Defining multimorbidity in people with HIV – what matters most? : Current Opinion in HIV and AIDS

Secondary Logo

Journal Logo

CO-MORBIDITIES: Edited by Patrick W. G. Mallon

Defining multimorbidity in people with HIV – what matters most?

Sukumaran, Luxsenaa,b; Sabin, Caroline A.a,b

Author Information
Current Opinion in HIV and AIDS 18(2):p 59-67, March 2023. | DOI: 10.1097/COH.0000000000000778



Multimorbidity is commonly defined as the coexistence of two or more chronic conditions in an individual [1]. The widespread use of, and advances in, antiretroviral therapy (ART) have markedly improved the life expectancy of people with HIV [2,3]. Consequently, this group is developing comorbidities associated with aging, such as cardiovascular disease, osteoporosis and chronic kidney disease, more frequently and/or at an earlier age than people without HIV [4–6]. By 2030, 84% and 28% of Europeans living with HIV are predicted to have ≥1 and ≥3 comorbidities, respectively [7]. This increased burden adds complexity to HIV clinical care and management, requiring multidisciplinary healthcare expertise. Additionally, the provision of multiple medications (including ART) may compound comorbidity risk and/or cause drug-drug interactions that could lead to clinically suboptimal treatment of HIV and other comorbidities. Whilst several guidelines for the management of comorbidities exist for people with HIV, the complexities of managing people with multiple morbidities may not be fully reflected. Consequently, negative outcomes of multimorbidity, including lower health-related quality of life, higher healthcare utilization and costs, polypharmacy-associated toxicity and mortality, may be exacerbated among people with HIV [8–11].

Given these potential detrimental effects, understanding the prevalence, trends and magnitude of multimorbidity among people with HIV is crucial. However, no clear consensus exists on how to define multimorbidity in this population. Previous reviews have examined the variation in the definition of multimorbidity among non-HIV populations [12,13,14▪], with recognition that differences in this have resulted in heterogeneous estimates of multimorbidity prevalence and burden. These differences include the number and type of conditions considered and the sources of morbidity data. The comorbidity profile used to define multimorbidity in people with HIV may, however, be more complex than that of non-HIV populations, including a wider (and potentially different) range of comorbidities, that may be of low prevalence in general populations and which may have occurred as a result of HIV infection itself or its treatment [15,16]. Therefore, applying a definition of multimorbidity that was derived in the general population may result in an under-estimate of the true burden of multimorbidity experienced by people living with HIV.

Here, we present a narrative review of the literature on multimorbidity among people with HIV, with a particular focus on how multimorbidity is defined. By providing a comprehensive synthesis of current evidence we aim to identify common themes/gaps, highlight research priorities, and discuss implications for clinical practice. 

Box 1:
no caption available


We systematically searched the following electronic library databases in September 2022: MEDLINE (Ovid), Web of Science (Clarivate Analytics), and Scopus (Elsevier). Our aim was to identify original research papers that measured multimorbidity in people with HIV. The search was restricted to full-text English-language publications in peer-reviewed journals. Relevant articles were identified using search terms (variations of multimorbidity, measure and HIV, Table S1, Supplemental Digital Content, that were applied to titles in all databases, and we restricted searches to studies in adults aged ≥18 years. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Table S2, Supplemental Digital Content,

We selected studies that explicitly state the definition and measurement used to examine multimorbidity in populations of people with HIV, and therefore not all study designs were eligible for inclusion. We also restricted this review to studies that stated the conditions included in their definition of multimorbidity to identify the trends and implications of conditions considered in multimorbidity research among people with HIV.

Our initial database search identified 117 articles, which was reduced to 59 after removing duplicates. After abstract review, 25 articles were selected for full text review, of which 22 were included (Figure 1, Supplemental Digital Content,


