The Epidemiology of Age-Associated Conditions Among Individuals Living with HIV in North America
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Background: Individuals receiving antiretroviral therapy (ART) for their HIV infection are getting older, but optimal management of care is complicated by the development of age-associated comorbidities. The goals of this dissertation are to examine the development of age-associated comorbidities as well as disparities in their occurrence, and assess the changing prevalence of their co-occurrence by demographics, route of HIV acquisition, and geographic residence, using data within 2000-2013. Methods: We analyzed data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). We estimated rates of first occurrence for hypertension, diabetes, and chronic kidney disease by demographic subgroup using Poisson regression methods. Cumulative incidences by age 70 were estimated for each outcome, accounting for the competing risk of death using the Fine and Gray method. Trends and disparities in the prevalence of multimorbidity, defined as the co-occurrence of ≥2 age-associated conditions (inclusive of: hypertension, diabetes, chronic kidney disease, hypercholesterolemia, end-stage renal disease, and non-AIDS-related malignancies), were assessed by logistic and Poisson regression with robust variance, respectively, using generalized estimating equations to adjust for within person correlation over time. Results: We identified significant disparities in the occurrence of hypertension, diabetes, and chronic kidney disease between black and non-black men and women, even after adjusting for individual-level characteristics. Rates of first occurrence (per 100 person-years) were: 2.6 (hypertension), 1.2 (diabetes), and 0.6 (chronic kidney disease). Multimorbidity prevalence increased from 8.2% in 2000 to 22.4% in 2009 (ptrend<0.001) and the most commonly occurring conditions were hypertension and hypercholesterolemia. Adjusting for age, sex, race, HIV risk, year, other HIV-related variables, individuals residing in the South (aPR=1.55 [1.30,1.85]) and the West (aPR=1.33 [1.11,1.60]) relative to the Northeast were more likely to have multimorbidity. There was no difference by sex and blacks were less likely to have multimorbidity (compared to whites, aPR=0.86 [0.75,0.98]). Conclusions: In a population with equal access to clinical care and ART, disparities between sex and race persist, and the rise in the prevalence of multimorbidity is likely to continue. The increase in the number of patients who will require complicated care plans will require evidence-based strategies to improve their health outcomes.