People living with HIV (PLHIV) are more likely than the general population to develop AIDS‐defining malignancies (ADMs) and several non‐ADMs (NADMs). Information is lacking on survival outcomes and cause‐specific mortality after cancer diagnosis among PLHIV. We investigated causes of death within 5 years of cancer diagnosis in PLHIV enrolled in European and North American HIV cohorts starting antiretroviral therapy (ART) 1996–2015, aged ≥16 years, and subsequently diagnosed with cancer. Cancers were grouped: ADMs, viral NADMs and nonviral NADMs. We calculated cause‐specific mortality rates (MR) after diagnosis of specific cancers and compared 5‐year survival with the UK and France general populations. Among 83,856 PLHIV there were 4,436 cancer diagnoses. Of 603 deaths after ADM diagnosis, 292 (48%) were due to an ADM. There were 467/847 (55%) and 74/189 (39%) deaths that were due to an NADM after nonviral and viral NADM diagnoses, respectively. MR were higher for diagnoses between 1996 and 2005 versus 2006–2015: ADMs 102 (95% CI 92–113) per 1,000 years versus 88 (78–100), viral NADMs 134 (106–169) versus 111 (93–133) and nonviral NADMs 264 (232–300) versus 226 (206–248). Estimated 5‐year survival for PLHIV diagnosed with liver (29% [19–39%]), lung (18% [13–23%]) and cervical (75% [63–84%]) cancer was similar to general populations. Survival after Hodgkin's lymphoma diagnosis was lower in PLHIV (75% [67–81%]). Among ART‐treated PLHIV diagnosed with cancer, MR and causes of death varied by cancer type, with mortality highest for liver and lung cancers. Deaths within 5 years of NADM diagnoses were more likely to be from cancer than AIDS.
Introduction: Moderate alcohol consumption has been shown to protect against coronary artery disease (CAD) in the general population, but this relationship has not been well studied among U.S. Veterans. Methods: 61,587 Million Veteran Program (MVP) participants completed a baseline and lifestyle survey that included questions about frequency and volume of alcohol consumption. We combined grams of ethanol in wine, beer, and spirits to create the exposure variable for this analysis. Using the VA electronical health record, incident CAD events included myocardial infarction, angina pectoris, other forms of chronic ischemic heart disease (ICD9 codes 410-414.9) or coronary procedures (ICD9 procedure codes 36.0-36.99). Participants with prevalent CAD (n=27,844) before the baseline survey date or alcohol abuse using ICD9 codes 303.0 and 305.0 (n=16,048) were excluded from the analysis. We used a Cox Proportional Hazard model to estimate hazard ratios (HR) and 95% confidence intervals (CI) for CAD adjusting for age, sex, body mass index, and smoking status. Results: Among 59,288 participants analyzed, the mean age was 65y (SD=11.9), mean BMI was 28.9 kg/m 2 , 90% were men, 33% were never smokers, 86% self-reported as White, 11% Black, and 6% Hispanic. Participants were categorized into 6 alcohol consumption categories: Never, former, and current drinkers of half drink/d, >half to 1 drink/d, >1 to 2 drinks/d, >2 to 3 drinks/d, >3 to 4 drinks/d, and >4 drinks/d. During a mean follow up of 3.3 years, 3,670 CAD events were documented. Using current drinkers of ≤half a drink/d as the reference group, we found a 19% lower risk of CAD in drinkers of >1 to 2 drinks/d, a 25% lower risk of CAD with alcohol intake of >3 to 4 drinks/d, and 34% lower risk in the highest alcohol category in a multivariable adjusted model (Table 1). As expected, former drinkers had a slightly higher risk of CAD. We did not have enough data on women to conduct sex-specific analyses. Conclusion: Our data show a lower risk of CAD with moderate alcohol consumption among MVP participants.
Objective: We examined the relationship between alcohol use trajectories and HIV disease severity among men and women participating in the Veterans Aging Cohort Study (VACS). Design: Prospective cohort of HIV-infected persons in care at eight US Veterans Health Administration sites. Methods: Between 2002 and 2010, we assessed alcohol consumption annually using the alcohol use disorders identification test-consumption (AUDIT-C). HIV disease severity was ascertained using the VACS index, a validated measure of morbidity and all-cause mortality. We examined the relationship between alcohol use and HIV disease severity patterns using joint trajectory modeling. Alcohol use trajectories were validated using phosphatidylethanol – a biomarker of alcohol consumption – measured between 2005 and 2006 among a subset of participants. We examined associations between membership in alcohol use and VACS index trajectories using multinomial regression. Results: Among eligible participants, we identified four alcohol consumption trajectories: abstainers (24% of the sample), lower risk (44%), moderate risk (24%), and higher risk drinkers (8%). Alcohol use trajectories were highly correlated with phosphatidylethanol (Cramér's V = 0.465, P < 0.001): mean concentrations were 4.4, 17.8, 57.7, and 167.6 ng/ml in the abstainer, lower risk, moderate risk, and higher risk groups, respectively. Four VACS index trajectories were identified: low (2%), moderate (46%), high (36%), and extreme (16%). Higher risk drinkers were most common in the extreme VACS index group, and were absent in the low index group. In multivariable analysis, the association between alcohol use and VACS index trajectory membership remained significant (P = 0.002). Conclusion: Alcohol use trajectories characterized by persistent unhealthy drinking are associated with more advanced HIV disease severity among HIV-infected veterans in the United States.
