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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 16-22

Multimorbidity among persons living with human immunodeficiency virus in a moroccan referral hospital


Department of Dermatology-Venereology, Mohammed V Military Teaching Hospital, Mohammed V University, Rabat, Morocco

Date of Submission17-Jan-2022
Date of Decision28-Jan-2022
Date of Acceptance26-Feb-2022
Date of Web Publication12-Mar-2022

Correspondence Address:
Hicham Titou
Department of Dermatology-Venereology, Mohammed V Military Teaching Hospital, Mohammed V University, Rabat 10100
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2212-5531.307070

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  Abstract 


Background: Multimorbidity is the co-existing of two or more chronic health conditions in addition to human immunodeficiency virus (HIV). In Morocco, the prevalence of and factors associated with multimorbidity in HIV-infected patients have not been well-documented. Methods: This cross-sectional analysis was conducted in 2018 and included 269 HIV-infected patients. Medical records were reviewed to identify chronic health conditions and to rate multimorbidity using the Cumulative Illness Rating Scale (CIRS). Associations between a higher CIRS score and risk factors were assessed using linear regression. Results: The mean age was 48.9 ± 10.7 years with a male predominance (75.5%). One in 5 (20,8%) had ever been diagnosed with acquired immunodeficiency syndrome. More than a 3rd (34.8%) of the patients had two or more chronic health conditions in addition to HIV. The most frequently documented comorbidities were metabolic complications followed by vascular disease. In multivariate analysis, older age, male gender, duration of receiving antiretroviral therapy, taking indinavir-containing antiretroviral regimen, having ever been stage Centers for Disease Control and Prevention B or C, and current viral load ≥50 copies mL–1 were associated with a higher CIRS score. Conclusion: The prevalence of comorbidities is substantially high. Care models for people living with HIV should include assessing and managing multimorbidity, particularly in patients who present with these associated factors.

Keywords: Ageing, Cumulative Illness Rating Scale score, comorbidities, human immunodeficiency virus, multimorbidity


How to cite this article:
Titou H, Kerrouch H, Boui M, Hjira N. Multimorbidity among persons living with human immunodeficiency virus in a moroccan referral hospital. Int J Mycobacteriol 2022;11:16-22

How to cite this URL:
Titou H, Kerrouch H, Boui M, Hjira N. Multimorbidity among persons living with human immunodeficiency virus in a moroccan referral hospital. Int J Mycobacteriol [serial online] 2022 [cited 2022 May 20];11:16-22. Available from: https://www.ijmyco.org/text.asp?2022/11/1/16/307070




  Introduction Top


Since the widespread use of combination antiretroviral therapy (ART), the life expectancy of people living with human immunodeficiency virus (PLWH) has increased substantially, nearing that of the general population.[1],[2] As a result, human immunodeficiency virus (HIV)-related morbidity and mortality have decreased substantially[3],[4] and the issue of healthy aging with HIV has become a major concern. HIV-related care has transformed from acquired immunodeficiency syndrome (AIDS) and diseases related to immune deficiency to other diseases.[5]

The aging of the HIV-positive population has resulted in a change in the causes of mortality of PLWH and an increasing impact of nonAIDS-related comorbidities.[6],[7] A literature review demonstrates that nonAIDS-related comorbidities appear[8] earlier and with a higher prevalence.[6],[9] These include cardiovascular disease, metabolic syndrome, renal and bone disease, neurocognitive impairment, and cancer.[7],[10]

In several research studies, multimorbidity is defined as the co-occurrence of two or more chronic health conditions in addition to HIV.[11],[12],[13] Among PLWH, studies have reported associations of multimorbidity with age, low immune status, the duration of receiving ART, male gender, and specific drug regimens.[7],[10],[14] In a population of PLWH, multimorbidity has been associated with adverse health outcomes, such as poor quality of life[15] and increased medical care costs.[16] However, studies investigating the prevalence and determinants of multimorbidity of PLWH in low- and middle-income countries, such as Morocco, are scarce. Concomitant management of HIV and other conditions is complicated by polypharmacy/drug interactions and toxicity.[17] HIV and other conditions (obesity, diabetes, and hepatitis C virus coinfection) may amplify, increasing the risk of a third condition or multimorbidity, more than either condition alone.[13],[18]

As the median age of PLWH increases, advocates of PLWH, healthcare workers, and policymakers will need to design health services to manage patients with multimorbidity. For that, improved understanding of the burden and risk factors of multimorbidity contribute to improving the management and care of PLWH. The aims of this study were to investigate the prevalence of and associations with multimorbidity in HIV-positive patients in a Moroccan hospital.


