AIDS and Behavior

, Volume 20, Issue 3, pp 555–564 | Cite as

Alcohol-Related Diagnoses and All-Cause Hospitalization Among HIV-Infected and Uninfected Patients: A Longitudinal Analysis of United States Veterans from 1997 to 2011

  • Christopher RentschEmail author
  • Janet P. Tate
  • Kathleen M. Akgün
  • Stephen Crystal
  • Karen H. Wang
  • S. Ryan Greysen
  • Emily A. Wang
  • Kendall J. Bryant
  • David A. Fiellin
  • Amy C. Justice
  • David Rimland
Original Paper


Individuals with HIV infection are living substantially longer on antiretroviral therapy, but hospitalization rates continue to be relatively high. We do not know how overall or diagnosis-specific hospitalization rates compare between HIV-infected and uninfected individuals or what conditions may drive hospitalization trends. Hospitalization rates among United States Veterans were calculated and stratified by HIV serostatus and principal diagnosis disease category. Because alcohol-related diagnoses (ARD) appeared to have a disproportional effect, we further stratified our calculations by ARD history. A multivariable Cox proportional hazards model was fitted to assess the relative risk of hospitalization controlling for demographic and other comorbidity variables. From 1997 to 2011, 46,428 HIV-infected and 93,997 uninfected patients were followed for 1,497,536 person-years. Overall hospitalization rates decreased among HIV-infected and uninfected patients. However, cardiovascular and renal insufficiency admissions increased for all groups while gastrointestinal and liver, endocrine, neurologic, and non-AIDS cancer admissions increased among those with an alcohol-related diagnosis. After multivariable adjustment, HIV-infected individuals with an ARD had the highest risk of hospitalization (hazard ratio 3.24, 95 % CI 3.00, 3.49) compared to those free of HIV infection and without an ARD. Still, HIV alone also conferred increased risk (HR 2.08, 95 % CI 2.04, 2.13). While decreasing overall, risk of all-cause hospitalization remains higher among HIV-infected than uninfected individuals and is strongly influenced by the presence of an ARD.


Inpatient care HIV Substance abuse Clinical epidemiology Aging 



This work was supported by the National Institutes of Health: AHRQ [R01-HS018372], NIAAA [U24-AA020794, U01-AA020790, U01-AA020795, U01-AA020799, U24-AA022001, U24 AA022007, U10 AA013566-completed], NHLBI [R01-HL095136; R01-HL090342], NIAID [U01-A1069918], NIMH [P30-MH062294], NIDA [R01DA035616], NCI [R01 CA173754] and the Veterans Health Administration Office of Research and Development [VA REA 08-266, VA IRR Merit Award, VISN 1 Career Development Award [V1CDA2012-20]] and Office of Academic Affiliations [Medical Informatics Fellowship]. This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, and Office of Research and Development. We must disclaim that the views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Supplementary material

10461_2015_1025_MOESM1_ESM.doc (39 kb)
Supplementary material 1 (DOC 39 kb)


