HIV infection has been associated with an increased risk of fragility fracture. We explored whether or not this increased risk persisted in HIV infected and uninfected men when controlling for ...traditional fragility fracture risk factors.
Cox regression models were used to assess the association of HIV infection with the risk for incident hip, vertebral, or upper arm fracture in male Veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC). We calculated adjusted hazard ratios comparing HIV status and controlling for demographics and other established risk factors. The sample consisted of 119,318 men, 33% of whom were HIV infected (34% aged 50 years or older at baseline, and 55% black or Hispanic). Median body mass index (BMI) was lower in HIV infected compared with uninfected men (25 vs. 28 kg/m²; p<0.0001). Unadjusted risk for fracture was higher among HIV infected compared with uninfected men HR: 1.32 (95% CI: 1.20, 1.47). After adjusting for demographics, comorbid disease, smoking and alcohol abuse, HIV infection remained associated with an increased fracture risk HR: 1.24 (95% CI: 1.11, 1.39). However, adjusting for BMI attenuated this association HR: 1.10 (95% CI: 0.97, 1.25). The only HIV-specific factor associated with fragility fracture was current protease inhibitor use HR: 1.41 (95% CI: 1.16, 1.70).
HIV infection is associated with fragility fracture risk. This risk is attenuated by BMI.
Analogous to the business model of customer satisfaction and retention, patient satisfaction could serve as an innovative, patient-centered focus for increasing retention in HIV care and adherence to ...HAART, and ultimately HIV suppression.
To test, through structural equation modeling (SEM), a model of HIV suppression in which patient satisfaction influences HIV suppression indirectly through retention in HIV care and adherence to HAART.
We conducted a cross-sectional study of adults receiving HIV care at two clinics in Texas. Patient satisfaction was based on two validated items, one adapted from the Consumer Assessment of Healthcare Providers and Systems survey ("Would you recommend this clinic to other patients with HIV?) and one adapted from the Delighted-Terrible Scale, ("Overall, how do you feel about the care you got at this clinic in the last 12 months?"). A validated, single-item question measured adherence to HAART over the past 4 weeks. Retention in HIV care was based on visit constancy in the year prior to the survey. HIV suppression was defined as plasma HIV RNA <48 copies/mL at the time of the survey. We used SEM to test hypothesized relationships.
The analyses included 489 patients (94% of eligible patients). The patient satisfaction score had a mean of 8.5 (median 9.2) on a 0- to 10- point scale. A total of 46% reported "excellent" adherence, 76% had adequate retention, and 70% had HIV suppression. In SEM analyses, patient satisfaction with care influences retention in HIV care and adherence to HAART, which in turn serve as key determinants of HIV suppression (all p<.0001).
Patient satisfaction may have direct effects on retention in HIV care and adherence to HAART. Interventions to improve the care experience, without necessarily targeting objective clinical performance measures, could serve as an innovative method for optimizing HIV outcomes.
Background
Although 50 years represents middle age among uninfected individuals, studies have shown that persons living with HIV (PWH) begin to demonstrate elevated risk for serious falls and ...fragility fractures in the sixth decade; the proportions of these outcomes attributable to modifiable factors are unknown.
Methods
We analyzed 21,041 older PWH on antiretroviral therapy (ART) from the Veterans Aging Cohort Study from 01/01/2010 through 09/30/2015. Serious falls were identified by Ecodes and a machine‐learning algorithm applied to radiology reports. Fragility fractures (hip, vertebral, and upper arm) were identified using ICD9 codes. Predictors for both models included a serious fall within the past 12 months, body mass index, physiologic frailty (VACS Index 2.0), illicit substance and alcohol use disorders, and measures of multimorbidity and polypharmacy. We separately fit multivariable logistic models to each outcome using generalized estimating equations. From these models, the longitudinal extensions of average attributable fraction (LE‐AAF) for modifiable risk factors were estimated.
