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Comorbidities Among US Patients with Prevalent HIV Infection—A Trend Analysis Joel Gallant,1 Priscilla Y

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Comorbidities Among US Patients with Prevalent HIV Infection—A Trend Analysis Joel Gallant,1 Priscilla Y The Journal of Infectious Diseases MAJOR ARTICLE Comorbidities Among US Patients With Prevalent HIV Infection—A Trend Analysis Joel Gallant,1 Priscilla Y. Hsue,2 Sanatan Shreay,3 and Nicole Meyer4 1Southwest CARE Center, Santa Fe, New Mexico; 2University of California San Francisco, San Francisco, and 3Gilead Sciences, Foster City, California; and 4Truven Health Analytics, Cambridge, Massachusetts Objective. Quantify proportion of human immunodeficiency virus (HIV)–infected patients with specific comorbidities receiv- ing healthcare coverage from commercial, Medicaid, and Medicare payers. Methods. Data from MarketScan research databases were used to select adult HIV-infected patients from each payer. Treated HIV-infected patients were matched to HIV-negative controls. Cross-sectional analyses were performed between 2003 and 2013 among HIV-infected patients to quantify the proportion with individual comorbidities over the period, by payer. XX Results. Overall, 36 298 HIV-infected patients covered by commercial payers, 26 246 covered by Medicaid payers, and 1854 covered by Medicare payers were identified between 2003 and 2013. Essential hypertension (31.4%, 39.3%, and 76.2%, respectively), XXXX hyperlipidemia (29.2%, 22.1%, and 49.6%), and endocrine disease (21.8%, 27.2%, and 54.0%) were the most common comorbidities. Comparison of data from 2003 to data from 2013 revealed significant increases across payers in the percentage of patients with the comorbidities specified above (P < .05). Across all payers, the proportions of treated HIV-infected patients with deep vein throm- bosis, hepatitis C, renal impairment, thyroid disease, and liver disease from 2003 to 2013 was significantly greater (P < .05) than for matched controls. Conclusions. Comorbidities are common among the aging HIV-infected population and have increased over time. There should be a consideration in treatment choices for HIV infection, including the choices of antiretroviral regimens. Keywords. Prevalent HIV; comorbidity trend; US-specific HIV-infected patients. Improvements in care, including the introduction of antire- aging. The term “inflammaging” has been used to describe the troviral therapy (ART) for the treatment of people infected process whereby ongoing low-grade inflammation that occurs with human immunodeficiency virus (HIV), have resulted in with aging contributes to the development of various conditions increased life expectancy [1–8]. With early diagnosis and treat- [4]. The chronic immune activation and inflammation caused ment, patients in resource-rich countries can expect to live into by HIV infection has been suggested as a factor for acceler- their 70s or beyond, although life-span varies on the basis of the ated or early aging, whereby HIV-infected patients develop mode of HIV transmission, race, and CD4+ T-cell count at the comorbidities at younger ages than persons who are HIV neg- start of ART [2, 4, 5, 8]. In addition to the increased life-span ative [9]. Because certain ART agents have been associated of diagnosed and successfully treated HIV-infected patients, with an increased risk of comorbidity, ART may also contrib- STANDARD approximately 15% of incident cases of HIV infection are in ute to higher rates of comorbidities in HIV-infected patients persons ≥50 years old. As a result of improvements in patient as compared to age-matched HIV-negative controls [1, 4, 7, 9, outcomes and longevity, 30% of prevalent cases of HIV infec- 10]. A recent study found that the prevalence of noninfectious tion are in people ≥50 years old [3, 4, 7]. comorbidities among ART-experienced HIV-infected persons The longer life-span of the HIV-infected population has intro- was similar to findings for HIV-uninfected persons who were duced a new dynamic into the management of these patients, 10 years older [11]. as providers must contend with comorbidities associated with HIV-infected patients have been shown to be at higher risk for cardiovascular (CV) disease, hepatic and renal disease, oste- Received 10 March 2017; editorial decision 26 August 2017; accepted 25 September 2017. oporosis and fractures, metabolic disorders, and several non– Presented in part: American Society of Nephrology, San Diego, California, 3–8 November AIDS-defining cancers [4, 10, 12–27]. Causal relationships 2015; International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention, Vancouver, Canada, 19–22 July 2015; IDWeek 2015, San Diego, California, 7–11 October 2015; have not been established for all of these associations. Persons IDWeek 2016, New Orleans, Louisiana, 