Disparities in multimorbidity and mortality among people living with and without HIV across British Columbia's health regions: a population-based cohort study.

OBJECTIVES: Longer survival has increased the likelihood of antiretroviral-treated people living with HIV (PLWH) developing age-associated comorbidities. We compared the burden of multimorbidity and all-cause mortality across HIV status in British Columbia (BC), and assessed the longitudinal effect of multimorbidity on all-cause mortality among PLWH. METHODS: Antiretroviral-treated PLWH aged ≥19 years and 1:4 age-sex-matched HIV-negative individuals from a population-based cohort were followed for ≥1 year during 2001-2012. Diagnoses of seven age-associated comorbidities were identified from provincial administrative databases and grouped into 0, 1, 2, and ≥3 comorbidities. Multimorbidity prevalence and age-standardized mortality rates (ASMRs) in both populations were stratified by BC's health regions. Marginal structural models were used to estimate the effect of multimorbidity on mortality among PLWH, adjusted for time-varying confounders affected by prior multimorbidity. RESULTS: Among 8031 PLWH and 32,124 HIV-negative individuals, 25% versus 11% developed multimorbidity, and 23.53 deaths/1000 person-years (95% confidence interval [95% CI]: 22.02-25.13) versus 3.04 (2.81-3.29) were observed, respectively. PLWH in Northern region had the highest ASMR, but those in South Vancouver Island experienced the greatest difference in mortality compared with HIV-negative individuals. Among PLWH, compared with those with zero comorbidities, adjusted hazard ratios for those with 1, 2, and ≥3 comorbidities were 3.36 (95% CI: 2.86-3.95), 6.92 (5.75-8.33), and 12.87 (10.45-15.85), respectively. CONCLUSION: PLWH across BC's health regions experience excess multimorbidity and associated mortality. We highlight health disparities which are key when planning the distribution of healthcare resources across BC, and provide evidence for improved HIV care models integrating prevention and management of chronic diseases.

RéSUMé: OBJECTIF: Les nouvelles thérapeutiques antirétrovirales (ARV) ont permis une plus longue espérance de vie aux personnes porteuses du VIH. Cependant, le vieillissement augmente la probabilité de développer des comorbidités au sein même de la population des personnes vivant avec le VIH (PVVIH) qui suivent des traitements ARV. On a comparé le fardeau de la multimorbidité et mortalité, toutes causes confondues, lié au statut VIH à travers la Colombie-Britannique. On a aussi évalué l'effet longitudinal de la multimorbidité sur la mortalité, toutes causes confondues, parmi les PVVIH. MéTHODES: L'étude comprit des PVVIH suivant un traitement ARV âgés de ≥19 ans et un groupe témoin séronégatif (4 témoins par PVVIH) comparable en termes d'âge et de sexe, tous provenant d'une cohorte de surveillance continue d'au moins 1 an sur une période allant de 2001 à 2012. Des diagnostics de sept comorbidités liées à l'âge ont été identifiés à partir des bases de données administratives provinciales et regroupés en 0, 1, 2 et ≥3 comorbidités. La prévalence de la multimorbidité et les taux de mortalité normalisés selon l'âge (TMNA) dans les deux populations ont été stratifiés selon les régions sociosanitaires de la Colombie-Britannique. Des modèles structurels marginaux ont été utilisés pour estimer l'effet de la multimorbidité sur la mortalité chez les PVVIH, ajustant pour les facteurs de confusion variables affectés par une multimorbidité antérieure. RéSULTATS: Parmi 8 031 PVVIH et 32 124 personnes séronégatives pour le VIH, 25 % contre 11 % ont développé une multimorbidité et 23,53 décès pour 1 000 personnes-années (intervalle de confiance à 95 % [IC à 95 %]: 22,02­25,13) contre 3,04 (2,81­3,29) ont été observés, respectivement. Les PVVIH de la région septentrionale avaient le TMNA le plus élevé, alors que ceux du sud de l'île de Vancouver ont connu la plus grande différence de mortalité par rapport aux personnes séronégatives. Parmi les PVVIH, les personnes atteintes de 1, 2 et ≥3 comorbidités avaient respectivement 3,36 (IC à 95 %: 2,86­3,95), 6,92 (5,75­8,33) et 12,87 (10,45­15,85) fois plus la probabilité de mourir que les personnes sans comorbidités. CONCLUSION: Les PVVIH des régions sociosanitaires de la Colombie-Britannique connaissent une multimorbidité excessive et la surmortalité s'y associant. Notre étude souligne les disparités-clés en matière de santé qu'il faut prendre en compte lors de la planification de la distribution des ressources de soins de santé à travers la Colombie-Britannique. Elle fournit aussi des preuves pour des modèles de soins du VIH améliorés, y intégrant la prévention et la gestion des maladies chroniques.

Indigenizing our research: indigenous community leadership in HIV epidemiology research.