  Methods Top


Study population

This was an analytical study conducted on a monocentric retrospective cohort. The study population consists of all patients infected with HIV type 1 and followed in the Dermatology–Venereology Department of Mohamed V Military Hospital, between February 1, 2018, and January 31, 2019. This regional referral center ensures care and monitoring of HIV-positive military personnel and their families in Morocco.

Data collection

In this study, the inclusion criteria were age ≥18 years, the presence of HIV-1-positive serology confirmed by the Western blot or polymerase chain reaction, and on ART for at least 6 months. Data, including sociodemographic characteristics (age, sex), addictive behaviors (smoking, alcohol and drug use), clinical data (HIV history, duration of receiving ART, current and past therapeutic regimens, number of visits to the clinic), anthropometric data (weight, height), biological data (cluster de differentiation 4 [CD4] counts, viral load). The data were extracted by a single investigator from medical records using a preestablished list of the most common conditions among PLWH.

We evaluated the prevalence of multimorbidity as described by the presence of two or more chronic health conditions in addition to HIV. Multimorbidity was also assessed using the Fourteen-system Modified Version Cumulative Illness Rating Scale (CIRS).[19] As a rapid assessment technique which is objective and easily quantified, The CIRS provides for the rating of 14 independent organ areas. Rating is given on a 5 point “degree of severity” scale, ranging from 0 (none) to 5 (extremely severe). The theoretical score varies from 0 to 56, but scores near the highest value are incompatible with life. The CIRS has been shown to be valid[20] and reliable as a predictor of health-related quality of life.[21] We also calculated the number of systems affected and the number of systems with a score of three or more.[22]

HIV progression was measured using the index Veterans Aging Cohort Study (VACS). It incorporates Age and CD4 count, viral load, renal function, hemoglobin, index of liver fibrosis, and HCV co-infection routinely.[23] The VACS Index is strongly associated with inflammatory biomarkers.

Statistical analysis

The primary outcome measure was the CIRS score. Univariate and multivariate linear regressions were conducted to determine factors associated with a higher CIRS score. Multivariable analyses were performed using the variables with P < 0.05 (95% confidence interval) from the univariable analysis to identify risk factors for multimorbidity. The smoking was excluded in building the multivariate model. The backward stepwise method was used to build a multivariate model.

The chronic health conditions were not included in building a multivariate model, as the existence of these conditions certainly increases the CIRS score. After achieving the final model, we analyzed each of the chronic health conditions individually in the multivariate model. We also used Akaike Information Criteria (AIC) to establish relative participation in the quality of fit of the multivariate model. A lower AIC shows a better quality of fit. Statistical analysis was conducted using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 25.0; IBM Corp., Armonk, New York).


  Results Top


A total of 269 PLWH was recruited into the study with a predominance of males (75.5%) [Table 1]. The mean age was 48.9 ± 10.7 years and the median duration of receiving ART was 11 years (interquartile range [IQR] 6–15 years). More than 70% of patients had ever had A or B clinical Centers for Disease Control and Prevention (CDC) stage. The median CD4 + T-cell count was 613 cells ml–1 (IQR 390–784 cells ml–1). Additional patient characteristics are summarized in [Table 1].
Table 1: Characteristics of 269 HIV-infected patients

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Multimorbidity

Of the specific chronic health conditions evaluated, metabolic complications diagnosis was the most common, followed by vascular disease and mental health disorder [Table 2]. More than a third of the patients (34.8%) had multimorbidity, defined as the co-occurrence of more than one chronic health condition in addition to HIV [Figure 1]. In patients younger than 40 years, multimorbidity was present in 15.4%. In patients aged 41–50 years, multimorbidity was present in 25.6%. Multimorbidity increased over the age of 50 years, with 45.8% and 51.6% of patients aged 51–60 years and 61 years and older, respectively, developed multimorbidity.
Table 2: Prevalence of chronic health conditions in Mohamed V Military Hospital, Department of Dermatology-Venereology

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Figure 1: Percentage of patients and number of comorbidities

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All patients with metabolic complications, renal disease and stroke had another chronic health condition in addition to HIV and hence had multimorbidity. The most prevalent multimorbidity was the concomitant of metabolic complication diagnosis and alcohol or other drug issues, occurring in 13 patients (4.8%), followed by metabolic complication diagnosis and vascular disease, occurring in 9 patients (3.3%), followed by vascular disease diagnosis and alcohol or other drug issues, occurring in 9 patients (3.3%). The most prevalent combination of three chronic health conditions was the diagnosis of metabolic complications, vascular disease, and alcohol or other drug issues in 10 patients (3.7%).