Study characteristics

A majority of studies (63.6%) were published in the last 4 years (Table S3, Supplemental Digital Content, The number of people with HIV included varied from 189 to 38 868 (median 1080, interquartile range [IQR] 651–5368). Most studies were conducted in North America (9 [40.9%]), followed by Europe (7 [31.8%]). Multimorbidity was most commonly examined in community-based settings (12 [54.5%]) (Table 1). Most studies (18 [81.8%]) focused on all adults (those aged ≥18 years), whereas a smaller proportion included middle-aged/older adults (≥45 years) (3 [13.6%]) or older adults (aged ≥65 years) (1 [4.5%]) only. Morbidity data was predominately sourced from electronic health records (17 [77.3%]). Over half of studies (16 [72.7%]) defined multimorbidity as the presence of ≥2 conditions, with other studies defining multimorbidity as the presence of ≥1 condition (2 [9.1%]), or ≥3 conditions (1 [4.5%]); three studies (13.6%) did not state a reference definition. The most common purpose for measuring multimorbidity was to examine potential risk factors (13 [59.1%]), followed by identification of multimorbidity patterns/clusters (6 [27.3%]). Fourteen studies (63.6%) used a simple count of conditions to measure multimorbidity, one study (4.5%) used weighted indices (Cumulative Illness Rating Scale), and two (9.1%) used both types of measures together. Other measures included those derived using statistical approaches (6 [27.3%]) such as cluster, factor or principal component analysis.

Table 1 - Summary of study characteristics
Study characteristic No. of studies (n = 22) %
Study setting
 Community 12 54.5
 Secondary/tertiary care 7 31.8
 Hospital 3 13.6
Data source
 Electronic health records 17 77.3
 Self-reported 3 13.6
 Self-reported/health records 1 4.5
 Administrative data 1 4.5
Study population
 All adults (aged ≥18 years) 18 81.8
 Middle-aged and older adults (aged ≥45 years) 3 13.6
 Older adults (≥65 years) 1 4.5
Study purpose
 Association of risk factors with multimorbidity 13 59.1
 Patterns or clusters of MM 6 27.3
 Prevalence or burden of multimorbidity (without examining associations with risk factors or outcomes) 2 9.1
 Association of multimorbidity with outcome 1 4.5
Definition for multimorbidity
 ≥1 2 9.1
 ≥2 16 72.7
 ≥3 1 4.5
 Not stated 3 13.6
Type of multimorbidity measure
 Simple count 14 63.6
 Weighted index 1 4.5
 Simple count & weighted index 1 4.5
 Statistical approach 6 27.3
Number of conditions included in measure
 1–10 12 54.5
 11–20 6 27.3
 21–30 3 13.6
 31–40 0 0.0
 41–50 0 0.0
 >50 1 4.5
How were conditions considered
 Individual 7 31.8
 Grouped & individual 15 68.2
Condition selection criteria stated
 Yes 10 45.5
 No 12 54.5

The number of conditions selected

The number of conditions considered in each definition of multimorbidity has varied across studies among people with HIV, ranging from 4 to 65 (median 10, IQR 7–15) (Table S3, Supplemental Digital Content, Over half of studies reviewed included <10 conditions, while other studies included 11–20 (n = 6 [27.3%]) and 21–30 conditions (n = 3 [13.6%]); only one study included >30 conditions (65 comorbidities were included in the analysis) (Table 1) [17]. Heterogeneity in the number of conditions included is likely to influence prevalence estimates of multimorbidity. Furthermore, while general population studies often refer to a review from Fortin et al.[18] when selecting the number of conditions (this review recommends authors to select >12 conditions), none of the studies among people with HIV provided a justification for why the specific number of conditions was chosen.

Selection criteria for conditions

Less than half of the reviewed studies provided selection criteria for conditions included in their multimorbidity definition. Among studies that stated selection criteria (n = 10), five reported one criterion, four reported two and one reported four criteria (Table 2). These selection criteria are discussed below.

Table 2 - Selection criteria used by reviewed studies (n = 10)
Author No. of selection criteria Selection criteria category Selection criteria
Wong et al. 2018 4 Prevention, prevalence, clinical significance & review of studies • Amenable to primary and secondary prevention
• Higher occurrence among people with HIV
• Contribute to causes of death among people with HIV
• Inclusion in other multimorbidity studies among people with HIV
Guaraldi et al. 2018 1 Guidelines • Based on European AIDS Clinical Society (EACS) guidelines (2018)
Arant et al. 2021 2 Prevalence & review of studies • Higher occurrence among people with HIV
• Inclusion in other multimorbidity studies (Scouten et al. 2014 & Kim et al. 2021)
Castilho et al. 2019 1 Clinical significance • Clinical significance (in terms of morbidity and mortality)
Edmiston et al. 2015 2 Prevalence & guidelines • Higher occurrence among people with HIV (Deeks et al. 2009 & EACS Guidelines 2013)
Kim et al. 2012 2 Clinical significance & review of studies • Review of multimorbidity literature
• Relevance and clinical significance to people with HIV (determined by three of the authors)
Mefford et al. 2022 2 Clinical significance & guidelines • Recommendations by the US Department of Health and Human Services Strategic Framework on Multiple Chronic Conditions and previous work conducted by the Cardiovascular Research Network (CVRN).
• Relevant to placing persons at increased risk for hospitalisation
Yang et al. 2021 1 Review of studies • Review of existing comorbidity literature in both the general and HIV-infected populations (Althoff et al. 2015; Kim et al. 2012; van den Bussche et al. 2011)
Ahmed et al. 2022 1 Prevalence • ’Top 30 co-occurring conditions” in the study population
De Francesco et al. 2018 1 Prevalence • Conditions with a prevalence ≥1.5% in the study population

