High population-attributable fractions of traditional risk factors for non-AIDS-defining diseases among people living with HIV in China: a cohort study

Abstract

Morbidity and mortality of non-AIDS-defining diseases (NADs) have become the increasing burden of people living with HIV (PLWH) with long-term antiretroviral therapy (ART). We aimed to quantify the contribution of modifiable risk factors to NADs. We included PLWHs starting ART at the Third People's Hospital of Shenzhen (China) from Jan 1, 2010 to Dec 31, 2017. We defined NAD outcomes of interest as cardiovascular disease (CVD), end-stage liver disease (ESLD), advanced renal disease (ARD), and non-AIDS-defining cancers (NADCs). We estimated incidence of outcomes and population-attributable fractions (PAFs) of modifiable traditional and HIV-related risk factors for each outcome. Overall, 8,301 participants (median age at study entry, 31 years) contributed 33,146 person-years of follow-up (PYFU). Incidence of CVD (362/100,000 PYFU) was the highest among outcomes, followed by that of ARD (270/100,000 PYFU), ESLD (213/100,000 PYFU), and NADC (152/100,000 PYFU). Totally, 34.14% of CVD was attributable to smoking, 7.98% to hypertension, and 6.44% to diabetes. For ESLD, 24.57% and 25.04% of it could be avoided if chronic hepatitis B and C virus infection, respectively, did not present. The leading PAFs for ARD were declined estimated glomerular filtration rate (eGFR) (39.68%) and low CD4 count (39.61%), followed by diabetes (10.19%). PAFs of hypertension, diabetes, and smoking for CVD, and declined eGFR and diabetes for ARD increased with age. The contribution of traditional risk factors for these NADs far outweighed the HIV-related risk factors. Individual-level interventions and population-level policy-making is needed to focus on these factors to prevent NADs in long-term management of HIV infection.

Keywords: AIDS; Human immunodeficiency virus; incidence; non-AIDS-defining diseases; population attributable fraction.

Figure 1.

Incident non-AIDS-defining diseases. Cross-section of number of patients with different comorbidities of non-AIDS-defining diseases between 2010 and 2019, based on observed 299 patients who developed non-AIDS-defining diseases (each square represents a patient) (A). Incidences of various comorbidities of non-AIDS-defining diseases between 2010 and 2019 (B). ARD: Advanced renal disease. CVD: cardiovascular disease. ESLD: end-stage liver disease. NADC: non-AIDS-defining cancer. NADs: non-AIDS-defining diseases.

Figure 2.

Population attributable fractions for traditional and HIV-related risk factors for cardiovascular diseases. Whiskers indicate 95% CI. Below the plot, prevalence is the prevalence of the risk factor at study entry among those with incident cardiovascular diseases. aHRs were adjusted for age and sex. aHR: adjusted hazard ratio. ART: antiretroviral therapy. eGFR: estimated glomerular filtration rate. BMI: body-mass index. HCV: hepatitis C virus.

Figure 3.

Population attributable fractions for traditional and HIV-related risk factors for end-stage liver disease. Whiskers indicate 95% CI. Below the plot, prevalence is the prevalence of the risk factor at study entry among those with incident end-stage liver diseases. aHRs were adjusted for age and sex. aHR: adjusted hazard ratio. ART: antiretroviral therapy. BMI: body-mass index. HBV: hepatitis B virus. HCV: hepatitis C virus.

Figure 4.

Population attributable fractions for traditional and HIV-related risk factors for advanced renal disease. Whiskers indicate 95% CI. Below the plot, prevalence is the prevalence of the risk factor at study entry among those with incident advanced renal diseases. aHRs were adjusted for age and sex. aHR: adjusted hazard ratio. ART: antiretroviral therapy. eGFR: estimated glomerular filtration rate. HCV: hepatitis C virus.