Incidence of stroke in patients with HIV infection: A population-based study in Taiwan

Hui-Lin Lin, Chih-Hsin Muo, Cheng-Yu Lin, Hsuan-Ju Chen, Pei-Chun Chen, Hui-Lin Lin, Chih-Hsin Muo, Cheng-Yu Lin, Hsuan-Ju Chen, Pei-Chun Chen

Abstract

Background: Few studies have evaluated whether people infected with human immunodeficiency virus (HIV) are at an increased risk of stroke in an Asian population. We investigated the association between HIV infection and the risk of developing stroke by age, calendar year of HIV diagnosis, and follow-up duration in Taiwan.

Methods: Using the claims data of a universal health insurance program, we identified 5,961 patients with HIV and 23,844 matched non-HIV subjects without previous stroke from 1998 to 2005 and followed them up until the end of 2011 to measure the incidence of stroke. Cox proportional hazards models adjusted for potential confounders were used to estimate hazard ratios (HR) and 95% confidence intervals (CI), with the non-HIV group as reference.

Results: During a median follow-up of 8 years, the incidence rates for total, ischemic, and hemorrhagic stroke per 1000 person-years were 2.12, 1.22, and 0.60, respectively, in patients with HIV infection, and 1.98, 1.14, and 0.54, respectively, in the comparison group. HIV infection was associated with an elevated risk of developing total stroke (adjusted HR [95% CI], 1.57 [1.15-2.14]) and ischemic stroke (1.91 [1.25-2.91]) in patients aged less than 45 years, but no association was observed in other age groups (P for interaction with age, p = 0.048 and 0.024, respectively). Patients diagnosed with HIV infection in 1998-1999 had a greater HR for total stroke and ischemic stroke than those diagnosed in 2000-2002 and 2003-2005 (P for interaction, for total stroke p = 0.034, for ischemic stroke p = 0.056). The HRs did not differ by follow-up duration.

Conclusions: HIV infection among a young age group is associated with increased risk of developing overall and ischemic stroke. The findings highlight the importance of screening and correcting risk factors for young stroke prevention immediately and aggressively.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Flow chart of study subjects’…
Fig 1. Flow chart of study subjects’ selection.
aDeath was defined by using hospital discharged records and registry of catastrophic illness dataset. NHI indicates National Health Insurance Program; HIV, human immunodeficiency virus.
Fig 2. Risk of stroke in association…
Fig 2. Risk of stroke in association with HIV infection according to time of follow-up.

