Association of Syndemic Unhealthy Alcohol Use, Smoking, and Depressive Symptoms on Incident Cardiovascular Disease among Veterans With and Without HIV-Infection
Open accessAbstract
Unhealthy alcohol use, smoking, and depressive symptoms are risk factors for cardiovascular disease (CVD). Little is known about their co-occurrence - termed a syndemic, defined as the synergistic effect of two or more conditions-on CVD risk in people with HIV (PWH). We used data from 5621 CVD-free participants (51% PWH) in the Veteran's Aging Cohort Study-8, a prospective, observational study of veterans followed from 2002 to 2014 to assess the association between this syndemic and incident CVD by HIV status. Diagnostic codes identified cases of CVD (acute myocardial infarction, stroke, heart failure, peripheral artery disease, and coronary revascularization). Validated measures of alcohol use, smoking, and depressive symptoms were used. Baseline number of syndemic conditions was categorized (0, 1, ≥ 2 conditions). Multivariable Cox Proportional Hazards regressions estimated risk of the syndemic (≥ 2 conditions) on incident CVD by HIV-status. There were 1149 cases of incident CVD (52% PWH) during the follow-up (median 10.1 years). Of the total sample, 64% met our syndemic definition. The syndemic was associated with greater risk for incident CVD among PWH (Hazard Ratio [HR] 1.87 [1.47-2.38], p < 0.001) and HIV-negative veterans (HR 1.70 [1.35-2.13], p < 0.001), compared to HIV-negative with zero conditions. Among those with the syndemic, CVD risk was not statistically significantly higher among PWH vs. HIV-negative (HR 1.10 [0.89, 1.37], p = .38). Given the high prevalence of this syndemic combined with excess risk of CVD, these findings support linked-screening and treatment efforts.
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One hypothesized reason for the mixed success of alcohol interventions in the HIV literature is an increasingly recognized syndemic of co-occurring unhealthy alcohol use and other mental health-related problems among people with HIV.
“One hypothesized reason for the mixed success of alcohol interventions in the HIV literature is an increasingly recognized syndemic of co-occurring unhealthy alcohol use and other mental health-related problems among PWH [20, 21].”
From A Randomized Feasibility/Acceptability Trial of Acceptance and Commitment Therapy for People with HIV Who Drink at Unhealthy Levels. (2026) · cites this paper as [21]
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“…and vascular disease may play an important role in SCA in PLWH. Depression is one of the most prevalent neuropsychiatric disorders among PLWH (Chichetto et al. 2021; Dew et al. 1997; Rabkin 2008) and has been associated with greater disease progression and mortality (So-Armah et al. 2020).”
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“…et al. 2011), substance use disorders, sexually transmitted infections (Shuper et al. 2009), obesity (Obry-Roguet et al. 2018), and cardiometabolic disease (Chichetto et al. 2021), all of which are associated with worse HIV outcomes such as higher or uncontrolled viral load (Chichetto et al. 2025).”
Camard, M., Hendou, S., Bitu, M., Mouanga, C., Boufassa, F., Laurans, S., Chenadec, J. L., Plaçais, L., Avettand-Fènoël, V., Meyer, L., et al. (2026) · Open Forum Infectious Diseases · doi:10.1093/ofid/ofag513
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- Authors
- Chichetto, N. E., Kundu, S., Freiberg, M. S., Koethe, J. R., Butt, A. A., Crystal, S., So-Armah, K. A., Cook, R. L., Braithwaite, R. S., Justice, A. C., Fiellin, D. A., Khan, M., Bryant, K. J., Gaither, J. R., Barve, S. S., Crothers, K., Bedimo, R. J., Warner, A., Tindle, H. A., & Study, O. B. O. T. V. A. C.
- Affiliations
- Vanderbilt University Medical Center (US)
- VA Tennessee Valley Healthcare System (US)
- VA Pittsburgh Healthcare System (US)
- Rutgers, The State University of New Jersey (US)
- University of Florida Health (US)
- New York University (US)
- Yale University (US)
- National Institute on Alcohol Abuse and Alcoholism (US)
- University of Louisville (US)
- University of Washington (US)
- VA North Texas Health Care System (US)
- University of California, Los Angeles (US)
- Corresponding author
- Chichetto, Natalie E.
- ORCID
- Venue
- AIDS and Behavior
- Published
- 2021-06-08
- Volume
- 25
- Issue
- 9
- Pages
- 2852-2862
- ISSN
- 1090-7165 (ISSN-L)
- 1573-3254
- PMC
- PMC8376776
- OpenAlex
- W3170641577
- Cited by
- 20
- References
- 110
- Citations by year
- 2026: 5 · 2025: 3 · 2024: 7 · 2023: 4 · 2022: 1
- FWCI
- 3.13
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- AIDS and Behavior (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Heart, Lung, and Blood Institute (K12HL143956)
- National Institute on Alcohol Abuse and Alcoholism (U24AA020794, U01AA020790, U01AA02201, U10AA013566, K01AA029042)
- Topics
- Health Sciences › Medicine › Emergency Medicine › HIV-related health complications and treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- syndemic, cardiovascular disease, HIV infection, veterans, unhealthy alcohol use, smoking, depressive symptoms, incident cardiovascular disease, comorbidities, cardiovascular risk factors
- MeSH terms
- Syndemic, Cardiovascular Diseases, Depression, Humans, Prospective Studies, Risk Factors, Smoking, Veterans, Cohort Studies, HIV Infections, Incidence
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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