Multi-dimensional Social Adversity and Mortality Outcome in People Living With HIV and Heart Failure: Insights from NYC Health + Hospitals HIV-Heart Failure cohort

BackgroundHeart failure (HF) is an increasingly common comorbidity among people living with HIV (PLHIV), complicating care and heightening vulnerability of this population to social adversity (SA). However, the impact of different SA domains on outcomes in this population remains poorly understood. MethodsWe analyzed data on PLHIV with HF from the NYC Health + Hospitals HIV-Heart Failure cohort. Baseline multidimensional SA was assessed by licensed clinical social workers using standardized evaluations and grouped into five domains: (1) economic hardship, (2) healthcare access barriers, (3) neighborhood/built environment instability, (4) social support challenge, and (5) Psycho-behavioral instability. We used multivariable adjusted Cox models to estimate hazard ratios (HRs) of all-cause, cardiovascular, and infection-related mortality; and logistic regression to estimate odds ratios (ORs) of 6-month rehospitalization risk. ResultsAmong participants 1044 (62.9% males, mean age: 61.6 years), 601 (58%) reported at least 1social adversities: economic hardship (n=130), limited healthcare access (n=155), unstable housing (n=129), social support challenge (n=179), or psycho-behavioral instability (n=438). Over a mean follow up of 3.8 years, exposure to any SA was associated with higher all-cause mortality (HR 4.32; 95% confidence interval [CI] 3.03-6.14), CV mortality (HR 4.05; 95% CI 2.17-6.83), and infection-related mortality (HR 2.37; 95% CI 1.23-4.56). Social support challenge (HR 2.19; 95% CI 1.35-3.55) and psycho-behavioral instability (HR 1.96; 95% CI 1.24-3.11) were associated with higher CV mortality; economic hardship (HR 2.40; 95% CI 1.22-4.70) and social support challenge (HR 3.09; 95% CI 1.75-5.48) were associated with higher infection-related mortality. Compared with patients without SA, those with an environment instability, psycho-behavioral instability, or social support challenges had a 73% (aOR 1.73; 95% CI, 1.15-2.06), 75% (aOR 1.75; 95% CI, 1.31-2.35), and 44% (aOR 1.44; 95% CI, 1.00-2.06) higher risk of rehospitalization within 6 months, respectively. ConclusionSA was significantly associated with mortality and rehospitalization among PLHIV with HF, with domain-specific pathways influencing specific outcomes. A multidimensional assessment of social vulnerability may be useful to risk-stratify HF mortality risk in PLHIV.