Multidimensional Social Adversity and Mortality in People With HIV Infection and Heart Failure: Insights from NYC Health + Hospitals HIV–Heart Failure Cohort

BACKGROUND: Heart failure is an increasingly common comorbidity among people with HIV infection, complicating care and heightening the vulnerability of this population to social adversity (SA). However, the impact of different SA domains on outcomes in this population remains poorly understood. METHODS: We analyzed data on people with HIV infection and heart failure from the NYC 4H (NYC Health + Hospitals HIV-Heart Failure) cohort. Baseline multidimensional SA was assessed by licensed clinical social workers using standardized evaluations and grouped into 5 domains: economic hardship, health care access barriers, neighborhood or built environment instability, social support challenge, and psychobehavioral 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 of 6-month rehospitalization risk. RESULTS: Among 1044 participants (62.9% male; mean age, 61.6 years), 601 (58%) reported at least 1 SA: economic hardship (n=130), limited health care access (n=155), unstable housing (n=129), social support challenge (n=179), or psychobehavioral 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% CI, 3.03-6.14]), cardiovascular 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 psychobehavioral instability (HR, 1.96 [95% CI, 1.24-3.11]) were associated with higher cardiovascular 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 environmental instability, psychobehavioral instability, or social support challenges had a 73% (adjusted odds ratio, 1.73 [95% CI, 1.15-2.06]), 75% (adjusted odds ratio, 1.75 [95% CI, 1.31-2.35]), and 44% (adjusted odds ratio, 1.44 [95% CI, 1.00-2.06]) higher risk of rehospitalization within 6 months, respectively. CONCLUSIONS: SA was significantly associated with mortality and rehospitalization among people with HIV infection and heart failure, with domain-specific pathways influencing specific outcomes. Multidimensional assessment of SA may offer a framework for domain-specific risk stratification in people with HIV infection and heart failure.