Results
Key risk factors for both outcomes included physiologic frailty (VACS Index 2.0) (serious falls 15%; 95% CI 14%–15%; fractures 13%; 95% CI 12%–14%), a serious fall in the past year (serious falls 7%; 95% CI 7%–7%; fractures 5%; 95% CI 4%–5%), polypharmacy (serious falls 5%; 95% CI 4%–5%; fractures 5%; 95% CI 4%–5%), an opioid prescription in the past month (serious falls 7%; 95% CI 6%–7%; fractures 9%; 95% CI 8%–9%), and diagnosis of alcohol use disorder (serious falls 4%; 95% CI 4%–5%; fractures 8%; 95% CI 7%–8%).
Conclusions
This study confirms the contributions of risk factors important in the general population to both serious falls and fragility fractures among older PWH. Successful prevention programs for these outcomes should build on existing prevention efforts while including risk factors specific to PWH.
Given conflicting data regarding the association of HIV infection and ischemic stroke risk, we sought to determine whether HIV infection conferred an increased ischemic stroke risk among male ...veterans.
The Veterans Aging Cohort Study-Virtual Cohort consists of HIV-infected and uninfected veterans in care matched (1:2) for age, sex, race/ethnicity, and clinical site. We analyzed data on 76,835 male participants in the Veterans Aging Cohort Study-Virtual Cohort who were free of baseline cardiovascular disease. We assessed demographics, ischemic stroke risk factors, comorbid diseases, substance use, HIV biomarkers, and incidence of ischemic stroke from October 1, 2003, to December 31, 2009.
During a median follow-up period of 5.9 (interquartile range 3.5-6.6) years, there were 910 stroke events (37.4% HIV-infected). Ischemic stroke rates per 1,000 person-years were higher for HIV-infected (2.79, 95% confidence interval 2.51-3.10) than for uninfected veterans (2.24 2.06-2.43) (incidence rate ratio 1.25 1.09-1.43; p < 0.01). After adjusting for demographics, ischemic stroke risk factors, comorbid diseases, and substance use, the risk of ischemic stroke was higher among male veterans with HIV infection compared with uninfected veterans (hazard ratio 1.17 1.01-1.36; p = 0.04).
HIV infection is associated with an increased ischemic stroke risk among HIV-infected compared with demographically and behaviorally similar uninfected male veterans.
Background. Although it has been shown that human immunodeficiency virus (HIV)-infected adults are at greater risk for aging-associated events, it remains unclear as to whether these events happen at ...similar, or younger ages, in HIV-infected compared with uninfected adults. The objective of this study was to compare the median age at, and risk of, incident diagnosis of 3 age-associated diseases in HIV-infected and demographically similar uninfected adults. Methods. The study was nested in the clinical prospective Veterans Aging Cohort Study of HIV-infected and demographically matched uninfected veterans, from 1 April 2003 to 31 December 2010. The outcomes were validated diagnoses of myocardial infarction (MI), end-stage renal disease (ESRD), and non-AIDS-defining cancer (NADC). Differences in mean age at, and risk of, diagnosis by HIV status were estimated using multivariate linear regression models and Cox proportional hazards models, respectively. Results. A total of 98 687 (31% HIV-infected and 69% uninfected) adults contributed >450 000 person-years and 689 MI, 1135 ESRD, and 4179 NADC incident diagnoses. Mean age at MI (adjusted mean difference, –0.11; 95% confidence interval CI, –.59 to .37 years) and NADC (adjusted mean difference, –0.10 95% CI, –.30 to .10 years) did not differ by HIV status. HIV-infected adults were diagnosed with ESRD at an average age of 5.5 months younger than uninfected adults (adjusted mean difference, –0.46 95% CI, –.86 to –.07 years). HIV-infected adults had a greater risk of all 3 outcomes compared with uninfected adults after accounting for important confounders. Conclusions. HIV-infected adults had a higher risk of these age-associated events, but they occurred at similar ages than those without HIV.
