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Disparities in multimorbidity and mortality among people living with and without HIV across British Columbia’s health regions: a population-based cohort study

Abstract

Objectives

Longer survival has increased the likelihood of antiretroviral-treated people living with HIV (PLWH) developing age-associated comorbidities. We compared the burden of multimorbidity and all-cause mortality across HIV status in British Columbia (BC), and assessed the longitudinal effect of multimorbidity on all-cause mortality among PLWH.

Methods

Antiretroviral-treated PLWH aged ≥19 years and 1:4 age-sex-matched HIV-negative individuals from a population-based cohort were followed for ≥1 year during 2001–2012. Diagnoses of seven age-associated comorbidities were identified from provincial administrative databases and grouped into 0, 1, 2, and ≥3 comorbidities. Multimorbidity prevalence and age-standardized mortality rates (ASMRs) in both populations were stratified by BC’s health regions. Marginal structural models were used to estimate the effect of multimorbidity on mortality among PLWH, adjusted for time-varying confounders affected by prior multimorbidity.

Results

Among 8031 PLWH and 32,124 HIV-negative individuals, 25% versus 11% developed multimorbidity, and 23.53 deaths/1000 person-years (95% confidence interval [95% CI]: 22.02–25.13) versus 3.04 (2.81–3.29) were observed, respectively. PLWH in Northern region had the highest ASMR, but those in South Vancouver Island experienced the greatest difference in mortality compared with HIV-negative individuals. Among PLWH, compared with those with zero comorbidities, adjusted hazard ratios for those with 1, 2, and ≥3 comorbidities were 3.36 (95% CI: 2.86–3.95), 6.92 (5.75–8.33), and 12.87 (10.45–15.85), respectively.

Conclusion

PLWH across BC’s health regions experience excess multimorbidity and associated mortality. We highlight health disparities which are key when planning the distribution of healthcare resources across BC, and provide evidence for improved HIV care models integrating prevention and management of chronic diseases.

Résumé

Objectif

Les nouvelles thérapeutiques antirétrovirales (ARV) ont permis une plus longue espérance de vie aux personnes porteuses du VIH. Cependant, le vieillissement augmente la probabilité de développer des comorbidités au sein même de la population des personnes vivant avec le VIH (PVVIH) qui suivent des traitements ARV. On a comparé le fardeau de la multimorbidité et mortalité, toutes causes confondues, lié au statut VIH à travers la Colombie-Britannique. On a aussi évalué l’effet longitudinal de la multimorbidité sur la mortalité, toutes causes confondues, parmi les PVVIH.

Méthodes

L’étude comprit des PVVIH suivant un traitement ARV âgés de ≥19 ans et un groupe témoin séronégatif (4 témoins par PVVIH) comparable en termes d’âge et de sexe, tous provenant d’une cohorte de surveillance continue d’au moins 1 an sur une période allant de 2001 à 2012. Des diagnostics de sept comorbidités liées à l’âge ont été identifiés à partir des bases de données administratives provinciales et regroupés en 0, 1, 2 et ≥3 comorbidités. La prévalence de la multimorbidité et les taux de mortalité normalisés selon l’âge (TMNA) dans les deux populations ont été stratifiés selon les régions sociosanitaires de la Colombie-Britannique. Des modèles structurels marginaux ont été utilisés pour estimer l’effet de la multimorbidité sur la mortalité chez les PVVIH, ajustant pour les facteurs de confusion variables affectés par une multimorbidité antérieure.

Résultats

Parmi 8 031 PVVIH et 32 124 personnes séronégatives pour le VIH, 25 % contre 11 % ont développé une multimorbidité et 23,53 décès pour 1 000 personnes-années (intervalle de confiance à 95 % [IC à 95 %]: 22,02–25,13) contre 3,04 (2,81–3,29) ont été observés, respectivement. Les PVVIH de la région septentrionale avaient le TMNA le plus élevé, alors que ceux du sud de l’île de Vancouver ont connu la plus grande différence de mortalité par rapport aux personnes séronégatives. Parmi les PVVIH, les personnes atteintes de 1, 2 et ≥3 comorbidités avaient respectivement 3,36 (IC à 95 %: 2,86–3,95), 6,92 (5,75–8,33) et 12,87 (10,45–15,85) fois plus la probabilité de mourir que les personnes sans comorbidités.

