哪些健康狀況在 HIV 感染者中或多或少會較常見?
英國的大型研究強調了愛滋病毒感染者的非典型模式
資料來源:格斯凱恩斯 / 2022 年 5 月 30 日 / 財團法人台灣紅絲帶基金會編譯
圖片:Domizia Salusest | www.domiziasalusest.com
一項針對英國衛生服務機構患者的橫斷面研究比較了 HIV 感染者與非 HIV 感染者的大量不同健康狀況的盛行率。大多數研究結果證實了之前的研究,但該研究還發愛滋病病毒感染者的許多心血管疾病和類風濕性關節炎的盛行率較低,而不孕症、雙相情感障礙和多種感染更為常見。
這項研究由鄧迪大學的 Daniel Morales 博士及其同事進行,研究了來自英國臨床研究數據庫 GOLD 的匿名患者數據,其中包含去識別的電子初級保健記錄,以及來自醫院事件統計數據庫的住院數據。
研究人員只查看了截至特定日期 – 2015 年 11 月 30 日完成的記錄。選擇近七年前的日期的原因是為了確保數據的完整性和匿名性,但這意味著從那時起獲得的條件和隨後的結果(從復原至死亡)不包括在內。
總共包括 942,077 條記錄,佔英國 18 歲以下人口的 1.8%。其中,964 人感染了愛滋病毒。為了糾正可能的代表性不足,研究人員還與國家統計局截至 2021 年的數據進行了交叉核對,這些數據回顧性地提到了 2015 年 11 月 30 日之前做出的愛滋病毒診斷。儘管如此,記錄的 0.1% 的 HIV 流行率低於英國 18 歲以上人群的實際 HIV 流行率(1.9%),這可能意味著某些疾病的流行率可能被高估或低估。
未感染愛滋病毒的人男女比例均衡,而愛滋病毒感染者中有 61% 是男性。雖然四分之一的愛滋病毒陰性者年齡至少為 65 歲,但愛滋病毒感柴者則只有 7%的。儘管下面的數據根據性別和年齡進行了調整,但愛滋病毒陽性組中老年人的缺乏使得與年齡相關的疾病的數據不太可靠。
研究人員將 304 個診斷代碼組合成 47 組健康狀況。群體的例子從極其常見的群體(如高血脂,約 40% 的人記錄)或心理健康/神經系統問題(約 35%)到罕見的群體,如腦膜炎等中樞神經系統感染(在不到 0.2% 的人)和肺癌等呼吸道癌症(不到 0.5%)。
該研究發現,愛滋病毒感染者不太可能,或者在某些情況下不太可能患有最常見的疾病組。然而,它發現他們更有可能患有更罕見的疾病。這些罕見的情況主要是感染——這表明愛滋病毒感染者免疫力受損的影響。
在最流行的前 50% 的情況中,只有兩組情況,即 HIV 感染者比 HIV 陰性者更容易感染。愛滋病病毒感染者出現貧血或白細胞計數低等後天性血液異常的可能性是愛滋病病毒陰性者的兩倍,但這並不奇怪。還有一個包羅萬象的群體,稱為「感染 – 其他」,愛滋病毒感染者的可能性是愛滋病毒感染者的四倍。
另一方面,一些常見疾病在 HIV 感染者中的可能性較低,包括高血壓(可能性降低 22%)、哮喘(可能性降低 35%)以及骨骼和關節疾病(可能性降低 44%)。
但是,愛滋病病毒感染者更容易出現幾組罕見的疾病。最罕見的一組疾病是真菌感染。在所有受試者中僅記錄了 479 例真菌感染——患病率為 0.05%,即不到 2000 人中有 1 例。但在研究中的 964 名 HIV 感染者中發現了其中 47 例,患病率為 4.9%,或 20 人中有 1 例以上。這意味著當根據年齡和性別進行調整時,真菌感染在 HIV 感染者中的發生率是未感染者的 121 倍。
結核病在愛滋病毒感染者中也更為常見:所有患者的患病率為 0.6%,但艾滋病毒感染者的患病率接近 7%,這意味著它的可能性高出 13.5 倍。 HIV 感染者的其他疾病發生率是 HIV 陰性者的 5 倍以上,包括免疫疾病(可能性為 7.4 倍)和胃腸道感染(可能性為 5.7 倍)。還有病毒感染,作為一個群體的可能性高出 7.7 倍,但這受到病毒性肝炎患病率特別高的影響(可能性高出 22 倍)。同樣,這些發現都不是特別令人驚訝的。
在絕對數字上,其他一些情況——例如高血脂——更為常見。例如,399 例 HIV 感染者的高血脂病例與 50 例病毒感染形成對比。但高脂血症的盛行率並不明顯高於沒有愛滋病毒的人。大多數其他與心血管疾病相關的疾病在 HIV 感染者中不太常見,包括心房顫動(可能性降低 63%)和冠狀動脈疾病(可能性降低 48%),但肺栓塞(肺部血栓)的發生率是其兩倍.