Review of multimorbidity literature

Although four of the reviewed studies selected conditions that were included in previous multimorbidity studies, these reference studies often had distinct, noncomparable, study characteristics (e.g. were conducted among on Veterans living with HIV [4], injection drug users [19], or those with elevated body mass index [BMI]) [20]. One study, referenced by the other three, focused on a US-based population (aged ≥19 years) and considered 15 conditions [20], selected based on previous literature in both the general and HIV-populations. Another reference study was conducted within an older (65 years) German population without HIV [21], but was used by a US-based study measuring multimorbidity in people with HIV (aged ≥18 years) [22]. This German study selected the most frequent conditions among attendees at general practitioner (GP) surgeries, restricting their analysis to conditions with a prevalence >1% in those aged >65 years, which included chronic liver disease and dementia. However this list may not accurately capture conditions more commonly seen in younger populations or in those from different geographical regions or healthcare settings. Additionally, selection of conditions based on those observed in GP attendees may not necessarily reflect the conditions with the greatest burden (in terms of healthcare utilization or health outcomes) to an individual or healthcare system. Another US study [23] based their selection on what had been included in a Dutch study [16]. Although both studies considered a similar age group (aged ≥45 years), the reference study based their condition list on the availability of data (clinical/laboratory) rather than on the clinical significance of conditions among people with HIV.

Guidelines/recommendations from health organizations

Three studies [24–26] selected their conditions based on guidelines from either the European AIDS Clinical Society (EACS) [27] or the US Department of Health and Human Services (DHHS) [28]. Selection of conditions based on the EACS guidelines suggests that authors have considered relevant conditions for people with HIV. In contrast, the DHHS guidelines offer generalized recommendations for the American population, and thus the comorbidities included may not necessarily reflect those that are most burdensome among people with HIV.

Prevalent conditions among people with HIV

Five studies selected conditions based on their prevalence among people with HIV. Two of these stated that they included the ‘top 30 chronic conditions’ and conditions with a prevalence ≥1.5%, but no reasoning was provided for these specific thresholds [17,29]. A 2015 Australian study selected common conditions among people with HIV, referencing EACS guidelines and a review published in 2009 [30]. However, the latter may have provided an outdated representation of relevant conditions among people with HIV at the time of the later study. Additionally, two US studies [23,31] referred to a publication from the AGEhIV Cohort Study in the Netherlands. However, there are likely to be country-level differences in terms of prevalent conditions among people with HIV which may have not been considered.

Relevance and clinical significance

Four studies included conditions based on their clinical significance. Specifically, two studies included conditions associated with mortality, one of which used mortality trends from the Data collection on Adverse events of anti-HIV Drugs (D:A:D) study (212 clinics across Europe, USA and Australia) [31], whereas the other did not provide references to support this selection criterion [32]. Similarly, authors from another study stated that their final list of conditions was chosen based on relevance and clinical significance to people with HIV [20]. How this was determined was not described by authors but could potentially be driven by conditions associated with obesity (a central focus of their analysis). Furthermore, a study that examined the association of multimorbidity in people with HIV with incident heart failure selected conditions associated with increased risk for hospitalization among adults with heart failure. However, authors did not consider conditions associated with this outcome among people with HIV generally [25]. It is important that conditions are selected based on clinical significance, but authors should consider conditions that contribute to a broader physical and psychosocial burden (e.g. everyday functioning, quality of life and treatment burden) rather than solely focusing on severe outcomes (e.g. mortality or hospitalization). A holistic approach that considers these conditions will provide a more accurate representation of multimorbidity among this population with which to better inform future care pathways.