26–30 October 2016; Interscience Conference on with HIV infection have a higher number of comorbidities, Antimicrobial Agents and Chemotherapy, San Diego, California, 17–21 September 2015. Correspondence: N. Meyer, MA, Truven Health Analytics, an IBM Company, 75 Binney St, compared with HIV-negative people, and the risk for specific Cambridge, MA 02142 ([email protected]). comorbidities is higher in older age [9, 12]. A pattern of higher The Journal of Infectious Diseases® 2017;XX00:1–9 rates of multiple comorbidities has also been observed in older © The Author(s) 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected]. HIV-infected patients who seroconverted at an earlier age as DOI: 10.1093/infdis/jix518 compared to those who were infected at a later age [13]. Comorbidity Trends in HIV-Infected US Patients • JID 2017:XX (XX XXXX) • 1 Downloaded from https://academic.oup.com/jid/advance-article-abstract/doi/10.1093/infdis/jix518/4743770 by Jules Levin on 15 December 2017 HIV-infected patients receiving ART are now living longer procedures (based on ICD-9-CM codes, Current Procedural and are likely to acquire chronic conditions related to normal Terminology codes, and the Healthcare Common Procedure aging, as well as to HIV infection and its treatment. Certain Coding System), and pharmaceuticals (based on National Drug ART regimens have been associated with an increased risk of Code identifiers). The claims data are linked to person-level CV-, renal-, and bone-related adverse events [11, 14, 16, 19, 25, enrollment data through unique enrollee identifiers. 28]. Recent literature has documented an association between The commercial database contains the healthcare experi- abacavir-based regimens and an increased risk of myocardial ences of >35 million enrollees in 2013 covered under a variety infarction in HIV-infected patients, although the association of fee-for-service and managed care health plans. The Medicare diminished in magnitude and statistical significance after adjust- database includes the healthcare claims for approximately 3.5 ment for traditional risk factors [14, 28]. Tenofovir disoproxil million retirees with Medicare supplemental insurance paid for fumarate–based regimens have been associated with reduced by employers. The Medicaid database contains claims for ser- renal function [29, 30] and loss of bone mineral density [31, 32]. vices provided to approximately 8 million Medicaid enrollees Some evidence exists indicating tenofovir disoproxil fumarate– each year from multiple geographically dispersed states. associated reductions in bone mineral density may translate Because these databases are deidentified in compliance with into an increase in fracture risk [33]. Thus, optimal treatment Health Insurance Portability and Accountability Act regulations, for HIV-infected patients requires a focus beyond just viral sup- institutional review board approval was not required for this study. pression. Therapeutic management requires targeted efforts to Patient Selection and Analysis Periods preserve the long-term health of HIV-infected patients as they Study patients were required to have at least 1 medical claim age and experience an increased duration of ART exposure. (defined as an inpatient or outpatient claim that was not for a Many existing studies of comorbidities in the HIV-infected procedure that is used to confirm an HIV diagnosis) associ- population had a small sample size [7] or were conducted ated with an ICD-9-CM diagnosis code for HIV (codes 042. in countries outside the United States [9, 11, 12, 14, 28]. xx, 079.53, and v08.xx) from 1 July 2002 through 31 December Comorbidities in US HIV-infected patients have not been 2013. Selected patients were required to have at least 6 months of well documented across different healthcare coverage payers. continuous medical and prescription coverage before their first The objective of this study was to quantify the proportion of diagnosis of HIV infection (index diagnosis date) and at least US HIV-infected patients with specific comorbidities receiving 14 days after the index diagnosis. All patients were required to coverage under commercial, Medicaid, and Medicare payers be at least 18 years of age as of the index diagnosis date. over time. A more detailed understanding of comorbidity pat- terns can provide insight into patients at greater risk for poor Patients With Prevalent HIV Infection outcomes and inform selection of ART and treatments for Analysis of patients with prevalent HIV infection was per- comorbid chronic conditions. formed by calendar year. To be included in a given calendar year, patients were required to have continuous enrollment METHODS for that specific year. This study reported comorbidity rates for Study Design patients with prevalent HIV infection for the individual calen- A retrospective
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