Multimorbidity and mortality in an older, rural Black South African population cohort with high prevalence of HIV-findings from the HAALSI study

Alisha N Wade, Collin F Payne, Lisa F Berkman, Angela Y Chang, F Xavier Gómez-Olivé, Chodziwadziwa W Kabudula, Kathleen Kahn, Joshua A Salomon, Stephen M Tollman, Miles D Witham, Justine Davies

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Abstract

Objectives Multimorbidity is associated with mortality in high-income countries. Our objective was to investigate the relationship between multimorbidity (≥2 of the following chronic medical conditions: hypertension, diabetes, dyslipidaemia, anaemia, HIV, angina, depression, post-traumatic stress disorder, alcohol dependence) and all-cause mortality in an older, rural black South African population. We further investigated the relationship between HIV multimorbidity (HIV as part of the multimorbidity cluster) and mortality, while testing for the effect of frailty in all models. Design Population cohort study. Setting Agincourt subdistrict of Mpumalanga province, South Africa. Participants 4455 individuals (54.7% female), aged ≥40 years (median age 61 years, IQR 52-71) and resident in the study area. Primary and secondary outcome measures The primary outcome measure was time to death and the secondary outcome measure was likelihood of death within 2 years of the initial study visit. Mortality was determined during annual population surveillance updates. Results 3157 individuals (70.9%) had multimorbidity; 29% of these had HIV. In models adjusted for age and sociodemographic factors, multimorbidity was associated with greater risk of death (women: HR 1.72; 95% CI: 1.18 to 2.50; men: HR 1.46; 95% CI: 1.09 to 1.95) and greater odds of dying within 2 years (women: OR 2.34; 95% CI: 1.32 to 4.16; men: OR 1.51; 95% CI: 1.02 to 2.24). HIV multimorbidity was associated with increased risk of death compared with non-HIV multimorbidity in men (HR 1.93; 95% CI: 1.05 to 3.54), but was not statistically significant in women (HR 1.85; 95% CI: 0.85 to 4.04); when detectable, HIV viral loads were higher in men (p=0.021). Further adjustment for frailty slightly attenuated the associations between multimorbidity and mortality risk (women: HR 1.55; 95% CI: 1.06 to 2.26; men: HR 1.36; 95% CI: 1.01 to 1.82), but slightly increased associations between HIV multimorbidity and mortality risk. Conclusions Multimorbidity is associated with mortality in this older black South African population. Health systems which currently focus on HIV should be reorganised to optimise identification and management of other prevalent chronic diseases.

Original languageEnglish
Article numbere047777
Number of pages9
JournalBMJ
Volume11
Issue number9
DOIs
Publication statusPublished - 15 Sept 2021

Bibliographical note

Funding Information:
Acknowledgements We would like to acknowledge the residents of the Agincourt subdistrict and Health and socio-Demographic Surveillance System who participated in this study. MW acknowledges support from the NIHR Newcastle Biomedical Research Centre.

Funding Information:
We would like to acknowledge the residents of the Agincourt subdistrict and Health and socio-Demographic Surveillance System who participated in this study. MW acknowledges support from the NIHR Newcastle Biomedical Research Centre.

Funding Information:
Funding This work was supported by the National Institute on Ageing at the National Institutes of Health (grant number 1P01AG041710-01A1); the Department of Science and Innovation, South Africa (no grant number); the University of the Witwatersrand (no grant number); and the Medical Research Council (MRC), South Africa (no grant number); and previously the Wellcome Trust, UK (grant numbers 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z) to the MRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt Health and socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN); the Fogarty International Centre of the National Institutes of Health (grant number K43TW010698) to ANW; the Australian Research Council Discovery Early Career Award (DE210100087) and the Australian National University Futures Scheme (no grant number) to CFP. Competing interests None declared. Patient consent for publication Not required.

Publisher Copyright:
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

Keywords

  • multimorbidity
  • South Africa
  • population health
  • chronic disease
  • mortality

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