Injury Risk 40% to 90% Higher With HIV in Large Canadian Study

February 1, 2017

People with HIV had a 42% higher rate of accidental injury and a 93% higher rate of intentional injury than the general population in British Columbia, Canada. Injury accounted for a substantially higher proportion of deaths in the HIV group.

Injuries are responsible for 10% of worldwide morbidity and mortality. Because little is known about injury rates, risk and impact in people living with HIV, researchers at the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) conducted this province-wide injury comparison in people living with HIV and the HIV-negative general population.

The HIV-positive group consisted of British Columbians at least 20 years old and known to be positive between April 1996 and March 2013. The general-population group comprised a 10% random sample of the total British Columbian population at least 20 years old in the same period. Median follow-up measured 85 months in the HIV group and 149 months in the general population. The BC-CfE team used ICD 9 and 10 codes to identify injuries and classify them as intentional or unintentional (accidental). They used generalized estimating equation Poisson regression models to estimate the impact of HIV status on injury rates and to identify injury risk factors.

The analysis involved 13,764 adults with HIV and 417,416 HIV-negative adults in the general population. Median baseline age was 38 in the HIV group and 40 in the general population. Proportions of men were, respectively, 80.5% with HIV and 49.9% without HIV, percent employed 61% and 62%, and average income $27,919 and $29,796. The HIV group had substantially higher rates of liver disease, renal disease, mental health conditions and depression. During follow-up, injury-related death rates were 3.4% in the HIV group and 0.6% in the general population.

Crude incidence of unintentional (accidental) injury was 18.56 per 1000 person-years (p-y) in the HIV group and 8.51 per 1000 p-y in the general population. The most frequent respective unintentional injuries were falls (8.27 and 5.48 per 1000 p-y), poisoning (3.78 and 0.30) and motor vehicle accidents (2.71 and 1.08). Crude incidence of intentional injury was 10.60 per 1000 p-y in people with HIV and 0.99 per 1000 p-y in the HIV-negative group. The researchers divided intentional injuries into two types: respectively, self-harm (6.15 and 0.68 per 1000 p-y) and assault including homicide (4.45 and 0.31 per 1000 p-y) in the HIV-positive and negative groups.

Adjusted regression models linked HIV infection to a 42% higher rate of unintentional injury (incidence rate ratio [IRR] 1.42, 95% confidence interval [CI] 1.32 to 1.52) and to almost a doubled rate of intentional injury (IRR 1.93, 95% CI 1.70 to 2.18).

In people living with HIV, independent risk factors for unintentional injury were older age (IRR 1.20, 95% CI 1.11 to 1.30 per decade increase), indigenous ancestry (IRR 1.35, 95% CI 1.13 to 1.60), living on rural Vancouver Island (IRR 1.59, 95% CI 1.33 to 1.90) or in rural Northern British Columbia (IRR 1.62, 95% CI 1.23 to 2.14) versus in the urban Vancouver Coastal Health region, income (IRR 0.98, 95% CI 0.97 to 0.99 per $1000 increase), year of injury (2003-2007 IRR 0.51, 95% CI 0.44 to 0.59 and 2008-2013 IRR 0.45, 95% 0.39 to 0.52 relative to 1996-2002), liver disease (IRR 1.48, 95% CI 1.25 to 1.77), cardiovascular disease (IRR 1.66, 95% CI 1.36 to 2.03), renal disease (IRR 1.96, 95% CI 1.69 to 2.28), hepatitis B (HBV) (IRR 1.94, 95% CI 1.62 to 2.33) and mental health conditions (IRR 2.39, 95% CI 1.97 to 2.90).

In the HIV group, independent predictors of intentional injury were younger age (IRR 0.79, 95% CI 0.71 to 0.89 per decade increase), male sex (IRR 1.41, 95% CI 1.12 to 1.78), living on rural Vancouver Island (IRR 1.81, 95% CI 1.41 to 2.32) or in rural Northern British Columbia (IRR 2.79, 95% CI 2.03 to 3.83) versus in the urban Vancouver Coastal Health region, employment (IRR 0.26, 95% CI 0.09 to 0.77 per 10% increase in proportion employed), injecting drug use (IRR 1.81, 95% CI 1.33 to 2.47), year of injury (2003-2007 IRR 0.37, 95% CI 0.30 to 0.45 and 2008-2013 IRR 0.23, 95% CI 0.18 to 0.28 relative to 1996-2002), liver disease (IRR 1.52, 95% CI 1.20 to 1.92), HBV (IRR 2.35, 95% CI 1.84 to 3.00), depression (IRR 2.19, 95% CI 1.82 to 2.64) and mental health conditions (IRR 7.09, 95% CI 4.64 to 10.85).

Baseline CD4 count, baseline viral load and adherence in the first year of antiretroviral therapy were not associated with intentional or unintentional injury. Rates of both intentional and unintentional injury decreased from 1996 through 2012 in people living with HIV but never approached the lower, stable levels in the general population.

The researchers believe their findings represent "a call to action to better demonstrate which [people living with HIV] are most at risk for injury-related death and disability, and why." They underline the importance of addressing poverty, drug use and mental health in HIV populations to reduce their high injury burden. "Given that injuries are predominantly both predictable and preventable," they conclude, "the implementation of interventions that reduce the incidence of injury among [people living with HIV] is highly warranted."

Mark Mascolini writes about HIV infection.

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High Rates of Injury Found Among Some HIV-Positive People in British Columbia


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