Conditions included in multimorbidity studies among people with HIV

All studies measuring multimorbidity in people with HIV included a cardiovascular and metabolic condition (Figure 2, Supplemental Digital Content, Over half of the studies also included at least one urogenital, digestive, respiratory, musculoskeletal, and malignancy condition in their list. In contrast, only a small proportion of studies included chronic infections, ophthalmological, ear/nose/throat, and skin disorders. Oral and congenital conditions were not included in any of the reviewed studies. Among cardiovascular/metabolic conditions, diabetes was included by all studies (Fig. 1); hypertension, chronic kidney disease, stroke, chronic obstructive pulmonary disease, dyslipidaemia, and myocardial infarction were also commonly included across studies. In contrast, sexually transmitted diseases (chlamydia, gonorrhoea and human papillomavirus), AIDS-related events (Pneumocystis pneumonia, Kaposi's sarcoma and cytomegalovirus) and neurological disorders (migraines/headaches, epilepsy and encephalitis) were included in <5% of studies.

Conditions included in reviewed studies, categorized into commonly (≥60%), sometimes (10–60%) and rarely reported (<10%).

Inclusion of mental health conditions

Many studies (55%) only included physical comorbidities, while less than half included both physical and mental health comorbidities. Mental health conditions, including depression and anxiety, are more prevalent among people with HIV compared to those without HIV [33–35]. Factors contributing to an increase in psychological morbidity among those living with HIV include negative experiences and/or stigma around disclosure of HIV status and traumatic losses during the HIV epidemic [36]. Despite this, several studies continue to exclude mental health conditions when examining multimorbidity in this population. Moreover, among those that do incorporate mental health conditions, most only include depression (36%), whereas other mental health conditions such as sleeping problems, panic attacks and anxiety were included in less than 10% of studies. These conditions may also be important in terms of their individual (and synergistic) impact on everyday functioning and quality of life.

Defining beyond conditions and risk factors

The majority of reviewed studies often selected chronic conditions and/or risk factors (defined as ‘conditions or measurements associated with the probability of disease or death’ [37]) when defining multimorbidity. However, this may not necessarily capture the priorities of people with HIV with multimorbidity. Inclusion of symptoms (defined as ‘any expression of disturbed function or structure of the body and mind by patient’ [38]) may provide a deeper understanding of multimorbidity from the perspectives of people living with HIV. Although we recognize that symptoms are not necessarily an indication of an underlying disease [37], they may be sequelae of an undiagnosed and untreated condition. Additionally, people with HIV are likely to experience a higher number of symptoms compared to the general population due to contributions from prolonged ART exposure and HIV-mediated persistent inflammation, and therefore their inclusion may be relevant when defining multimorbidity among this specific population. This is of particular relevance as people with HIV have reported that the presence of symptoms may reduce an individual's ability to carry out routine day-to-day tasks and health-related quality of life [39,40▪▪,41]. Such symptoms include cognitive (e.g., memory problems and sleep disturbance) and physical (e.g. joint pain/neuropathy and gastrointestinal issues) complaints. Despite this, only a small proportion of reviewed studies (36%) included at least one of the following symptoms: angina (23%), back pain (9%), constipation (5%) and diarrhoea (5%).

Inclusion of conditions relevant to younger populations

Although people with HIV are more likely to develop age-associated comorbidities, multimorbidity is increasingly reported in younger adults [42,43]. Reviewed studies that included adults aged ≥18 years, however, often included conditions in previous studies conducted among middle-aged (≥45 years) and/or older (≥65 years) populations. These conditions, which are typically prevalent in older populations, included chronic liver and kidney disease, stroke and myocardial infarction. Therefore, conditions that may contribute to multimorbidity among younger populations, including sexually transmitted diseases and mental health conditions, may have been missed in their definition.


In this review, we have highlighted that definitions of multimorbidity vary significantly among studies of people with HIV. Drawbacks of many of the definitions used include the small number of conditions that are considered despite the far wider range of comorbidities generally seen in those with HIV. Conditions are often selected for inclusion based on lists used in previous studies with distinct population characteristics including people without HIV. Thus, conditions of particular relevance to people with HIV, including symptoms and mental health problems, continue to be overshadowed by conditions that are highly prevalent in different populations or that demonstrate a strong association with mortality and/or hospitalisation. We recognize that the definition will be subjective, depending on the research question, and may need to be pragmatic. However it is important that researchers are explicit about the selection criteria used. Based on our findings we also propose recommendations (Fig. 2) that we believe will capture and address the complexities of defining multimorbidity specifically among people with HIV.

Four key recommendations for researchers when defining multimorbidity among people with HIV.


