Patterns of Comorbidity and Sociodemographic and Psychosocial Correlates Among People Living With HIV in South Carolina, USA

X Yang X Li; S Qiao


HIV Medicine. 2020;21(4):205-216. 

In This Article

Abstract and Introduction


Objectives: Prevention of comorbidity with HIV infection warrants more attention as people living with HIV (PLWH) tend to live longer in the era of effective antiretroviral therapy (ART). This study aimed to investigate the associations between various psychosocial variables and different comorbid conditions in South Carolina (SC), USA.

Methods: A cross-sectional survey was conducted among PLWH from May to September 2018 in SC. Comorbid conditions were based on self-report data and grouped into sexually transmitted infection (STI) comorbidities, noninfectious chronic comorbidities or any comorbidity. Multivariate logistic regression models were used to analyse the relevant associations.

Results: Among 402 participants, the prevalence of STI comorbidities, noninfectious chronic comorbidities, and any comorbidity was 61.7%, 21.9% and 69.4%, respectively. The multivariate analysis showed that higher depression scores were associated with an increased risk of any comorbidity, while higher anxiety scores were associated with an increased risk of STI comorbidities or any comorbidity. Higher resilience scores were associated with a decreased risk of noninfectious chronic comorbidities or any comorbidity.

Conclusions: The association between psychosocial factors and different types of comorbidity could inform holistic interventions, such as providing integrated mental health services (e.g. treating mental health problems or building resilience), to effectively cope with and manage the co-existing medical conditions of PLWH.


South Carolina (SC), a predominately rural state, has consistently ranked in the top ten in the USA in terms of the total estimated number of HIV/AIDS cases for the past several years (e.g. seventh in 2017[1]). As of 31 December 2017, there were an estimated 19 749 people living with HIV (PLWH) in SC and this number has increased by 30% since 2008, with an incidence rate of 14.3 per 100 000 population.[1] The worldwide availability of antiretroviral therapy (ART) has extended the life expectancy of PLWH, ushering in a new era where comorbid medical conditions are replacing opportunistic infections as the most significant threats to the health of PLWH.

Different combinations of diseases may affect a person's health differently. To account for these differences, disease combinations can be categorized as either concordant (similar in risk profile and management) or discordant (not directly related in pathogenesis or management).[2] Theoretically, concordant conditions are more likely to be diagnosed and treated along with the index condition, because clinical guidelines often incorporate their interactions. For discordant conditions, however, the competing demands of dealing with different conditions may affect the quality of care provided.[3] With regard to HIV infection, existing literature in the USA suggests widespread infectious comorbidity with HIV infection, such as syphilis, chlamydia and gonorrhoea.[4] As they share common risk factors and modes of transmission,[5] different types of infectious disease can be considered as concordant conditions. As a result, the Centers for Disease Control and Prevention (CDC) has promoted collaboration and service integration as a priority for programmes addressing HIV infection, sexually transmitted infections (STIs) and viral hepatitis.[6]

In addition, as PLWH are living longer as a result of successful ART, noninfectious chronic conditions, such as diabetes, cardiovascular disease and cancer, have been recognized as a growing source of morbidity and mortality among PLWH. In the USA, more than one quarter of the 1.2 million PLWH are now ≥ 55 years of age.[7] Recent studies have demonstrated that PLWH experience approximately a 50 to 100% increased risk of myocardial infarction and stroke compared with HIV-seronegative individuals, and they also face higher risks of sudden death and heart failure.[8–11] With advances in ART, the incidence of AIDS-defining cancers (e.g. Kaposi's sarcoma and non-Hodgkin's lymphoma) has declined,[12] yet the non-AIDS-defining cancers (e.g. anal cancer, liver cancer and lung cancer) have been becoming more prevalent and are now an important cause of mortality among PLWH.[13–15] Similar results were also found in studies conducted in Canada,[16,17] indicating that noninfectious chronic conditions have become a leading cause of morbidity for this population.[18] HIV infection and certain other chronic conditions can mutually affect each other. For example, inadequate HIV viral suppression has been linked to inadequate management of the comorbid conditions of hypertension and diabetes.[19] In addition, the quality of life of PLWH with other chronic conditions has been shown to decrease as the disease burden increases.[20,21] This rising rate of noninfectious chronic comorbidities presents a threat to the progress achieved in reducing global HIV-related mortality.