當涉及到個人情況時,還有一些其他的驚喜。例如,類風濕性關節炎在 HIV 感染者中的發病率僅為未感染者的四分之一,儘管兩者都涉及自身免疫過程。更常見的關節炎形式,骨關節炎,也只有三分之一左右,腕管綜合症候群和腕部骨折等其他骨骼/關節問題也不太常見。
愛滋病毒感染者更容易患上性激素水平低下的疾病(男性和女性不育症和勃起功能障礙的發病率在愛滋病毒感染者都是兩倍),但患結腸憩室炎或膽囊炎的可能性只有一半。
眾所周知,某些癌症在 HIV 感染者中更為常見——以至於它們已經是 AIDS 的定義疾病。其中包括非霍奇金淋巴瘤(常見的 12 倍)、霍奇金淋巴瘤(常見的 4.7 倍)和子宮頸癌(常見的 4.6 倍)。但值得注意的是,沒有其他癌症在 HIV 感染者中更常見。
在愛滋病毒感染者中更常見的另一組情況提醒人們患有這種疾病的心理負擔。雙相情感障礙在 HIV 感染者中的發病率是 HIV 陰性者的 2.9 倍,藥物依賴是通常的 2.45 倍,酒精依賴超過通常的 64%,抑鬱超過通常的 45%。貝爾氏麻痺(是通常的三倍)和周邊神經病變(超過通常的 79%——其中一些可能與治療副作用有關)的神經系統疾病也是如此。
研究人員提到,這項研究的一個限制可能導致合併症和 HIV 記錄不足,即許多 HIV 感染者主要從醫院 HIV 門診而不是一般全科醫生那裡獲得醫療保健——而這種情況在2015年比現在更多。
「為了確保整體照護」,他們寫道,「專科和初級保健提供者需要在英國的特定環境中密切結合,在英國,愛滋病毒照護完全由二級保健提供。
參考文獻:
Morales DR等人。與普通人群相比,愛滋病毒感染者的健康狀況:基於人群的橫斷面分析。 臨床醫學線上期刊 (eClinicalMedicine) 47:101392,2022 年 4 月(開放獲取)。
https://doi.org/10.1016/j.eclinm.2022.101392
Which health conditions are more or less common in people with HIV?
Large UK study highlights atypical pattern in people with HIV
Gus Cairns / 30 May 2022
Domizia Salusest | www.domiziasalusest.com
A cross-sectional study of patients in UK health services has compared the prevalence of a large number of different health conditions in people with HIV, versus those without HIV. Most findings confirm previous research, but the study also found a lower prevalence of many cardiovascular conditions and rheumatoid arthritis in people with HIV, while infertility, bipolar disorder and numerous infections were more common.
The study, by Dr Daniel Morales and colleagues at Dundee University, looked at anonymised patient data from the UK Clinical Research Database GOLD, which contains de-identified electronic primary care records, plus data on hospitalisation from the Hospital Episodes Statistics database.
The researchers only looked at records completed up to a specific date – 30 November 2015. The reason to choose a date nearly seven years ago was to ensure completeness and anonymity of data, but it means that conditions acquired since then and subsequent outcomes (from recovery to death) were not included.
In total 942,077 records were included, representing 1.8% of the UK population under 18. Of these, 964 had HIV. To correct for likely under-representation, the researchers also crosschecked with Office for National Statistics data up to 2021 that retrospectively mentioned HIV diagnoses made before the 30 November 2015 date. Nonetheless, the 0.1% HIV prevalence recorded is lower than the actual prevalence of HIV in over-18s in the UK (1.9%) which could mean that the prevalence of some conditions could be over- or underestimated.
The people without HIV were evenly balanced between men and women, whereas 61% of those with HIV were men. While a quarter of the HIV negative people were aged at least 65, only 7% of the people with HIV were. Though the figures below are adjusted for sex and age, the lack of older people in the HIV-positive group make the figures for age-related conditions less reliable.