We acknowledge members of the NIHR HPRU Steering Committee: Professor Caroline Sabin (HPRU Director), Dr John Saunders (UKHSA Lead), Professor Catherine Mercer, Dr Hamish Mohammed, Professor Greta Rait, Dr Ruth Simmons, Professor William Rosenberg, Dr Tamyo Mbisa, Professor Rosalind Raine, Dr Sema Mandal, Dr Rosamund Yu, Dr Samreen Ijaz, Dr Fabiana Lorencatto, Dr Rachel Hunter, Dr Kirsty Foster and Dr Mamoona Tahir. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the UKHSA.

Financial support and sponsorship

LS was funded through the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU, Grant no: NIHR200911) in Blood Borne and Sexually Transmitted Infections at University College London in partnership with the UK Health Security Agency (UKHSA). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the UKHSA.

Conflicts of interest

C.S. has received funding from Gilead Sciences and ViiV Healthcare for membership of Advisory Boards and for preparation of educational materials. L.S. reports no conflicts of interest.


Papers of particular interest, published within the annual period of review, have been highlighted as:

▪ of special interest

▪▪ of outstanding interest


1. van den Akker M, Buntinx F, Knottnerus JA. Comorbidity or multimorbidity. Eur J Gen Pract 1996; 2:65–70.
2. May MT, Gompels M, Delpech V, et al. Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS 2014; 28:1193–1202.
3. Palella FJ, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N Engl J Med 1998; 338:853–860.
4. Althoff KN, McGinnis KA, Wyatt CM, et al. Comparison of risk and age at diagnosis of myocardial infarction, end-stage renal disease, and non-AIDS-defining cancer in HIV-infected versus uninfected adults. Clin Infect Dis 2015; 60:627–638.
5. d’Arminio Monforte A, Diaz-Cuervo H, De Luca A, et al. Evolution of major non-HIV-related comorbidities in HIV-infected patients in the Italian Cohort of Individuals, Naïve for Antiretrovirals (ICONA) Foundation Study cohort in the period 2004–2014. HIV Med 2019; 20:99–109.
6. Guaraldi G, Orlando G, Zona S, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis 2011; 53:1120–1126.
7. Smit M, Brinkman K, Geerlings S, et al. Future challenges for clinical care of an ageing population infected with HIV: a modelling study. Lancet Infect Dis 2015; 15:810–818.
8. Gebo KA. Epidemiology of HIV and response to antiretroviral therapy in the middle aged and elderly. Aging health 2008; 4:615–627.
9. Nachega JB, Hsu AJ, Uthman OA, et al. Antiretroviral therapy adherence and drug-drug interactions in the aging HIV population. AIDS 2012; 26: (Suppl 1): S39–53.
10. Van Duin MJ, Conde R, Wijnen B, et al. The impact of comorbidities on costs, utilities and health-related quality of life among HIV patients in a clinical setting in Bogotá. Expert Rev Pharmacoecon Outcomes Res 2017; 17:303–310.
11. Rodriguez-Penney AT, Ludicello JE, Riggs PK, et al. Co-morbidities in persons infected with HIV: increased burden with older age and negative effects on health-related quality of life. AIDS Patient Care STDS 2013; 27:5–16.
12. Prados-Torres A, Calderón-Larrañaga A, Hancco-Saavedra J, et al. Multimorbidity patterns: a systematic review. J Clin Epidemiol 2014; 67:254–266.
13. Johnston MC, Crilly M, Black C, et al. Defining and measuring multimorbidity: a systematic review of systematic reviews. Eur J Public Health 2019; 29:182–189.
14▪. Ho IS-S, Azcoaga-Lorenzo A, Akbari A, et al. Examining variation in the measurement of multimorbidity in research: a systematic review of 566 studies. Lancet Public Health 2021; 6:e587–e597.
15. Guaraldi G, Zona S, Menozzi M, et al. Late presentation increases risk and costs of noninfectious comorbidities in people with HIV: an Italian cost impact study. AIDS Res Ther 2017; 14:8.
16. Schouten J, Wit FW, Stolte IG, et al. Cross-sectional comparison of the prevalence of age-associated comorbidities and their risk factors between HIV-infected and uninfected individuals: the AGEhIV cohort study. Clin Infect Dis 2014; 59:1787–1797.
17. De Francesco D, Verboeket SO, Underwood J, et al. Patterns of co-occurring comorbidities in people living with HIV. Open Forum Infect Dis 2018; 5:ofy272.
18. Fortin M, Stewart M, Poitras ME, et al. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Ann Fam Med 2012; 10:142–151.
19. Salter ML, Lau B, Go VF, et al. HIV Infection, immune Suppression, and uncontrolled viremia are associated with increased multimorbidity among aging injection drug users. Clin Infect Dis 2011; 53:1256–1264.