  1. 1.
    Berry SA, Fleishman JA, Moore RD, Gebo KA. Trends in reasons for hospitalization in a multisite United States cohort of persons living with HIV, 2001–2008. J Acquir Immune Defic Syndr. 2012;59:368–75.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Buchacz K, Baker RK, Moorman AC, Richardson JT, Wood KC, Holmberg SD, et al. Rates of hospitalizations and associated diagnoses in a large multisite cohort of HIV patients in the United States, 1994–2005. AIDS. 2008;22:1345–56.CrossRefPubMedGoogle Scholar
  3. 3.
    Crum-Cianflone NF, Grandits G, Echols S, Ganesan A, Landrum M, Weintrob A. Trends and causes of hospitalizations among HIV-infected persons during the late HAART Era: what is the impact of CD4 counts and HAART use? J Acquir Immune Defic Syndr. 2010;54:248–57.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Bozzette S, Ake C, Tam H, Change S, Louis T. Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection. N Engl J Med. 2003;348:702–10.CrossRefPubMedGoogle Scholar
  5. 5.
    Powles T, Robinson D, Stebbing J, Shamash J, Nelson M, Gazzard B, et al. Highly active antiretroviral therapy and the incidence of non-AIDS-defining cancers in people with HIV infection. J Clin Oncol. 2009;27(6):884–90.CrossRefPubMedGoogle Scholar
  6. 6.
    Akgun KM, Tate JP, Pisani M, Fried T, Butt AA, Gibert CL, et al. Medical ICU admission diagnoses and outcomes in human immunodeficiency virus-infected and virus-uninfected Veterans in the combination antiretroviral era. Crit Care Med. 2013;41(6):1458–67.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Fleishman JA, Gebo KA, Reilly E, Conviser R, Mathews WC, Korthuis P, et al. Hospital and outpatient health services utilization among HIV-infected adults in care 2000–2002. Med Care. 2005;43:III40–52.CrossRefPubMedGoogle Scholar
  8. 8.
    Gebo KA, Diener-West M, Moore RD. Hospitalization rates differ by hepatitis C status in an urban HIV cohort. J Acquir Immune Defic Syndr. 2003;34(2):165–73.CrossRefPubMedGoogle Scholar
  9. 9.
    Krentz HB, Dean S, Gill MJ. Longitudinal assessment (1995–2003) of hospitalizations of HIV-infected patients within a geographical population in Canada. HIV Med. 2006;7:457–66.CrossRefPubMedGoogle Scholar
  10. 10.
    Krupitsky E, Horton N, Williams E, Lioznov D, Kuznetsova M, Zvartau E, et al. Alcohol use and HIV risk behaviors among HIV-infected hospitalized patients in St. Petersburg, Russia. Drug Alcohol Depend. 2005;79(2):251–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Akgun KM, Gordon K, Pisani M, Fried T, McGinnis KA, Tate JP, et al. Risk factors for hospitalization and medical intensive care unit (MICU) admission among HIV infected Veterans. J Acquir Immune Defic Syndr. 2013;62(1):52–9.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Justice AC, Sullivan L, Fiellin D. HIV/AIDS, comorbidity, and alcohol: can we make a difference? Alcohol Res Health. 2010;33(3):258–66.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Purohit V, Bode JC, Bode C, Brenner DA, Choudhry MA, Hamilton F, et al. Alcohol, intestinal bacterial growth, intestinal permeability to endotoxin, and medical consequences: summary of a symposium. Alcohol. 2008;42(5):349–61.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Lim JK, Tate JP, Fultz SL, Goulet JL, Conigliaro J, Bryant KJ, et al. Relationship between alcohol use categories and noninvasive markers of advanced hepatic fibrosis in HIV-infected, chronic hepatitis C virus-infected, and uninfected patients. Clin Infect Dis. 2014;58(10):1449–58.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Anderson JP, Tchetgen Tchetgen EJ, Lo Re V 3rd, Tate JP, Williams PL, Seage GR 3rd, et al. Antiretroviral therapy reduces the rate of hepatic decompensation among HIV- and hepatitis C virus-coinfected Veterans. Clin Infect Dis. 2014;58(5):719–27.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Re VL III, Kallan MJ, Tate JP, Locallo AR, Lim JK, Goetz MB, et al. Hepatic decompensation in antiretroviral-treated patients co-infected with HIV and hepatitis C virus compared with hepatitis C virus-monoinfected patients. Ann Intern Med. 2014;160:369–79.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med. 2005;118(4):330–41.CrossRefPubMedGoogle Scholar
