medication, 5.31%(95%CI:3.83-7.32%) dietary supplements, and 25%(95%CI:21.82-28.46%) any other medication.

Average time from HIV diagnosis and starting treatment was 5.46 years (95%CI:5.08-5.85years) and 4.33 years (95%CI:3.94- 4.71years), respectively. 468 (69.96%) had at least one comorbidity with an average comorbidity-free time of 9.7 years (95%CI: 8.76-10.64). Females were found to live significantly more time with no comorbidities when compared to males 13.24years (95%CI 11.38-15.11 years) vs. 8.26 years (95%CI 7.21-9.32years), respectively(p<0.001).

A total of 6,492 patient-time years were analyzed to assess comorbidity-free years. Significant differences were observed when comparing patients under 50 years old with those 50 years and older: 136 events observed (comorbidities) versus 51 (p=0.001). Comorbidity-free years curves by of those receiving treatment versus those not receiving treatment and gender are shown in figure 1.

Figure 1 Comorbidity-free years curves (95%CI), 1a by receiving treatment or not and 1b by gender 

Older patients have had more opportunity to receive long-time HIV treatment due their age. Thus the more years on treatment, the less expected comorbidity-free years. Treatment administration was positively associated with risk of having co-morbidities, most likely due to the fact that once patients are diagnosed of any comorbidity, they may require chronic medication. Proportional risk assumption was adequately verified (p=0.200). Significant effects are showed in Table 3.

Table 3 Adjusted analysis of comorbidity-free years in patients diagnosed with HIV 

Discussion

This study included patients from two specialized HIV treatment centers. Patients over 50 years or with long-term medication use had a significantly higher risk of comorbidities. Women were at lower risk. 71% of the patients had at least one comorbidity, the most frequent of which were dyslipidemia, hypertension, lipodystrophy, tuberculosis and depression. Results are similar to other studies previously reported12.

Regarding age groups, significant differences were observed for those 50 years or older compared to younger counterparts regarding frequency of BMI, diabetes, high blood pressure, dyslipidemia, and tobacco, alcohol and drug use, as well as for the Framingham risk score21. These conditions are common in this population, regardless of HIV status, and are related with other symptoms, not recorded here, like decreased sexual desire, back pain, avoiding intimacy, skin changes and few help-seeking attitudes22. Women were found to have longer comorbidity-free periods, probably related to better health-seeking behavior as it has been reported before23.

Our results showed a significant association with life-style factors, such as smoking and alcohol use with lipodystrophy. This is probably related to psychological distress, economic or autonomy deprivation in HIV+ patients; however, this kind of outcomes has not been adequately studied in low-income countries24. Furthermore, receiving treatment acts like a risk factor for reducing time living free of comorbidities, probably because co-infections and side effects are prevalent among HIV+ patients attending healthcare facilities, or patients requiring some medications can exhibit a more complicated health condition or not healthy life-styles25.

There are several limitations for this study. First, it is a not general population-based study where only two care centers were included by means of a convenience sampling scheme. Therefore, the results may not be representative of all the people living with HIV in Colombia. Second, the information examined here is mainly from laboratory data that were accumulated during the clinical care consultation. Some other comorbidities were not systematically examined, such as malignancy. Third, we did not have an HIV(-) population for comparison in terms of the frequency of comorbidity. Therefore, it is not known whether the frequency of any comorbidity examined in this study is higher in HIV+ patients than in HIV(-) ones, although several studies have suggested that HAART and HIV infection may accelerate aging and increase risk of metabolic, cardiovascular and other chronic complications26. Finally, a high percentage of unrecorded data was found in the review of clinical records, which is why greater emphasis on clinical record documentation is recommended. Notwithstanding, this study serves to draw attention to the need to strengthen the comprehensive approach of the HIV+ patient, in addition to drawing attention to greater control of the clinical records.

These findings are consistent with previous reports and lead to consider the underlying processes the patients with HIV live with, producing multiple comorbidities, in particular chronic ones. This can be due to several factors, including poly-pharmacy, adherence, lifestyle behaviors, and drug-drug interactions. Comprehensive approaches to the management of other than HIV-related problems in the long-term are needed in HIV+ population27.

