The Role of Comorbidity in Determining Outcomes in HIV Amy C. Justice, MD, PhD Grand Rounds University of Pittsburgh School of Medicine February 1, 2002.

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Presentation transcript:

The Role of Comorbidity in Determining Outcomes in HIV Amy C. Justice, MD, PhD Grand Rounds University of Pittsburgh School of Medicine February 1, 2002

Topics To Be Covered HIV/AIDS Treatment and Survival Definitions of Comorbidity Prevalence of Comorbidity in HIV Medical Comorbidity and Outcomes Psychiatric Comorbidity and Outcomes Alcohol and Outcomes

Learning Objectives Common comorbid conditions in HIV How comorbid conditions influence outcomes Role of alcohol use/abuse as a comorbidity

HIV/AIDS Timeline AIDS 1st Recognized Test for HIV AZT Multidrug Rx Protease Inhibitors (HAART) Prevention for PC Pneumonia 2002

HIV to AIDS to Death HIV + AIDS-Defining Condition Death 8-10 yrs. 1-3 yrs.

Median Years Survival with AIDS CD4 Count (mm3) Prior to HAART (‘92-95’) Post HAART Short Term Extrapolation Estimation Adjusted for Aging and Rx Failure > < < King et al Long-Term HIV/AIDS Survival Estimation in the HAART Era. Under review.

Not All Equally Benefit From Rx Gaps in Survival –by Age –by Insurance Status Suggest differences in –Access, adherence to treatment –Comorbid medical/psychiatric disease –Susceptibility to treatment toxicity

Median Survival (Months) with AIDS by Age Research on Aging 1998;

Extrapolated Median Survival (Months) After AIDS Extrapolated from New England Journal of Medicine 1998;338:13;

Patient Outcomes in HIV in 2002 Access to HIV Treatment HIV Aging Comorbid Disease and Drug Toxicity

Strict Definition of Comorbidity “Many…elements of illness may be due to … other diseases… [than the disease under study]. The associated illness arising from these other diseases produces a co-morbidity that may affect … prognosis and therapeutic response…” AR Feinstein, Clinical Judgment, 1967

Comorbidity May be –Medical or psychiatric –Exacerbated by “primary disease” May exacerbate “primary disease” But, is not caused by “primary disease” Treating primary disease will not treat the comorbidity (may exacerbate comorbidity)

Identifying Role of Comorbidity Difficult to know whether condition is – Caused by “primary disease” – Toxicity from treatment for “primary disease” –“Independent” of “primary disease” Must study those with/without primary disease Etiology of condition may facilitate treatment

Example : Medical Comorbidity Macrocytic anemia –HIV infection –Zidovudine and stavudine –Alcohol abuse

Example: Psychiatric Comorbidity Depression –Situational depression associated with dx of HIV –Antiretrovirals associated with depression –HIV risk behaviors (substance abuse and sex with multiple partners) associated with depression

Functional Definition of Comorbidity Any condition not included in the CDC list of AIDS defining conditions.

How Common is Major Medical Comorbidity in HIV?

HIV/AIDS Conditions Provider-Reported (N = 810) %

General Medical Comorbidities Provider-Reported (N = 811) %

Mean Comorbidity Counts (N = 810) *P <0.001 based on Studentized T-test

Distribution of HIV and General Medical Condition Counts Provider-Report (N = 810) % Number of Conditions

Mean Conditions Counts By CD4 Count /mm 3 (N = 805) *P < *P = 0.77

General Medical Comorbidity By Age HTNHyper- lipidemia DMStrokePacrea- titis CancerMI/CADCHFPVD <50 Yrs 50+ Yrs P<.05 in all cases

Mean Counts By Age (N = 800) *P < *P = 0.22

How Common is Neuro- Psychiatric Comorbidity in HIV?

Cognitive Dysfunction* by Age *Provider-report Cognitive Impairment?AIDS Dementia %

Prevalence of Mental Disorders (3 year) in VACS 3

How Important Is Comorbidity in HIV Infection? Does it influence quality of life? Does it complicate treatment? Does it influence survival?