A median of 4 systems (range 1–11) were affected in CIRS and 160 (96.6%) lived morbidity across two or more systems. The median CIRS score was 8 (range 1–21). The median severity index (score divided by the number of systems touched) was 1.60 (range 1.00–2.75). Ninety-six (35.6%) scored 3–4 in at least one system, showing severe or extremely severe condition, while 37 (13.7%) scored 3–4 in two or more systems in addition to HIV.

Correlates of multimorbidity

In univariate linear regression analysis, increasing age, male gender, smoking, duration of receiving ART, indinavir-containing antiretroviral regimen, having ever been stage CDC B or C, nadir CD4 count <200 cells mL–1, current CD4 cell count >700 cells mL–1, peak viral load >10,000 copies mL–1, and current viral load >50 copies mL–1 were significantly associated with a higher CIRS score [Table 3].
Table 3: Correlates of multimorbidity

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In multivariate analysis, a higher CIRS score was significantly associated with increasing age, male gender, duration of receiving ART, indinavir-containing antiretroviral regimen, having ever been stage CDC B or C, and current viral load > 50 copies mL–1 [Table 3].

We explored the correlation between alternative multimorbidity measures and the CIRS score. While all were significantly associated with a higher CIRS score (P < 0.01).

Contribution of chronic health conditions

In univariate analysis, all chronic health conditions except hepatitis C were significantly associated with the CIRS score. As intended, when we fitted each of the conditions into the final model, all except strokes reduced the AIC, meaning everyone contributed to the model. Metabolic complications diagnosis contributed the most to the multivariate model Followed by malignancy. The condition with the next largest contribution to the final model was smoking equals with the mental health diagnosis and renal disease.


  Discussion Top


The present study documents the results of the follow-up of a cohort of 269 PLWH, on ART. To the best of our knowledge, this is the first effort to characterize multimorbidity profiles in an HIV-infected population in Morocco. The results are in line with other epidemiological studies showing an increased prevalence of chronic comorbidities in HIV patients.[8],[11],[12],[18]

More than a third of the study population had 2 or more of chronic health conditions in addition to HIV. The same trend was found in a retrospective study conducted in Thailand in 2011 (41%).[24] Other cross-sectional studies of PLWH in North America have shown multimorbidity rates between 34.4% and 69.0%.[7],[10],[18] However, direct comparisons are not possible because several previous studies used a heterogeneous definition of multimorbidity[21],[25] and a much more restrictive list of chronic conditions.[18],[26]

The CIRS was used in our study to quantify the severity of comorbid conditions. The CIRS is a multivalent tool, benefits a validation[20] and a published guide.[19] In this study, a higher CIRS score was associated with increasing age, male gender, duration of receiving ART, indinavir-containing antiretroviral regimen, having ever been stage CDC B or C, and current viral load >50 copies mL–1.

In the present study, older adults had a higher chance of having multimorbidity compared to younger adults. A similar finding has been reported in previous studies conducted in Australia,[22] Thailand,[24] Italy,[8] and the United States.[11],[12],[18] Some noninfectious comorbidities, such as cardiovascular disease, malignancy, and cognitive decline,[27],[28] occur in excess and at chronologically younger ages among PLWH[18] (approximately 10 years before HIV-uninfected persons).[7],[8]

In our study, adult males were associated with a higher CIRS score. Previous studies have shown that the male gender is a risk factor for metabolic complications.[24],[29] In fact, adult males had a higher rate of the behavioral risk factor for many chronic diseases, such as smoking and substance use disorders.[17]

In this study, the duration of receiving ART was associated with a higher CIRS score. Previous research has identified a similar association.[22],[30] This may be explained by the legacy effects from previous exposure to metabolically toxic regimens or more advanced disease at ART initiation. Following initiation of ART in PLWH, reduction in inflammation has been reported in several studies[31],[32],[33],[34],[35] but there is additional evidence that at some point during continuous ART, the level of inflammation stabilizes and no longer continues to decline.[36]

