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Open Forum Infect Dis. 2019 May 16;6(6):ofz188. doi: 10.1093/ofid/ofz188. eCollection 2019 Jun.

Association of Syndemic Unhealthy Alcohol Use, Cigarette Use, and Depression With All-Cause Mortality Among Adults Living With and Without HIV Infection: Veterans Aging Cohort Study.

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Vanderbilt University Medical Center, Nashville, Tennessee.
Geriatric Research Education and Clinical Centers (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee.
VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
Weill-Cornell Medical College, Doha, Qatar, and New York City, New York.
Hamad Medical Corporation, Doha, Qatar.
Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey.
Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, Florida.
Department of Population Health, New York University School of Medicine, New York, New York.
Yale University Schools of Medicine and Public Health, New Haven, Connecticut.
National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland.
Center for Interdisciplinary Research on AIDS, Yale University, New Haven, Connecticut.
Departments of Medicine and Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, Kentucky.
Department of Medicine, University of Washington, Seattle, Washington.
Veterans Affairs North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas, Texas.
Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California.



The prevalence and risk of concurrent unhealthy drinking, cigarette use, and depression on mortality among persons living with HIV (PLWH) is unclear. This study applied a syndemic framework to assess whether these co-occurring conditions increase mortality and whether such risk is differential by HIV status.


We evaluated 6721 participants (49.8% PLWH) without baseline cancer from the Veterans Aging Cohort Study, a prospective, observational cohort of PLWH and matched uninfected veterans enrolled in 2002 and followed through 2015. Multivariable Cox proportional hazards regressions estimated risk of a syndemic score (number of conditions: that is, unhealthy drinking, cigarette use, and depressive symptoms) on all-cause mortality by HIV status, adjusting for demographic, health status, and HIV-related factors.


Fewer than 10% of participants had no conditions; 25.6% had 1, 51.0% had 2, and 15.0% had all 3. There were 1747 deaths (61.9% PLWH) during the median follow-up (11.4 years). Overall, age-adjusted mortality rates/1000 person-years increased with a greater number of conditions: (0: 12.0; 1: 21.2; 2: 30.4; 3: 36.3). For 3 conditions, the adjusted hazard ratio of mortality was 36% higher among PLWH compared with uninfected participants with 3 conditions (95% confidence interval, 1.07-1.72; P = .013), after adjusting for health status and HIV disease progression. Among PLWH and uninfected participants, mortality risk persisted after adjustment for time-updated health status.


Syndemic unhealthy drinking, cigarette use, and depression are common and are associated with higher mortality risk among PLWH, underscoring the need to screen for and treat these conditions.


HIV; alcohol; depression; mortality; smoking

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