Inflammation in human immunodeficiency virus (HIV)-infected patients is associated with poorer health outcomes. Whether inflammation as measured by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) adds information to existing prognostic indices is not known.
Chronic obstructive pulmonary disease (COPD) prevalence is increasing among aging HIV-infected individuals. We determined the association between COPD and self-reported measures of frailty [adapted frailty-related phenotype (aFRP)] and physical limitation, and a clinical biomarker of physiologic frailty [Veterans Aging Cohort Study (VACS) Index] in HIV-infected compared with uninfected individuals.Cross-sectional study of VACS participants between 2002 and 2012.Prefrail/aFRP was obtained from self-reported surveys. Prefrail was defined as 1-2 domains of physical shrinking, exhaustion, slowness and low physical activity; aFRP was defined as at least 3 domains. Physical limitation scale was determined from 12 self-reported survey items assessing limitations performing physical activities. VACS index includes age and laboratory measurements. We used regression models to test for associations between COPD and outcomes in models stratified by HIV status.The sample included 3538 HIV-infected and 3606 uninfected participants; 67 and 63% were black (P = 0.0003), 97 and 92% were men (P < 0.0001) and 4 and 5% had COPD (P = 0.2). In unadjusted analyses, COPD was associated with all three outcomes (P < 0.0001). In adjusted analyses, COPD was associated with increased prefrail and aFRP in HIV-infected and uninfected participants (P ≤ 0.01 for all comparisons). COPD was associated with physical limitation in both groups (P < 0.0001). There was an interaction between COPD and physical limitation by HIV status with increased physical limitation among HIV-infected participants (P = 0.04). COPD was not associated with VACS index.COPD was strongly associated with aFRP and physical limitations. COPD management may mediate frailty through functional limitations rather than physiologic biomarkers, especially in HIV-infected individuals.
Abstract Effect estimates from randomized trials and observational studies might not be directly comparable because of differences in study design, other than randomization, and in data analysis. We propose a 3-step procedure to facilitate meaningful comparisons of effect estimates from randomized trials and observational studies: 1) harmonization of the study protocols (eligibility criteria, treatment strategies, outcome, start and end of follow-up, causal contrast) so that the studies target the same causal effect, 2) harmonization of the data analysis to estimate the causal effect, and 3) sensitivity analyses to investigate the impact of discrepancies that could not be accounted for in the harmonization process. To illustrate our approach, we compared estimates of the effect of immediate with deferred initiation of antiretroviral therapy in individuals positive for the human immunodeficiency virus from the Strategic Timing of Antiretroviral Therapy (START) randomized trial and the observational HIV-CAUSAL Collaboration.
Dual epidemics of human immunodeficiency virus (HIV) and alcohol use disorders, and a dearth of professional resources for behavioral treatment in sub-Saharan Africa, suggest the need for development of culturally relevant and feasible interventions. The purpose of this study was to test the preliminary efficacy of a culturally adapted six-session gender-stratified group cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use among HIV-infected out-patients in Eldoret, Kenya.
With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.
Background: Electronic health records (EHRs) are a rich source of health information; however social determinants of health, including incarceration, and how they impact health and health care disparities can be hard to extract. Objective: The main objective of this study was to compare sensitivity and specificity of patient self-report with various methods of identifying incarceration exposure using the EHR. Research Design: Validation study using multiple data sources and types. Subjects: Participants of the Veterans Aging Cohort Study (VACS), a national observational cohort based on data from the Veterans Health Administration (VHA) EHR that includes all human immunodeficiency virus–infected patients in care (47,805) and uninfected patients (99,060) matched on region, age, race/ethnicity, and sex. Measures and Data Sources: Self-reported incarceration history compared with: (1) linked VHA EHR data to administrative data from a state Department of Correction (DOC), (2) linked VHA EHR data to administrative data on incarceration from Centers for Medicare and Medicaid Services (CMS), (3) VHA EHR-specific identifier codes indicative of receipt of VHA incarceration reentry services, and (4) natural language processing (NLP) in unstructured text in VHA EHR. Results: Linking the EHR to DOC data: sensitivity 2.5%, specificity 100%; linking the EHR to CMS data: sensitivity 7.9%, specificity 99.3%; VHA EHR-specific identifier for receipt of reentry services: sensitivity 7.3%, specificity 98.9%; and NLP, sensitivity 63.5%, specificity 95.9%. Conclusions: NLP tools hold promise as a feasible and valid method to identify individuals with exposure to incarceration in EHR. Future work should expand this approach using a larger body of documents and refinement of the methods, which may further improve operating characteristics of this method.
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