References

    1. Benjamin LA, Bryer A, Emsley HCA, Khoo S, Solomon T, Connor MD. HIV infection and stroke: current perspectives and future directions. The Lancet Neurology. 2012;11(10):878–90. 10.1016/S1474-4422(12)70205-3
    1. Freiberg MS, Chang CC, Kuller LH, Skanderson M, Lowy E, Kraemer KL, et al. HIV infection and the risk of acute myocardial infarction. JAMA Intern Med. 2013;173(8):614–22. Epub 2013/03/06. 10.1001/jamainternmed.2013.3728 .
    1. Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet (London, England). 2012;380(9859):2197–223. Epub 2012/12/19. 10.1016/s0140-6736(12)61689-4
    1. Emsley HCA, Hopkins SJ. Acute ischaemic stroke and infection: recent and emerging concepts. The Lancet Neurology. 2008;7(4):341–53. 10.1016/S1474-4422(08)70061-9
    1. Rasmussen LD, Engsig FN, Christensen H, Gerstoft J, Kronborg G, Pedersen C, et al. Risk of cerebrovascular events in persons with and without HIV: a Danish nationwide population-based cohort study. AIDS (London, England). 2011;25(13):1637–46. Epub 2011/06/08. 10.1097/QAD.0b013e3283493fb0 .
    1. Yen YF, Jen I, Chen M, Chuang PH, Liu YL, Sharp GB, et al. Association of Cytomegalovirus End-Organ Disease with Stroke in People Living with HIV/AIDS: A Nationwide Population-Based Cohort Study. PloS one. 2016;11(3):e0151684 Epub 2016/03/18. 10.1371/journal.pone.0151684 .
    1. Vinikoor MJ, Napravnik S, Floris-Moore M, Wilson S, Huang DY, Eron JJ. Incidence and clinical features of cerebrovascular disease among HIV-infected adults in the Southeastern United States. AIDS research and human retroviruses. 2013;29(7):1068–74. Epub 2013/04/10. 10.1089/AID.2012.0334 .
    1. Chow FC, Regan S, Feske S, Meigs JB, Grinspoon SK, Triant VA. Comparison of ischemic stroke incidence in HIV-infected and non-HIV-infected patients in a US health care system. Journal of acquired immune deficiency syndromes (1999). 2012;60(4):351–8. Epub 2012/05/15. 10.1097/QAI.0b013e31825c7f24 .
    1. Sico JJ, Chang CC, So-Armah K, Justice AC, Hylek E, Skanderson M, et al. HIV status and the risk of ischemic stroke among men. Neurology. 2015;84(19):1933–40. Epub 2015/04/12. 10.1212/WNL.0000000000001560 .
    1. Marcus JL, Leyden WA, Chao CR, Chow FC, Horberg MA, Hurley LB, et al. HIV infection and incidence of ischemic stroke. AIDS (London, England). 2014;28(13):1911–9. Epub 2014/06/18. 10.1097/QAD.0000000000000352 .
    1. Durand M, Sheehy O, Baril JG, LeLorier J, Tremblay CL. Risk of spontaneous intracranial hemorrhage in HIV-infected individuals: a population-based cohort study. J Stroke Cerebrovasc Dis. 2013;22(7):e34–41. Epub 2012/05/05. 10.1016/j.jstrokecerebrovasdis.2012.03.014 .
    1. Chow FC, He W, Bacchetti P, Regan S, Feske SK, Meigs JB, et al. Elevated rates of intracerebral hemorrhage in individuals from a US clinical care HIV cohort. Neurology. 2014;83(19):1705–11. Epub 2014/10/05. 10.1212/WNL.0000000000000958 .
    1. Bijker R, Choi JY, Ditangco R, Kiertiburanakul S, Lee MP, Siwamogsatham S, et al. Cardiovascular Disease and Cardiovascular Disease Risk in HIV-Positive Populations in the Asian Region. The open AIDS journal. 2017;11:52–66. Epub 2018/01/06. 10.2174/1874613601711010052 .
    1. Yen YF, Chen M, Jen I, Lan YC, Chuang PH, Liu YL, et al. Association of HIV and Opportunistic Infections With Incident Stroke: A Nationwide Population-Based Cohort Study in Taiwan. Journal of acquired immune deficiency syndromes (1999). 2017;74(2):117–25. Epub 2016/10/28. 10.1097/qai.0000000000001216 .
    1. Chow FC, Wilson MR, Wu K, Ellis RJ, Bosch RJ, Linas BP. Stroke incidence is highest in women and non-Hispanic Blacks living with HIV in the ALLRT cohort. AIDS (London, England). 2018. Epub 2018/03/17. 10.1097/qad.0000000000001799
    1. Chow FC, Regan S, Zanni MV, Looby SE, Bushnell CD, Meigs JB, et al. Elevated ischemic stroke risk among women living with HIV infection. AIDS (London, England). 2018;32(1):59–67. Epub 2017/09/20. 10.1097/qad.0000000000001650 .
    1. Ovbiagele B, Nath A. Increasing incidence of ischemic stroke in patients with HIV infection. Neurology. 2011;76(5):444–50. Epub 2011/01/21. 10.1212/WNL.0b013e31820a0cfc .
    1. Enrique Gonzalez RD, Bamshad Mike, Mummidi Srinivas, Geevarghese Reni, Catano Gabriel, Andersoni Stephanie A., Walter Elizabeth A., Stephan Kevin T., Hammer Michael F., Mangano Andrea, Sen Luisa, Clark Robert A., Ahuja Seema S., Dolan Matthew J., and Ahuja Sunil K. Global survey of genetic variation in CCR5,RANTES,and MIP-1a: Impact on the epidemiology of the HIV-1 pandemic. PNAS 2001; April 24, 2001 u vol. 98 u no. 9 u 5199.
    1. Geretti AM. HIV-1 subtypes: epidemiology and significance for HIV management. Curr Opin Infect Dis. 2006;19(1):1–7. Epub 2005/12/24. .