In conclusion, our results show that a significant proportion of the HIV+ people have multiple comorbidities that may in crease risk of other complications or reduced years free of illness and life-span. Issues of poly-pharmacy among the adults VIH+ need to be addressed to ensure adherence and minimize drug-drug interactions. Other preventive actions and initiatives are also recommended taking into account the similarity of some risk factors and the psychological and functional impact on this population28. Comprehensive approaches to the management of metabolic, cardiovascular and, in general non-communicable diseases are required in the long-term successful management of HIV+ elderly population.

References

1. Wu P-Y, Chen M-Y, Hsieh S-M, Sun H-Y, Tsai M-S, Lee K-Y, et al. Comorbidities among the HIV-infected patients aged 40 years or older in Taiwan. PLoS One. 2014;9(8):e104945. [ Links ]

2. Organizacion Panamericana de la Salud. Tratamiento antirretroviral de la infección por el VIH en adultos y adolescentes en Latinoamérica y el Caribe: en la ruta hacia el acceso universal [Internet]. Washington, D.C; 2008. Available from: http://www1.paho.org/hq/dmdocuments/2008/ GuiaARVadultos.pdfLinks ]

3. The antiretroviral therapy cohort collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;372(9635):293-9. [ Links ]

4. Battegay M, Elzi L. Morbidity and mortality in HIV-infected individuals - a shift towards comorbidities. Swiss Med Wkly. 2009;139(39-40):564-70. [ Links ]

5. Butt AA, Khan UA, Skanderson M. Comorbidities and Their Impact on Mortality in HCV and HCV-HIV-coinfected Persons on Dialysis. J Clin Gastroenterol. 2008;42(9):1054-9. [ Links ]

6. Narayan KMV, Miotti PG, Anand NP, Kline LM, Harmston C, Gulakowski R, et al. HIV and Noncommunicable Disease Comorbidities in the Era of Antiretroviral Therapy: A Vital Agenda for Research in Low- and Middle- Income Country Settings. J Acquir Immune Defic Syndr. 2014;67(Suppl 1):S2-7. [ Links ]

7. Lake JE, Currier JS. Metabolic disease in HIV infection. Vol. 13, The Lancet Infectious Diseases. 2013. p. 964-75. [ Links ]

8. Reyskens KMSE, Essop MF. HIV protease inhibitors and onset of cardiovascular diseases: a central role for oxidative stress and dysregulation of the ubiquitin-proteasome system. Biochim Biophys Acta. 2014;1842(2):256-68. [ Links ]

9. Antonello VS, Carlos Ferreira Antonello I, Grossmann TK, Tovo CV, Brasil Dal Pupo B, de Quadros Winckler L. Hypertension-an emerging cardiovascular risk factor in HIV infection. J Am Soc Hypertens. 2015;9(5):403-7. [ Links ]

10. Matoga MM, Hosseinipour MC, Aga E, Ribaudo HJ, Kumarasamy N, Bartlett J, et al. Hyperlipidaemia in HIV-infected patients on lopinavir/ritonavir monotherapy in resource-limited settings. Antivir Ther. 2017;22(3):205- 13. [ Links ]

11. Islam FM, Wu J, Jansson J, Wilson DP. Relative risk of renal disease among people living with HIV: a systematic review and meta-analysis. BMC Public Health. 2012;12:234. [ Links ]

12. Young L, Wohl DA, Hyslop WB, Lee YZ, Napravnik S, Wilkin A. Effects of raltegravir combined with tenofovir/emtricitabine on body shape, bone density, and lipids in African-Americans initiating HIV therapy. HIV Clin Trials. 2015;16(5):163-9. [ Links ]

13. Iniesta-Navalon C, Franco-Miguel J, Gascon-Canovas J, Rentero-Redondo L. Identification of potential clinically significant drug interactions in HIV-infected patients: A comprehensive therapeutic approach. HIV Med. 2015; 16(5):273-9. [ Links ]