Comorbidity and Quality of Life

SF-12 Scores Comorbidity Regressions (N = 759) †Separate regressions for HIV and general medical comorbidities; and for SF- 12 physical and mental health scores; adjusted for age, race, and CD4 count

Comorbidity and Hospitalization

Inpatient Admissions: Zero Inflated Poisson Regression *Adjusting for age, race, CD4 count, viral load, ART, CES-D score **Includes Toxoplasmosis, Histoplasmosis, and Coccidiomycosis Log Likelihood = -796

Comorbidity and Survival

Survival: Cox Proportional Hazards Model (N=761) *Adjusting for age, race, CD4 count, viral load, ART, CES-D score **Includes Toxoplasmosis, Histoplasmosis, and Coccidiomycosis C Statistic = 0.82

Provider-Reported Illness Severity Comorbidity-Regressions (N = 800) †Separate regressions for HIV and general medical comorbidities; adjusted for age, race. and CD4 count

Special Role of Substance Use

Effects of Substance Use/Abuse Nonadherence Hepatitis Addiction PsychiatricMedical Risky Sexual Behaviors Depression Bone Marrow Suppression

How Common is Substance Use/Abuse in HIV?

ICD-9 Diagnoses of Substance Abuse 37% 21% Drug AbuseAlcohol Abuse

Substance Use * *Patient and Provider Report % Illicit Drugs Alcohol Pt. Current Pro. Current Pt. Ever Pro. Ever

Why is Alcohol of Special Concern? Risky sexual behavior Nonadherence to antiretroviral therapy Increased susceptibility to ADRs –liver injury –Peripheral red cell destruction –bone marrow injury Susceptibility to CNS injury Susceptibility to immune dysfunction

How Common is Alcohol Use/Abuse (HIV+ Veteran Report) Drinks alcohol86% Drinks currently40% AUDIT (  8) 33% > 6 drinks one occasion33%

Are Providers Aware of Alcohol Use? Patient ever drank Patient currently drinks Agreement (patient) Kappa 57% 13% 63% 0.14

What do we Need to Know? Does alcohol exacerbates HIV progression or associated conditions? Does alcohol mitigate effectiveness and increases toxicity of antiretroviral treatment? Does HIV infection increase the risk of common complications of alcohol? What level of alcohol consumption is “safe”?

VACS 5 & Alcohol: Specific Aims 1)Influence of alcohol consumption on laboratory measures and patient outcomes among veterans with/without HIV infection and hepatitis C 2) Provider awareness of and attitudes about alcohol consumption among their patients 3) Patient awareness and attitudes toward alcohol consumption

What Can Be Done? Behavioral Interventions with providers and patients Targeted computer reminders

Veterans Aging Cohort Study Center (Pittsburgh) Alcohol Faculty –Joseph Conigliaro (Co PI) –Nancy Day –Adam Gordon –Robert Cook –Kevin Kramer Faculty –Charles Rinaldo –John Mellors –Scott Braithwaite –Adeel Butt –Shawn Fultz (GIM Fellow) –Gabriel Silverman (MS I) Staff –Tamra Madenwald –Susan Smola –Kathleen McGinnis –Joseph Wagner –Melissa Skanderson –Elaine Lasky –Rose Pfeuffer –Sonia Bhatt –Jerome Lee

VACS Sites PIs and CoPIs Los Angeles, CA –Matthew Goetz –David Leaf –Kurt Willis (Coord) Manhattan/Brooklyn, NY –Michael Simberkoff –David Blumenthal –Joseph Leung –Cathryn Mancini (Coord) –Darlene Chavis (Asst) Atlanta, GA –David Rimland (PI) –Cedrella Jones-Taylor (Co PI) –Laura Gallaher (Coord) –Stephanie Grupinski (Asst) Bronx, NY –Sheldon Brown (PI) –Sarah Garrison (Co PI) –Peying Xao (Coord) –Katherine Elliot (Asst) Houston, TX –Maria Rodriguez-Barradas (PI) –Alain Bouckenooghe (Co PI) –Deborah Terry (Coord) –Cythia Rose (Asst)