    1. Chow FC, Boscardin WJ, Mills C, Ko N, Carroll C, Price RW, et al. Cerebral vasoreactivity is impaired in treated, virally suppressed HIV-infected individuals. AIDS (London, England). 2016;30(1):45–55. Epub 2015/09/16. 10.1097/qad.0000000000000875 .
    1. Alvaro-Meca A, Berenguer J, Diaz A, Micheloud D, Aldamiz-Echevarria T, Fanciulli C, et al. Stroke in HIV-infected individuals with and without HCV coinfection in Spain in the combination antiretroviral therapy era. PloS one. 2017;12(6):e0179493 Epub 2017/06/16. 10.1371/journal.pone.0179493 .
    1. Chen Y-C, et al. " 862: 365–380. Taiwan’s National Health Insurance Research Database: administrative health care database as study object in bibliometrics." Scientometrics. 2011.
    1. Cheng TM. Taiwan’s new national health insurance program: genesis and experience so far. Health Aff (Millwood). 2003;22(3):61–76. Epub 2003/05/22. 10.1377/hlthaff.22.3.61 .
    1. National Health Insurance Research Database. Longitudinal Health Insurance Database for one million people insured. .
    1. Bijker R, Jiamsakul A, Uy E, Kumarasamy N, Ditango R, Chaiwarith R, et al. Cardiovascular disease-related mortality and factors associated with cardiovascular events in the TREAT Asia HIV Observational Database (TAHOD). HIV medicine. 2019;20(3):183–91. Epub 2019/01/09. 10.1111/hiv.12687 .
    1. Behrouz R, Topel CH, Seifi A, Birnbaum LA, Brey RL, Misra V, et al. Risk of intracerebral hemorrhage in HIV/AIDS: a systematic review and meta-analysis. Journal of neurovirology. 2016;22(5):634–40. Epub 2016/04/05. 10.1007/s13365-016-0439-2 .
    1. Singer EJ, Valdes-Sueiras M, Commins DL, Yong W, Carlson M. HIV stroke risk: evidence and implications. Ther Adv Chronic Dis. 2013;4(2):61–70. Epub 2013/04/05. 10.1177/2040622312471840 .
    1. Ake JA, Erickson JC, Lowry KJ. Cerebral aneurysmal arteriopathy associated with HIV infection in an adult. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2006;43(5):e46–50. Epub 2006/08/04. 10.1086/506566 .
    1. Chetty R. Vasculitides associated with HIV infection. J Clin Pathol. 2001;54(4):275–8. Epub 2001/04/18. 10.1136/jcp.54.4.275 .
    1. Park YD, Belman AL, Kim TS, Kure K, Llena JF, Lantos G, et al. Stroke in pediatric acquired immunodeficiency syndrome. Ann Neurol. 1990;28(3):303–11. Epub 1990/09/01. 10.1002/ana.410280302 .
    1. Roquer J, Palomeras E, Knobel H, Pou A. Intracerebral haemorrhage in AIDS. Cerebrovasc Dis. 1998;8(4):222–7. Epub 1998/07/31. 10.1159/000015855 .
    1. Berlit P, Popescu O, Weng Y, Malessa R. Disseminated cerebral hemorrhages as unusual manifestation of toxoplasmic encephalitis in AIDS. J Neurol Sci. 1996;143(1–2):187–9. Epub 1996/11/01. .
    1. Tipping B, de Villiers L, Wainwright H, Candy S, Bryer A. Stroke in patients with human immunodeficiency virus infection. Journal of neurology, neurosurgery, and psychiatry. 2007;78(12):1320–4. Epub 2007/05/02. 10.1136/jnnp.2007.116103 .
    1. Arentzen M, Jubt F, Evers S, Hesselmann V, Fiori W, Reichelt D, et al. Cerebrovascular events in HIV-infected patients: an analysis of a cohort of 3203 HIV+ patients during the times of cART. Int J Neurosci. 2015;125(8):601–11. Epub 2014/08/27. 10.3109/00207454.2014.956870 .
    1. Heikinheimo T, Chimbayo D, Kumwenda JJ, Kampondeni S, Allain TJ. Stroke outcomes in Malawi, a country with high prevalence of HIV: a prospective follow-up study. PloS one. 2012;7(3):e33765 Epub 2012/04/06. 10.1371/journal.pone.0033765 .
    1. Correia M, Magalhaes R, Silva MR, Matos I, Silva MC. Stroke types in rural and urban northern portugal: incidence and 7-year survival in a community-based study. Cerebrovascular diseases extra. 2013;3(1):137–49. Epub 2013/12/19. 10.1159/000354851 .
    1. Putaala J, Metso AJ, Metso TM, Konkola N, Kraemer Y, Haapaniemi E, et al. Analysis of 1008 consecutive patients aged 15 to 49 with first-ever ischemic stroke: the Helsinki young stroke registry. Stroke. 2009;40(4):1195–203. Epub 2009/02/28. 10.1161/STROKEAHA.108.529883 .
    1. Libman RB, Wirkowski E, Alvir J, Rao TH. Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Archives of neurology. 1995;52(11):1119–22. Epub 1995/11/01. .
    1. Hatzitolios A, Savopoulos C, Ntaios G, Papadidaskalou F, Dimitrakoudi E, Kosmidou M, et al. Stroke and conditions that mimic it: a protocol secures a safe early recognition. Hippokratia. 2008;12(2):98–102. Epub 2008/10/17. .
    1. Forster A, Griebe M, Wolf ME, Szabo K, Hennerici MG, Kern R. How to identify stroke mimics in patients eligible for intravenous thrombolysis? Journal of neurology. 2012;259(7):1347–53. Epub 2012/01/11. 10.1007/s00415-011-6354-9 .
    1. Philip-Ephraim EE, Charidimou A, Williams E, Kajogbola G. Stroke-Like Presentation of Cerebral Toxoplasmosis: Two HIV-Infected Cases. Cerebrovascular diseases extra. 2015;5(1):28–30. Epub 2015/05/12. 10.1159/000375180 .

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