Background
We sought to compare self‐reported alcohol consumption using Timeline Followback (TLFB) to biomarker‐based evidence of significant alcohol use (phosphatidylethanol PEth > 20 ng/ml). Using ...data from patients with HIV (PWH) entering a clinical trial, we asked whether TLFB could predict PEth > 20 ng/ml and assessed the magnitude of association between TLFB and PEth level.
Methods
We defined unhealthy alcohol use as any alcohol use in the presence of liver disease, at‐risk drinking, or alcohol use disorder. Self‐reported alcohol use obtained from TLFB interview was assessed as mean number of drinks/day and number of heavy drinking days over the past 21 days. Dried blood spot samples for PEth were collected at the interview. We used logistic regression to predict PEth > 20 ng/ml and Spearman correlation to quantify the association with PEth, both as a function of TLFB.
Results
Among 282 individuals (99% men) in the analytic sample, approximately two‐thirds (69%) of individuals had PEth > 20 ng/ml. The proportion with PEth > 20 ng/ml increased with increasing levels of self‐reported alcohol use; of the 190 patients with either at‐risk drinking or alcohol use disorder based on self‐report, 82% had PEth > 20 ng/ml. Discrimination was better with number of drinks per day than heavy drinking days (AUC: 0.80 95% CI: 0.74 to 0.85 vs. 0.74 95% CI: 0.68 to 0.80). The number of drinks per day and PEth were significantly and positively correlated across all levels of alcohol use (Spearman’s R ranged from 0.29 to 0.56, all p values < 0.01).
Conclusions
In this sample of PWH entering a clinical trial, mean numbers of drinks per day discriminated individuals with evidence of significant alcohol use by PEth. PEth complements self‐report to improve identification of self‐reported unhealthy alcohol use among PWH.
Among patients with HIV entering a clinical trial, we assessed the magnitude of association between self‐reported alcohol consumption (using Timeline Followback (TLFB)) and a biomarker‐based evidence of significant alcohol use (using phosphatidylethanol PEth with a cut‐off >20 ng/ml), and whether TLFB could discriminate individuals with evidence of significant alcohol by PEth. We found mean numbers of drinks/day discriminated individuals with PEth evidence of significant alcohol use. PEth complements self‐report to improve alcohol measurement in clinical settings and trials.
Background. Weight gain after antiretroviral therapy (ART) initiation is common, but its implication for mortality is unknown. We evaluated weight change in the first year after ART initiation and ...its association with subsequent mortality. Methods. Human immunodeficiency virus-infected patients from the Veterans Aging Cohort Study (VACS) who initiated ART between 2000 and 2008, with weight recorded at baseline and 1 year later, were followed another 5 years for mortality. Baseline body mass index (BMI) was classified as underweight (<18.5 kg/m2), normal (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). We used multivariable Cox models to assess mortality risk with adjustment for disease severity using the VACS Index. Results. The sample consisted of 4184 men and 127 women with a mean age of 47.9 ± 10.0 years. After 1 year of ART, median weight change was 5.9 pounds (2.7 kg) (interquartile range, −2.9 to 17.0 pounds, −1.3 to 7.7 kg). Weight gain after ART initiation was associated with lower mortality among underweight and normal-weight patients. A minimum threshold of 10- to 19.9-pound (4.5 to 9.0 kg) weight gain was beneficial for normal-weight patients (hazard ratio, 0.56; 95% confidence interval, .41–.78), but there was no clear benefit to weight gain for overweight/obese patients. Baseline weight, CD4 cell count status, and hemoglobin level were strongly associated with weight gain. Risk for weight gain was higher among those with greater disease severity, regardless of weight at initiation. Conclusions. The survival benefits of weight gain after ART initiation are dependent on starting BMI. Weight gain after ART is associated with lower mortality for those who are not initially overweight.
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