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


The findings of this study highlight the alarmingly high prevalences of various comorbid conditions among PLWH in SC, comparable to the findings of previous studies.[17,55] The results also allow examination of regional differences in the rates of comorbid conditions. For instance, the prevalence of comorbidity with diabetes in our setting (15.2%) is lower than that in another study in a sample of HIV-infected patients from a US national MarketScan research database (31.1%)[44] but higher than that in the general population in the USA (8%).[56] Differences in characteristics of the populations may contribute to this regional disparity in comorbidity rates in the USA, and this warrants further investigation. Significant associations between psychosocial factors and different types of comorbidity were found in this study. Although these findings are in line with reports from other studies,[35,37] the nature of these associations is likely to be bidirectional. Further investigation of the cross-effects between these psychosocial variables and different types of comorbidity would be worthwhile. However, timely diagnosis of mental health problems (e.g. depression and anxiety) and improvement of patients' psychosocial wellbeing might be beneficial for managing their multiple physical health problems. Although the directions of the associations could not be established, adaptive forms of coping strategies, such as positive reinterpretation and growth and turning to religion, were negatively associated with the occurrence of comorbidity, while maladaptive forms of coping, such as alcohol-drug disengagement, may be risk factors for STI comorbidities. PLWH can benefit from assistance in seeking coping resources and learning coping strategies to solve problems, thereby dealing with stressful life events including HIV infection and comorbidity. Interventions such as coping skills training that teach PLWH how to handle HIV-related stressors such as depression may be particularly helpful in improving both their mental and physical health. At the same time, establishing and enhancing resilience will also help PLWH to manage and cope with their comorbidities.

The data obtained in the current study suggest that PLWH who self-identified as gay or bisexual or had a history of incarceration were more likely to have STI comorbidities. This is consistent with the existing literature suggesting that gay or bisexual men are more likely to report multiple STI risk behaviours (e.g. concurrent sexual partners or unprotected sexual intercourse) than their heterosexual counterparts.[57] Similarly, incarceration history may contribute to STI risk by facilitating contact with prisoners who engage in more risky behaviours and hence have an elevated risk of infection, which has also been suggested in previous studies.[58] Additionally, the sizes of both these populations are small, and they are often socially isolated. Such social and sexual exclusion intensifies the transmission of HIV and/or other STIs.[59] Also, PLWH who were older, did not have a full-time job and had been living with HIV infection for a longer time were more likely to have chronic comorbid conditions. Metabolic comorbidities were more prevalent among older patients,[60] and this result is consistent with previous findings.[61] These results signify that tailored intervention efforts are needed for populations with different traits in terms of relevant comorbidity patterns.

Despite the fact that many studies have looked at mental health problems among PLWH, this is one of the first studies to specifically assess the relationship between psychological factors and different patterns of comorbid conditions among PLWH in SC. Screening as well as early diagnosis of mental health problems in PLWH may be helpful in managing comorbid conditions. In this study, a higher religious coping score was found to be associated with a decreased risk of having comorbid conditions. This is probably related to the population characteristics in our study setting. SC is one of the most religious states in the USA, with 70% of the adult population having a religious belief. PLWH in SC are mainly black, and black individuals have been reported to be more likely to use spiritual coping strategies to deal with their illness than white individuals.[62] Churches have been successfully used as an avenue to address HIV/AIDS within the black community in SC.[63] A previous study also showed that social support and spiritual wellbeing obtained from religious involvement could predict engagement in HIV care.[64] Thus, it is plausible that some PLWH might have religious beliefs and turn to religious practices to receive spiritual support when dealing with the stressors of the disease, resulting in some positive health outcomes. Similar results have been reported in previous studies.[65] Therefore, in clinical practice, health care providers could encourage PLWH who have a religious belief to use religious thoughts or practices to cope with the distress associated with having physical illnesses, as suggested in other studies.[66] However, future longitudinal studies may be needed to test the causal hypothesis regarding religious beliefs and health outcomes.

The participants who had low denial coping scores were more likely to report STI comorbidities. A plausible explanation of this finding is that participants who prefer denial over knowledge are less likely to be tested for STIs, which are often asymptomatic. Therefore, they may be less likely to be diagnosed with STIs or aware of their own infections. Future studies could investigate interventions to change the attitudes of such individuals by facilitating open discussion of their health problems and promoting health-seeking behaviour.

In the current study, higher resilience scores were associated with a decreased risk of noninfectious chronic comorbidities. Building resilience might attenuate the negative effect of the psychological distress associated with HIV infection and in the long term might be beneficial to physical health. It is also possible that PLWH with comorbidities are more likely to build long-lasting resilience than those without comorbid conditions. Regardless, establishing and enhancing resilience, such as by building social support and encouraging hope in the future, to deal with either HIV monoinfection or HIV infection with comorbidities would be beneficial for both mental and physical health. As outpatient specialty services for mental health are less accessible to PLWH in the southern than northern regions of the USA,[67] interventions may be considered in the future to expand the availability of such services in the southern USA and to try to increase utilization of such services.

A number of limitations of the study are worth noting. First, the data on comorbidities were collected via self-report and were thus subject to recall bias. Furthermore, participants may have self-misdiagnosed some diseases as a consequence of low health literary. For example, they may not have been aware of the exact names or characteristics of their physical illnesses, especially if these were borderline conditions (e.g. they may not have been aware of the difference between anal intraepithelial neoplasia and anal cancer or not have been aware of the concentration of glucose required for a diabetes diagnosis). They may also have had diseases that presented some symptoms but were undiagnosed, which would have resulted in an underestimation of the prevalence of some comorbidities. More accurate data on the diagnosis of comorbid conditions from medical records or a physical check-up at the time of the survey are needed to avoid misdiagnosis and over- or underestimation of the prevalences of these comorbidities. Second, the assessment of chronic comorbidities needs to be refined in future studies. Given the constraints of the length of the questionnaire, we did not list specific types of some diseases, such as cancer and cardiovascular disease, but instead used categories. Consequently, the participants might not have considered some cancers in their responses, such as skin cancers, which are often excluded from cancer epidemiology studies because they are easily treatable (except melanoma, which is rare and has a much higher disease burden), although they may be the cancers with the highest prevalence worldwide. Moreover, as not all the participants were virally suppressed, some of them might have developed AIDS-defining cancers. The survey used did not allow us to distinguish AIDS-defining from non-AIDS-defining cancers, although the latter were more relevant to our study. In addition, the chronic comorbidity types considered were limited. Some other potentially important comorbidities, such as hypertension and hyperlipidaemia, may need to be taken into consideration in future studies. Third, causal relationships could not be established given the cross-sectional design and psychosocial variables can interact with each other. The nature of these associations is likely to be bidirectional. Fourth, allparticipants were recruited from a clinic centre in SC, which may limit the generalizability of the study findings to other settings. Future research should address these limitations by using a longitudinal design, and a larger and more geographically diverse sample.

In summary, the high prevalence of comorbid conditions among PLWH in SC highlights the need for prevention efforts. The findings suggest that different co-existing medical conditions may be influenced by or influence different psychosocial factors. Addressing mental health problems, such as reducing anxiety and building resilience, would probably be helpful in managing HIV comorbidities in the long term. In general, our findings may inform more holistic interventions, such as providing integrated mental health services (e.g. treating mental health problems, establishing religious coping or building resilience), to effectively manage and control the co-existing conditions of PLWH in the future.