Indinavir-containing regimens were at a higher risk of multimorbidity compared to efavirenz-containing regimens. Protease inhibitor-containing regimens were a risk factor for multimorbidity in previous studies in the United States and the Netherland.[7],[29] First-generation protease inhibitors have been implicated in the development of insulin resistance, cardiovascular disease, and dyslipidemia.[37],[38] For the two contemporary most frequently used protease inhibitors, darunavir, and atazanavir, has been shown to be associated with dyslipidemia and bone loss, compared to nonNRTIs and integrase inhibitors.[39],[40]

This study shows that adults having ever been staged CDC B or C was associated with a higher CIRS score. However, the nadir CD4 count was not retained among the determinants of multimorbidity in our study. A similar result has been previously described.[22],[41] In our center, the delay in diagnosis (stage B or C) was associated with the nonsuppression of the viral load[42] and a higher mortality.[43] Indeed, an AIDS-defining illness may result in direct end-organ injury and the eventual development of a chronic condition. Finally, having an AIDS-defining disease is likely to produce high levels of immune activation, which may be a factor of multimorbidity.[5]

In our study, the nonsuppression of viral load (≥50 copies mL−1) was a factor associated with the risk of multimorbidity. One observational cohort in Maryland found that Higher viral load has been associated with multimorbidity.[12] As all of the adults in our cohort were on ART, the numbers were likely too small to reveal any association between viral load and CIRS score.

The VACS is a risk index for hospitalization and all-cause mortality in uninfected and HIV-1 infected individuals.[44] It was developed in the US and validated in several European and North American cohorts.[45],[46] The VACS offers an alternative approach based on routinely obtained traditional markers of HIV disease and generic biomarkers of end-organ damage. The practitioners' estimate of complexity and the number of chronic health conditions all correlated better with the CIRS score than with VACS.

There are some limitations to our study that need to be considered. First, this work is limited to medical chronic health conditions. Second, the retrospective nature and the small size of the sample did not permit an assessment of causality or the direction (and whether they are bidirectional) of the associations between risk factors and the CIR score. Longitudinal studies would allow to shed light on the direction of the associations. Our results indicate that multimorbidity and individual chronic health conditions are extremely prevalent in PLWH and constitute a significant health problem for this population. The HIV primary care guidelines[47] offer recommendations for routine screening and preventive care in PLWH, much of which applies to older adults with HIV. Thus, it is not surprising that several studies indicate low or only moderate adherence to published recommendations.[48],[49]

Patient complexity is a combination of multimorbidity and socioeconomic determinants that may be bidirectional. Indeed, socioeconomic deprivation and poverty are strongly associated with multimorbidity.[50],[51] Multimorbidity places patients at an increased risk for functional decline and disability.[52],[53] However, comorbidity and its risk factors can be managed effectively at an early stage, thereby reducing the incidence of end-organ dysfunction. It is imperative, therefore, for clinicians to screen for chronic health conditions and intervene to prevent long-term complications, which pose a major threat to the health of the aging PLWH.

Limitations

There are some limitations to our study that need to be considered. First, this work is limited to medical chronic health conditions. Second, the retrospective nature and the small size of the sample did not permit an assessment of causality or the direction (and whether they are bidirectional) of the associations between risk factors and the CIR score. Longitudinal studies would allow to shed light on the direction of the associations.


  Conclusion Top


The prevalence of multimorbidity in PLWH is high in a middle-income country. Healthcare providers caring for PLWH must be knowledgeable not only about HIV but also about other chronic health conditions in addition to HIV. Our results highlight the necessity to recognize complex patients and provide them with coordinated care. Special attention must be thus paid to the management and prevention of these comorbidities, with the objective of their early detection, adequate ART selection, and consequently a continuous amelioration of the quality of life of PLWH.

Ethical clearance

Ethical clearance was obtained from the Institutional Review Board of the Faculty of Medicine and Pharmacy of Rabat, Mohammed V University. A formal letter of permission was obtained from the Medical Director of Military Hospital Mohammed V. All obtained data were preserved confidentially and this study was conducted in accordance with the Declaration of Helsinki.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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