14. Currie CJ, Poole CD, Jenkins-Jones S, Gale EAM, Johnson JA, Morgan CL. Mortality after incident cancer in people with and without type 2 diabetes: Impact of metformin on survival. Diabetes Care. 2012;35(2):299-304. [ Links ]

15. Mdodo R, Frazier EL, Dube SR, Mattson CL, Sutton MY, Brooks JT, et al. Cigarette smoking prevalence among adults with HIV compared with the general adult population in the United States: Cross-sectional surveys. Ann Intern Med. 2015;162(5):335-44. [ Links ]

16. Maartens G, Celum C, Lewin SR. HIV infection: Epidemiology, pathogenesis, treatment, and prevention. In: The Lancet. 2014. p. 258-71. [ Links ]

17. Ronit A, Haissman J, Kirkegaard-Klitbo DM, Kristensen TS, Lebech A-M, Benfield T, et al. Copenhagen comorbidity in HIV infection (COCOMO) study: a study protocol for a longitudinal, non-interventional assessment of non-AIDS comorbidity in HIV infection in Denmark. BMC Infect Dis. 2016;16(1):713. [ Links ]

18. Kaplan EL, Meier P. Nonparametric Estimation from Incomplete Observations. J Am Stat Assoc. 1958;53(282):457-81. [ Links ]

19. Xu R. Proportional hazards mixed models: a review with applications to twin models. Methodoloski Zv. 2004;1(1):205-12. [ Links ]

20. StataCorp. Stata Statistical Software: Release 14. 2015. [ Links ]

21. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837-47. [ Links ]

22. Sherr L, Molloy A, Macedo A, Croome N, Johnson MA. Ageing and menopause considerations for women with HIV in the UK. J virus Erad. 2016;2(4):215-8. [ Links ]

23. Cornell M. Gender inequality: Bad for men’s health. South Afr J HIV Med. 2013 Jan;14(1):12-4. [ Links ]

24. Tola HH, Shojaeizadeh D, Garmaroudi G, Tol A, Yekaninejad MS, Ejeta LT, et al. Psychological distress and its effect on tuberculosis treatment outcomes in Ethiopia. Glob Health Action. 2015;8:29019. [ Links ]

25. Nlooto M. Comorbidities of HIV infection and health care seeking behavior among HIV infected patients attending public sector healthcare facilities in KwaZulu-Natal: A cross sectional study. PLoS One. 2017;12(2). [ Links ]

26. Lo Y-C, Chen M-Y, Sheng W-H, Hsieh S-M, Sun H-Y, Liu W-C, et al. Risk factors for incident diabetes mellitus among HIV-infected patients receiving combination antiretroviral therapy in Taiwan: a case-control study. HIV Med. 2009;10(5):302-9. [ Links ]

27. Yanagisawa N, Ando M, Ajisawa A, Imamura A, Suganuma A, Tsuchiya K, et al. Clinical characteristics of kidney disease in Japanese HIV-infected patients. Nephron - Clin Pract. 2011;118(3). [ Links ]

28. ONUSIDA RETOS 2009 planteados por la epidemia del VIH en América Latina y el Caribe. [cited 2018 May 15]; Available from: Available from: http://onusidalac.org/1/pdf/ retos-planteados-por-latinoamerica-y-caribe.pdfLinks ]

Cómo citar este artículo: P.L. Martinez-Iglesias, et al. Comorbidities among adults living with hiv from two healthcare centers in Colombia. Infectio 2019; 23(S1): 92-96

Financial support MSD Colombia provided financial support for the study

Received: February 12, 2018; Revised: May 15, 2018; Accepted: August 11, 2018

* Autor para correspondencia. Correo electrónico: claudia.catalina.beltran.rodriguez@merck.com, Calle 127 A # 153 A 45, Complejo Empresarial Colpatria Torre 3 - Piso 8.

Conflict of interests

Jaime Enrique Ruiz-Sternberg2, Sebastian León-Leiva2, Claudia Catalina Beltran-Rodriguez2, Mónica María Rojas-Rojas are employees of MSD Colombia. William Lenis, has served as a paid expert lecturer for MSD. Jose Moreno received personal fees to carry out the statistical analysis.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License