The use of data intensive health research has allowed for greater understandings of population health. When conducting data intensive health research, engaging and involving the community is essential for conducting meaningful research that is responsive to the public's needs. Particularly, when engaging Indigenous communities in research, there is a need to understand historical and ongoing impacts of colonialism and recognize the strengths in Indigenous Peoples' knowledges and experiences while supporting Indigenous leadership and self-determination in research. This article describes the approach our research team/organization used to engage and involve Indigenous people living with HIV in three research projects using large, linked datasets and looking at HIV outcomes of Indigenous populations in Canada. The foundation of these projects was simultaneously: 1) supporting Indigenous people living with HIV to be involved as research team members, 2) developing research questions to answer with available datasets, and 3) integrating Indigenous and Western ways of knowing. We have identified important considerations and suggestions for engaging and involving Indigenous communities and individuals in the generation of research ideas and analysis of linked data using community-based participatory research approaches through our work. These include engaging stakeholders at the start of the project and involving them throughout the research process, honouring Indigenous ways of knowing, the land, and local protocols and traditions, prioritizing Indigenous voices, promoting co-learning and building capacity, and focusing on developing longitudinal relationships. We describe keys to success and learnings that emerged. Importantly, the methodology practiced and presented in this manuscript is not a qualitative study design whereby research subjects are surveyed about their experiences or beliefs. Rather, the study approach described herein is about engaging people with living experience to co-lead as researchers. Our approach supported Indigenous people to share research that addresses their research priorities and responds to issues relevant to Indigenous Peoples and communities.

Incidence of diabetes mellitus among people living with and without HIV in British Columbia, Canada between 2001 and 2013: a longitudinal population-based cohort study.

INTRODUCTION: People living with HIV (PLHIV) are increasingly at risk of age-related comorbidities such as diabetes mellitus (DM). While DM is associated with elevated mortality and morbidity, understanding of DM among PLHIV is limited. We assessed the incidence of DM among people living with and without HIV in British Columbia (BC), Canada, during 2001-2013. METHODS: We used longitudinal data from a population-based cohort study linking clinical data and administrative health data. We included PLHIV who were antiretroviral therapy (ART) naïve at baseline, and 1:5 age-sex-matched persons without HIV. All participants had ≥5 years of historic data pre-baseline and ≥1 year(s) of follow-up. DM was identified using the BC Ministry of Health's definitions applied to hospitalisation, physician billing and drug dispensation datasets. Incident DM was identified using a 5-year run-in period. In addition to unadjusted incidence rates (IRs), we estimated adjusted incidence rate ratios (IRR) using Poisson regression and assessed annual trends in DM IRs per 1000 person years (PYs) between 2001 and 2013. RESULTS: A total of 129 PLHIV and 636 individuals without HIV developed DM over 17 529 PYs and 88,672 PYs, respectively. The unadjusted IRs of DM per 1000 PYs were 7.4 (95% CI 6.2 to 8.8) among PLHIV and 7.2 (95% CI 6.6 to 7.8) for individuals without HIV. After adjustment for confounding, HIV serostatus was not associated with DM incidence (adjusted IRR: 1.03, 95% CI 0.83 to 1.27). DM incidence did not increase over time among PLHIV (Kendall trend test: p=0.9369), but it increased among persons without HIV between 2001 and 2013 (p=0.0136). CONCLUSIONS: After adjustment, HIV serostatus was not associated with incidence of DM, between 2001 and 2013. Future studies should investigate the impact of ART on mitigating the potential risk of DM among PLHIV.

Influence of the definition of rurality on geographic differences in HIV outcomes in British Columbia: a retrospective cohort analysis.

BACKGROUND: Improving rural health is often identified as a priority area for research and policy in Canada. We examined how findings on HIV outcomes (virologic suppression) can vary depending on the definition of rurality used. METHODS: We performed retrospective cohort analyses using the Comparative Outcomes and Service Utilization Trends study population-based cohort of adults (age ≥ 19 yr) living with HIV in British Columbia between Apr. 1, 2012, and Mar. 31, 2013. We performed univariate logistic regression analyses using the following geographic variables to predict HIV virologic suppression: rurality defined by forward sortation area, by Statistical Area Classification and by health authority. We mapped suppression using geographic information systems. RESULTS: Virologic suppression was observed in 5605 (65.2%) of 8598 participants. In univariate analysis, rurality defined by Statistical Area Classification (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.65-0.82), but not by forward sortation area, was associated with lower odds of suppression. When we examined suppression by health authority, Northern Health had the lowest odds of suppression (OR 0.46, 95% CI 0.36-0.58 compared to Vancouver Coastal Health). Geographic information systems mapping showed poorer suppression in northern areas. INTERPRETATION: Health outcome findings can vary depending on the definition of the geographic variable. When including geographic variables, researchers should carefully consider variable definitions and whether other classification systems, such as north-south, are more appropriate than rurality for their analysis.