Comorbidities with HIV infection can be complicated by psychological factors, such as depression.[22] Previous literature reviews from Canada[17] and Australia[23] confirmed that mental illness remains one of the most common problems among PLWH. For example, depression was very prevalent among PLWH, with rates ranging from 8% to 40%, which may be about two times higher than that in the general population.[24] Consequently, mental health problems can complicate HIV treatment and care and lead to poorer health outcomes[25] such as suboptimal ART adherence,[26] substance use and unprotected sexual behaviors,[27] and have been associated with faster disease progression.[28] Although not particularly targeting PLWH, the US Department of Health and Human Services' 2010 strategic framework also identified the psychological issues that are associated with multiple chronic conditions and acknowledged the challenges of emotion management, including depression.[29]

Previous studies have found a bidirectional association between mental health and certain chronic physical conditions. For example, a number of studies reported that depression symptoms are associated with increased stroke risk.[30–33] Likewise, anxiety was found to be common in stroke patients followed for a few years.[34] Although some studies have attempted to identify common clusters of mental health problems and their impact on HIV comorbidities, very limited studies have focused on PLWH[35–37] as suggested in a systematic literature review.[38] The findings from these limited studies revealed a high prevalence of HIV comorbidities (65%) as well as mood disorders, such as depression (48%).[36] These findings also suggested that both STI comorbidities [e.g. HIV/hepatitis C virus (HCV) coinfection] and noninfectious chronic comorbidities (e.g. comorbid with cardiovascular disease) were associated with worse mental health.[35,37]

A coping strategy, a complex multidimensional process that is sensitive to the environment and personality dispositions that influence the appraisal of stress and coping resources,[39] has been found to be associated with better service utilization among HIV-infected patients with comorbidities.[40] However, the relationship between a coping strategy and different patterns of HIV-associated comorbidities is unknown. Resilience, which is defined most succinctly as positive adaptation in the context of adversity,[41] has previously been found to be associated with better HIV-related health outcomes[42] yet remains understudied among PLWH. In summary, despite the prevalent mental health problems among PLWH, data on their association with STI comorbidities or noninfectious chronic comorbidities are limited, especially in SC, where there is a high burden of HIV epidemic. These are important knowledge gaps, as a better understanding of these relationships may help guide prevention and treatment strategies and help us to develop protocols for better patient care. Therefore, our study aimed to (1) estimate the prevalence of different types of comorbidity with HIV infection (i.e. STI comorbidities and noninfectious chronic comorbidities) and (2) investigate the sociodemographic and psychosocial correlates of these comorbid conditions among PLWH in SC.

Methods. Study Site and Participants: With the collaboration of a large Ryan White-funded immunological clinic that has an ongoing partnership with the research team, a cross-sectional study was conducted among PLWH in SC in 2018. The inclusion criteria of the current study were: (1) resident of SC, (2) ≥ 18 years of age, (3) living with HIV, and (4) willing to participate in a 35–40-min survey. Data were collected between May and September 2018, with all surveys being completed on site at the clinic. The study team coordinated with the clinic staff on data collection activities. All HIV-infected patients who came for the follow-up visits were approached and were briefed about the study by the clinic staff; those interested in participating in the study were referred to a member of the research team who then further explained the study and obtained informed consent from the participants. Each participant of the study was compensated with a $20 gift card for their time and effort. The anonymous survey was administered in designated areas at the clinic and, when requested, in a private room. Among those patients invited, > 80% agreed to participate in the survey. A total of 402 PLWH completed the survey and were included in the current data analysis. Ethic approval for the study was obtained from the University of South Carolina Institutional Review Board.