  18. 18.
    Sullivan LE, Goulet JL, Justice AC, Fiellin DA. Alcohol consumption and depressive symptoms over time: a longitudinal study of patients with and without HIV infection. Drug Alcohol Depend. 2011;117(2–3):158–63.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Alba ID, Samet JH, Saitz R. Burden of medical illness in drug- and alcohol-dependent persons without primary care. Am J Addict. 2004;13(1):33–45.CrossRefPubMedGoogle Scholar
  20. 20.
    Kirchner JE, Zubritsky C, Cody M, Coakley E, Chen H, Ware JH, et al. Alcohol consumption among older adults in primary care. J Gen Intern Med. 2007;22(1):92–7.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH. Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. Ann Intern Med. 2003;138:372–82.CrossRefPubMedGoogle Scholar
  22. 22.
    McDonald SA, Hutchinson SJ, Bird SM, Graham L, Robertson C, Mills PR, et al. Association of self-reported alcohol use and hospitalization for an alcohol-related cause in Scotland: a record-linkage study of 23,183 individuals. Addiction. 2009;104(4):593–602.CrossRefPubMedGoogle Scholar
  23. 23.
    Azar MM, Springer SA, Meyer JP, Altice FL. A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug Alcohol Depend. 2010;112(3):178–93.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Gordon A, McGinnis KA, Conigliaro J, Rodriguez-Barradas M, Rabeneck L, Justice AC. Associations between alcohol use and homelessness with healthcare utilization among human immunodeficiency virus-infected Veterans. Med Care. 2006;44(8):S37–43.CrossRefPubMedGoogle Scholar
  25. 25.
    Kraemer K, McGinnis KA, Skanderson M, Cook R, Gordon A, Conigliaro J, et al. Alcohol problems and health care services use in human immunodeficiency virus (HIV)-infected and HIV-uninfected Veterans. Med Care. 2006;44(8):S44–51.CrossRefPubMedGoogle Scholar
  26. 26.
    Palepu A, Horton NJ, Tibbetts N, Meli S, Samet JH. Substance abuse treatment and hospitalization among a cohort of hiv-infected individuals with alcohol problems. Alcohol Clin Exp Res. 2005;29(3):389–94.CrossRefPubMedGoogle Scholar
  27. 27.
    Cunningham W, Sohler N, Tobias C, Drainoni M, Bradford J, Davis C, et al. Health services utilization for people with HIV infection: comparison of a population targeted for outreach with the U.S. population in care. Med Care. 2006;44(11):1038–47.CrossRefPubMedGoogle Scholar
  28. 28.
    Josephs JS, Fleishman JA, Korthuis PT, Moore RD, Gebo KA, Network HIVR. Emergency department utilization among HIV-infected patients in a multisite multistate study. HIV Med. 2010;11(1):74–84.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Kim TW, Kertesz SG, Horton NJ, Tibbetts N, Samet JH. Episodic homelessness and health care utilization in a prospective cohort of HIV-infected persons with alcohol problems. BMC Health Serv Res. 2006;6:19.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Masson CL, Sorensen JL, Phibbs CS, Okin RL. Predictors of medical service utilization among individuals with co-occurring HIV infection and substance abuse disorders. AIDS Care. 2004;16(6):744–55.CrossRefPubMedGoogle Scholar
  31. 31.
    Fultz SL, Skanderson M, Mole L, Gandhi N, Bryant K, Crystal S, et al. Development and verification of a “virtual” cohort using the National VA Health Information System. Med Care. 2006;44:S25–30.CrossRefPubMedGoogle Scholar
  32. 32.
    Justice AC, Dombrowski E, Conigliaro J, Fultz SL, Gibson D, Madenwald T, et al. Veterans Aging Cohort Study (VACS): overview and description. Med Care. 2006;44(8):S13–24.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Justice AC, Lasky E, McGinnis KA, Skanderson M, Conigliaro J, Fultz SL, et al. medical disease and alcohol use among Veterans with human immunodeficiency infection: a comparison of disease measurement strategies. Med Care. 2006;44(8):S52–60.CrossRefPubMedGoogle Scholar
  34. 34.
    Rosner B. Fundamentals of biostatistics. 7th ed. Boston: Brooks/Cole; 2010.Google Scholar
  35. 35.
    Rancinan C, Neau D, Savès M, Lawson-Ayayi S, Bonnet F, Mercié P, et al. Is hepatitis C virus co-infection associated with survival in HIV-infected patients treated by combination antiretroviral therapy? AIDS. 2002;16:1357–62.CrossRefPubMedGoogle Scholar