The researchers grouped together 304 diagnosis codes into 47 groups of health conditions. Examples of groups range from ones that are extremely common (such as high blood lipids, recorded in about 40% of people) or mental health/neurological issues (in about 35%) to rarer ones such as central nervous system infections like meningitis (in less than 0.2% of people) and respiratory cancers such as lung cancer (in less than 0.5%).
The study found that the people with HIV were no more likely, or in some cases less likely, to have the most common groups of conditions. However it found that they were more likely to have rarer conditions. In the main these rarer conditions were infections – suggesting the influence of impaired immunity in people with HIV.
There were only two groups of conditions in the top 50% most prevalent ones, that people with HIV were more likely to have than HIV-negative people. Acquired blood abnormalities like anaemia or low white cell count were twice as likely in people with HIV as in HIV-negative people, but this is not surprising. There was also a catch-all group called ‘infections – other’, which were four times more likely in people with HIV.
On the other hand, several common conditions were less likely in people with HIV, including high blood pressure (22% less likely), asthma (35% less likely), and bone and joint disorders (44% less likely).
But several rare groups of conditions were very much more likely in people with HIV. The rarest group of conditions was fungal infections. Only 479 fungal infections were recorded in all subjects – a prevalence of 0.05% or one case in just under 2000 people. But 47 of these cases were seen in the 964 people with HIV in the study – a prevalence of 4.9%, or more than one case in 20. This means that fungal infections were 121 times more common in people with HIV than in people without it, when adjusted for age and sex.
Tuberculosis was also much more common in people with HIV: prevalence was 0.6% in all patients, but nearly 7% in people with HIV, meaning it was 13.5 times more likely. Other conditions more than five times more likely in people with HIV than in HIV negative people were immune disorders (7.4 times more likely) and gastro-intestinal infections (5.7 times more likely). Also viral infections, which as a group were 7.7 times more likely, but this was influenced by the specifically much greater prevalence of viral hepatitis (22 times more likely). Again, none of these findings were especially surprising.
In absolute numbers, some other conditions – such as high blood lipids – were much more common. The 399 cases of high blood lipids in people with HIV contrasts with the 50 viral infections, for example. But the prevalence of high lipids was not significantly higher than in people without HIV. Most other conditions related to cardiovascular disease were less common in people with HIV including atrial fibrillation (63% less likely) and coronary artery disease (48% less likely) but pulmonary embolism, (a blood clot in the lungs), was twice as common.
There were some other surprises when it came to individual conditions. For instance, rheumatoid arthritis was only a quarter as common in people with HIV as in people without it, even though autoimmune processes are involved in both. The more common form of arthritis, osteoarthritis, was also only about a third as common, and other bone/joint problems such as carpal tunnel syndrome and wrist fracture were also less common.
People with HIV were more likely to suffer from conditions influenced by low levels of sex hormones (male and female infertility and erectile dysfunction were all about twice as likely to be recorded in people with HIV), but only half as likely to suffer diverticulitis or gall bladder inflammation.
Certain cancers, as is well known, were more common in people with HIV – to the degree that they are already AIDS-defining conditions. These included non-Hodgkin’s lymphoma (12 times as common), Hodgkin’s lymphoma (4.7 times as common), and cervical cancer (4.6 times). But it was notable that no other cancers were recorded more often in people with HIV.
The other set of conditions significantly more common in people with HIV were a reminder of the psychological burden of having the disease. Bipolar disorder was 2.9 times more common in people with HIV than in HIV negative people, drug dependency 2.45 times as common, alcohol dependency 64% more common and depression 45% more common. So were the neurological conditions Bell’s palsy (three times as common) and peripheral neuropathy (79% more common – some of this may be related to treatment side effects).
One limitation of the study, which the researchers mention and which could lead to both co-morbidities and HIV being under-recorded, is that many people with HIV get their healthcare primarily from hospital HIV clinics rather than GPs – and this would have been more the case in 2015 than it is now.
“In order to assure holistic care,” they write, specialist and primary care providers need close integration in the particular context of the UK, where HIV care is exclusively delivered by secondary care.”
References
Morales DR et al. Health conditions in adults with HIV compared with the general population: a population-based cross-sectional analysis. eClinicalMedicine 47: 101392, April 2022 (open access).
https://doi.org/10.1016/j.eclinm.2022.101392