Divergent trajectories and risk profiles of multimorbidity among people living with HIV in China
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Background: With increased longevity among people living with HIV (PLWH), multimorbidity has emerged as a critical challenge, occurring at younger ages and involving both non-communicable diseases and persistent infections. Yet its long-term evolution and risk factors remain insufficiently described. Methods: We conducted a retrospective cohort study of 5,950 PLWH initiating antiretroviral therapy (ART) in Shenzhen, China, between 2009 and 2016, with follow-up through 2024. Multimorbidity was defined as ≥2 predefined 26 conditions and categorized into six evolving patterns. Longitudinal changes were assessed using Sankey plots and multivariable regression models. Results: At ART initiation, 25.9% had multimorbidity. Over 8 years, the overall prevalence rose to 42.5%, driven mainly by a threefold increase in incurable multimorbidity (7.7% to 25.5%). Nearly 36% of initially disease-free individuals developed multimorbidity during follow-up. Younger PLWH experienced the faster decline in comorbidity-free status over time, while older individuals more frequently progressed to multimorbidity. Dyslipidemia was the most frequent and persistent condition. Risk factors for metabolic multimorbidity included age at diagnosis ≥ 46 years (HR = 3.44, P < 0.01), body mass index (BMI) ≥ 24 (HR=1.69, P < 0.01), etc. In contrast, higher BMI appeared protective against mixed infectious–non-infectious patterns (HR = 0.72, P < 0.01). Conclusions: Multimorbidity is increasingly prevalent among PLWH in the ART era, with a shift from infectious to metabolic and behavioral comorbidities. Distinct risk profiles highlight the need for early identification and tailored interventions, especially among high-risk subgroups. Early identification and tailored management of key risk factors, particularly dyslipidemia, are essential for integrated HIV care.