Interventions to reduce traditional risk factors such as smoking, elevated total cholesterol, hypertension, and chronic hepatitis C infection can improve the proportion of non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults aging with HIV, according to a study recently published in the Lancet HIV.
Researchers used data from the North American AIDS Cohort Collaboration on Research and Design to analyze traditional and HIV-related risk factors for 4 validated noncommunicable disease outcomes: non-AIDS-defining cancer, myocardial infarction, end-stage liver disease, and end-stage renal disease. Participants receiving care in academic and community-based outpatient HIV clinics in the United States and Canada from January 1, 2000, to December 31, 2014, were included in the study.
Traditional risk factors were cigarette smoking, elevated total cholesterol, hypertension, type 2 diabetes, stage 4 chronic kidney disease, and hepatitis C and hepatitis B virus infections. HIV-related risk factors included low CD4 cell count (<200 cells/µL), detectable plasma HIV RNA (>400 copies/mL), and history of a clinical AIDS diagnosis.
A population attributable fraction approach was used to quantify the proportion of noncommunicable diseases that could be eliminated if particular risk factors were not present. The population attributable fraction approach accounts for the risk for the outcome associated with a risk factor and also the prevalence of the risk factor in people with the respective outcome. For example, therefore, high population attributable fraction can result from a risk factor with a weak or moderately strong association with the outcome but with a high prevalence; a low fraction can be the result of strong risk factor for an outcome with low prevalence.
Of 61,500 participants, 1405 had non-AIDS-defining cancer, 347 of 29,515 had myocardial infarction, 387 of 35,044 had end-stage liver disease, and 255 of 35,620 had end-stage renal disease. Approximately 17% of participants were older than age 50 years at study entry, approximately 80% were men, and nearly 50% were non-white.
The population attributable fraction for smoking was considerable for non-AIDS-defining cancer (24%; 95% CI, 13-35) and myocardial infarction (37%; 95% CI, 7-66). For the non-AIDS-defining cancer outcome, the population attributable fraction for smoking was greater than that for HIV-related risk factors, even after excluding lung cancer cases.
For myocardial infarction, and again larger than those for HIV-related risk factors, population attributable fractions were higher for elevated total cholesterol (44%; 95% CI, 30-58) and hypertension (42%; 95% CI, 28-56).
For end-stage liver disease, hepatitis C infection had the highest population attributable fraction (33%; 95% CI, 17-48) followed by low CD4 cell count (19%; 95% CI, 12-26) and hepatitis B infection (16%; 95% CI, 11-21).
Hypertension had the highest population attributable fraction for end-stage renal disease (39%; 95% CI, 26-51), followed by elevated total cholesterol (22%; 95% CI, 13-31), detectable HIV RNA (19%; 95% CI, 6-31), low CD4 cell count (13%; 95% CI, 4-21), and diabetes (6%; 95% CI, 1-10).
Findings showed that traditional risk factors accounted for a larger share of non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases incident outcomes than did HIV-related risk factors.
“Modifications to individual-level interventions and models of HIV care, and the implementation of structural and policy-level interventions that focus on prevention and modification of traditional risk factors are necessary to avoid noncommunicable diseases and preserve health among successfully antiretroviral-treated adults aging with HIV,” concluded the investigators.
Althoff KN, Gebo KA, Moore RD, et al; North American AIDS Cohort Collaboration on Research and Design. Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies. Lancet HIV. 2019;6(2):e93-e104.