Conclusion

Les PVVIH des régions sociosanitaires de la Colombie-Britannique connaissent une multimorbidité excessive et la surmortalité s’y associant. Notre étude souligne les disparités-clés en matière de santé qu’il faut prendre en compte lors de la planification de la distribution des ressources de soins de santé à travers la Colombie-Britannique. Elle fournit aussi des preuves pour des modèles de soins du VIH améliorés, y intégrant la prévention et la gestion des maladies chroniques.

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Data availability

The British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) is prohibited from making this data set available publicly due to prohibitions in the information sharing agreement under which the data stewards provided the data to the BC-CfE.

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Acknowledgements

Preliminary results of this study were presented by NGAN at the (virtual) 2020 Conference on Retroviruses and Opportunistic Infections (CROI) on March 8–11, 2020 (abstract 869). NGAN received a New Investigator Award for this work.

The authors would like to thank the COAST study participants, BC Cancer Agency, BC Centre for Excellence in HIV/AIDS, BC Ministry of Health, BC Vital Statistics Agency, PharmaNet, and the institutional data stewards for granting access to the data, and Population Data BC, for facilitating the data linkage process.

Code availability

The underlying analytical codes are available from the authors on request.

Funding

This work was supported as follows: COAST is funded by the Canadian Institutes of Health Research, through an Operating Grant (#130419), a Foundation Award to RSH (#143342) and support from the BC Centre for Excellence in HIV/AIDS. JSGM’s Treatment as Prevention (TasP) research, paid to his institution, has received support from Vancouver Coastal Health, the Public Health Agency of Canada, BC Ministry of Health, and US NIH (NIDA R01DA036307 and CTN 248). VDL is funded by a grant from the Canadian Institutes of Health Research (PJT-148595), by a Scholar Award from the Michael Smith Foundation for Health Research, and a New Investigator award from the Canadian Institutes of Health Research. NGAN is supported by Canadian Institutes of Health Research Canada Graduate Student – Master’s Award and the University of British Columbia’s Four-Year Doctoral Fellowship.

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Affiliations

Authors

Contributions

NGAN and GZ contributed equally. NGAN, GZ, and VDL conceptualized and designed the study. RSH, JSGM, and VDL curated the data and acquired funding. NGAN, GZ, HMT, and VDL constructed the methodology. NGAN, GZ, and HMT performed data and other statistical analyses. NGAN, GZ, and VDL wrote the original draft. NGAN, GZ, HMT, TM, JK, RSH, JSGM, and VDL reviewed and edited the final draft. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Viviane D. Lima.

Ethics declarations

Ethics approval

Ethics approval for the COAST study was granted from the University of British Columbia/Providence Health Care Research Ethics Board (#H09-02905; H16-02036) and Simon Fraser University Office of Research Ethics (#2013 s0566).

Consent to participate and for publication

The study complies with the BC Freedom of Information and Protection of Privacy Act (FIPPA) and did not require informed consent as it is conducted retrospectively for research and statistical purposes only using anonymized data.

Conflict of interest

JSGM’s institutional grants have been provided by Gilead, J&J, Merck and ViiV Healthcare.

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All inferences, opinions, and conclusions drawn in this manuscript are those of the authors and do not reflect the opinions or policies of the data stewards or the funders.

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Nanditha, N.G.A., Zheng, G., Tafessu, H.M. et al. Disparities in multimorbidity and mortality among people living with and without HIV across British Columbia’s health regions: a population-based cohort study. Can J Public Health (2021). https://doi.org/10.17269/s41997-021-00525-4

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Keywords

  • HIV
  • Mortality
  • Multimorbidity
  • Health regions
  • British Columbia

Mots-clés

  • VIH
  • mortalité
  • multimorbidité
  • régions sociosanitaires
  • Colombie-Britannique