The Shifting Picture of HIV Treatment, Comorbidity and Substance use Among US MSM Living With HIV

G D'Souza; L Benning; V Stosor; MD Witt; J Johnson; M Friedman; AG Abraham


HIV Medicine. 2021;22(7):538-546. 

In This Article

Abstract and Introduction


Objectives: People living with HIV (PLWH) have increased risk of chronic disease and poor mental health. We aimed to explore HIV disease indicators, comorbidity, and risk behavior of recent antiretroviral therapy (ART) initiators to inform current needs of PLWH.

Methods: Men who have sex with men (MSM) in the Multicenter AIDS Cohort Study (MACS) who initiated ART between 2010 and 2018 (recent initiators) were compared with age-, race- and geographic location-matched men who initiated ART during 2000–2009 (early initiators). Measures of HIV disease, behavior, comorbidity and mental health were collected prospectively every 6 months using standardized forms.

Results: Recent initiators had higher current CD4 (median CD4 451 vs. 307 cells/μL, P < 0.0001) and nadir CD4 (451 vs. 300 cells/μL, P < 0.0001) than earlier initiators. The proportion achieving viral suppression within a year of starting ART was significantly higher in recent compared with earlier initiators (92% vs. 74%, P < 0.0001). Median [interquartile range (IQR)] time from HIV diagnosis to ART initiation was 5.4 (1.7–23.1) months in recent initiators. Comorbidity prevalence was high in recent initiators, including obesity (24%), hypertension (25%) and kidney disease (15%). Substance use continues to be common, including cigarette use (40%), daily alcohol use (88%) and marijuana use (46%).

Conclusions: Improvements in getting individuals onto ART at an early stage have led to substantially higher CD4 cell counts at initiation. However, the high burden of comorbidity, substance use and poor mental health affecting MSM living with HIV in the US underscore ongoing challenges and our need to adapt and coordinate care.


Over the history of the HIV epidemic in the US, the face of HIV has transformed from a disease marked by immune suppression, infectious sequela and unchecked viraemia to one of multi-morbidity, poly-pharmacy and ageing. Changing and improving treatment paradigms, along with immediate initiation of effective antiretroviral therapy (ART) through test and treat strategies,[1–3] have allowed people living with HIV (PLWH) to achieve improved longevity.[4] This has reduced the spectre of AIDS in the US but replaced it with the threat of chronic disease accumulation, and the challenges of coordinated care of an ageing population living with HIV. Our understanding of this shift in the health needs of HIV-infected persons is incomplete.

Life expectancy of PLWH has increased substantially, nearing that of the general population.[5,6] However, living into older ages means that PLWH face both the complexity of lifelong HIV treatment and the increased risk of chronic disease. Even when on ART, rates of physical disability, poor mental health and cognitive impairment are higher in ageing PLWH than in the general public.[6,7] While the inflammatory context may contribute to higher risk of many outcomes, the prevalence of risk behaviours, including tobacco, alcohol and drug use,[8] is also high, adding to risk.

Men who have sex with men (MSM) still bear the largest burden of HIV in the US. Indeed, an estimated 10.6% of MSM in the US are living with HIV.[9] PLWH suffer continuing disparities in accessing non-HIV healthcare, which inhibits preventive measures and probably prolongs and exacerbates illness. Mental health and stigma remain challenges for MSM with and without HIV, and depression remains common among MSM in the US.[8] Inconsistent condom use and sexually transmitted disease risk have been reported in some recent studies of MSM[10–12] and do not appear to decrease with engagement in care,[13] but sexual behaviour among recent ART initiators has not been well described.

While the HIV research and policy communities are aware of the shifting needs of the ageing HIV population, the mental health and physical health burden of those currently engaged in care are not well understood. To provide a clearer picture of the current health status of PLWH on ART and challenges as this group ages with HIV, we explored physical health indicators and behavioural risk factors among recent ART initiators. We compared the prevalence of these measures with PLWH who initiated therapy in the prior decade (early initiators) to provide context for current measures. We also examined HIV disease characteristics and immunological response among MSM initiating ART therapy for the first time to quantify progress in the goal of initiating therapy earlier and improving disease management.