20. Kim DJ, Westfall AO, Chamot E, et al. Multimorbidity patterns in HIV-infected patients: the role of obesity in chronic disease clustering. J Acquir Immune Defic Syndr 2012; 61:600–605.
21. van den Bussche H, Koller D, Kolonko T, et al. Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 2011; 11:101.
22. Yang XY, Zhang JJ, Chen SJ, et al. Comorbidity patterns among people living with HIV: a hierarchical clustering approach through integrated electronic health records data in South Carolina. AIDS Care 2021; 33:594–606.
23. Arant EC, Harding C, Geba M, et al. Human immunodeficiency virus (HIV) and aging: multimorbidity in older people with HIV in One Nonurban Southeastern Ryan White HIV/AIDS Program Clinic. Open Forum Infect Dis 2021; 8:ofaa584.
24. Edmiston N, Passmore E, Smith DJ, Petoumenos K. Multimorbidity among people with HIV in regional New South Wales, Australia. Sex Health 2015; 12:425–432.
25. Mefford MT, Silverberg MJ, Leong TK, et al. Multimorbidity burden and incident heart failure among people with and without HIV: the HIV-HEART Study. Mayo Clin Proc 2022; 6:218–227.
26. Guaraldi G, Malagoli A, Calcagno A, et al. The increasing burden and complexity of multimorbidity and polypharmacy in geriatric HIV patients: a cross sectional study of people aged 65–74 years and more than 75 years. BMC Geriatr 2018; 18:99.
27. European AIDS Clinical Society (EACS) Guidelines Version 7.1, November 2014.
28. U.S. Department of Health and Human Services. Multiple chronic conditions—a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions. Washington, DC; December 2010.
29. Ahmed S, Algarin AB, Thadar H, et al. Comorbidities among persons living with HIV (PLWH) in Florida: a network analysis. AIDS Care 2022; 1–9.
30. Deeks SG, Phillips AN. HIV infection, antiretroviral treatment, ageing, and non-AIDS related morbidity. BMJ 2009; 338:a3172.
31. Wong C, Gange SJ, Moore RD, et al. Multimorbidity among persons living with human immunodeficiency virus in the United States. Clin Infect Dis 2018; 66:1230–1238.
32. Castilho JL, Escuder MM, Veloso V, et al. Trends and predictors of noncommunicable disease multimorbidity among adults living with HIV and receiving antiretroviral therapy in Brazil. J Int AIDS Soc 2019; 22:e25233.
33. Do AN, Rosenberg ES, Sullivan PS, et al. Excess burden of depression among HIV-infected persons receiving medical care in the united states: data from the medical monitoring project and the behavioral risk factor surveillance system. PLoS One 2014; 9:e92842.
34. Kendall CE, Wong J, Taljaard M, et al. A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario. BMC Public Health 2014; 14:161.
35. Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry 2001; 158:725–730.
36. Bristowe K, Clift P, James R, et al. Towards person-centred care for people living with HIV: what core outcomes matter, and how might we assess them? A cross-national multicentre qualitative study with key stakeholders. HIV Med 2019; 20:542–554.
37. Willadsen TG, Bebe A, Køster-Rasmussen R, et al. The role of diseases, risk factors and symptoms in the definition of multimorbidity – a systematic review. Scand J Prim Healthcare 2016; 34:112–121.
38. Bentzen N, Bridges-Webb C. An international glossary for general/family practice. Fam Pract 1995; 12:267.
39. Sabin CA, Harding R, Doyle N, et al. Associations between widespread pain and sleep quality in people with HIV. J Acquir Immune Defic Syndr 2020; 85:106–112.
40▪▪. Lazarus JV, Safreed-Harmon K, Kamarulzaman A, et al. Consensus statement on the role of health systems in advancing the long-term well being of people living with HIV. Nat Commun 2021; 12:4450.
41. Abboah-Offei M, Bristowe K, Koffman J, et al. How can we achieve person-centred care for people living with HIV/AIDS? A qualitative interview study with healthcare professionals and patients in Ghana. AIDS Care 2020; 32:1479–1488.
42. Fortin M, Hudon C, Haggerty J, et al. Prevalence estimates of multimorbidity: a comparative study of two sources. BMC Health Serv Res 2010; 10:111.
43. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for healthcare, research, and medical education: a cross-sectional study. Lancet 2012; 380:37–43.

HIV; multimorbidity; multimorbidity definition

Supplemental Digital Content

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.