  36. 36.
    Benhamou Y, Bochet M, Martino VD, Charlotte F, Azria F, Coutellier A, et al. Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. Hepatology. 1999;30(4):1054–8.CrossRefPubMedGoogle Scholar
  37. 37.
    Park LS, Tate JP, Justice AC, Lo Re V 3rd, Lim JK, Brau N, et al. FIB-4 index is associated with hepatocellular carcinoma risk in HIV-infected patients. Cancer Epidemiol Biomarkers Prev. 2011;20(12):2512–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    John U, Meyer C, Rumpf H-J, Hapke U. Probabilities of alcohol high-risk drinking, abuse or dependence estimated on grounds of tobacco smoking and nicotine dependence. Addiction. 2003;98:805–14.CrossRefPubMedGoogle Scholar
  39. 39.
    Bagnardi V, Blangiardo M, Vecchia CL, Corrao G. Alcohol consumption and the risk of cancer. Alcohol Res Health. 2001;25(4):263–70.PubMedGoogle Scholar
  40. 40.
    Bagnardi V, Rota M, Botteri E, Tramacere I, Islami F, Fedirko V, et al. Light alcohol drinking and cancer: a meta-analysis. Ann Oncol. 2013;24(2):301–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Unhealthy Saitz R, Use Alcohol. N Engl J Med. 2005;352:596–607.CrossRefGoogle Scholar
  42. 42.
    Wang L, Porter B, Maynard C, Evans G, Bryson C, Sun H, et al. Predicting risk of hospitalization or death among patients receiving primary care in the Veterans health administration. Med Care. 2013;51(4):368–73.CrossRefPubMedGoogle Scholar
  43. 43.
    Clark BJ, Moss M. Secondary prevention in the intensive care unit: does intensive care unit admission represent a “teachable moment?”. Crit Care Med. 2011;39(6):1500–6.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Samet JH, Walley A. Interventions targeting HIV-infected risky drinkers. Alcohol Res Health. 2010;33(3):267–79.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Williams EC, Palfai T, Cheng DM, Samet JH, Bradley KA, Koepsell TD, et al. Physical health and drinking among medical inpatients with unhealthy alcohol use: a prospective study. Alcohol Clin Exp Res. 2010;34(7):1257–65.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:557–68.CrossRefPubMedGoogle Scholar
  47. 47.
    Wilk AI, Jenson NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997;12:274–83.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889–900.CrossRefPubMedGoogle Scholar
  49. 49.
    Berry SA, Fleishman JA, Moore RD, Gebo KA. Trends in reasons for hospitalization in a multisite United States cohort of persons living with HIV, 2001-2008. J Acquir Immune Defic Syndr. 2012;59:368–75.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    May MT, Ingle SM, Costagliola D, Justice AC, de Wolf F, Cavassini M, et al. Cohort profile: antiretroviral therapy cohort collaboration (ART-CC). Int J Epidemiol. 2013;43(3):691–702.Google Scholar
  51. 51.
    HIV-Causal Collaboration, Ray M, Logan R, Sterne JA, Hernandez-Diaz S, Robins JM, et al. The effect of combined antiretroviral therapy on the overall mortality of HIV-infected individuals. AIDS. 2010;24(1):123–37.CrossRefGoogle Scholar
  52. 52.
    Gange SJ, Kitahata MM, Saag MS, Bangsberg DR, Bosch RJ, Brooks JT, et al. Cohort profile: the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Int J Epidemiol. 2007;36(2):294–301.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Christopher Rentsch
    • 1
    • 2
    • 3
    Email author
  • Janet P. Tate
    • 2
    • 3
  • Kathleen M. Akgün
    • 2
    • 3
  • Stephen Crystal
    • 4
  • Karen H. Wang
    • 2
    • 3
  • S. Ryan Greysen
    • 5
  • Emily A. Wang
    • 3
  • Kendall J. Bryant
    • 6
  • David A. Fiellin
    • 3
  • Amy C. Justice
    • 2
    • 3
  • David Rimland
    • 1
    • 7
  1. 1.Infectious DiseasesAtlanta VA Medical CenterDecaturUSA
  2. 2.Research, VA Connecticut Healthcare SystemWest HavenUSA
  3. 3.School of MedicineYale UniversityNew HavenUSA
  4. 4.School of Social WorkRutgers UniversityNew BrunswickUSA
  5. 5.Division of Hospital MedicineUniversity of CaliforniaSan FranciscoUSA
  6. 6.National Institute on Alcohol Abuse and AlcoholismNational Institutes of HealthBethesdaUSA
  7. 7.School of MedicineEmory UniversityAtlantaUSA

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