HIV-uninfected Veterans Research Articles

SAT-093 Effect of HIV Infection and Antiretroviral Therapy Use on Body Weight and Body Weight Changes over a 5-Year Period in US Veterans

Obesity has reached epidemic proportions in the U.S. and is more prevalent in Veterans. Obesity and obesity-related comorbidities are also very common in HIV-infected individuals and HIV- and antiretroviral therapy (ART)-specific factors may contribute to obesity and to the excess morbidity and mortality seen in this population. Our objective was to evaluate the weight trajectory in a retrospective cohort of HIV-infected and HIV-uninfected veterans. We also sought to establish the role of ART in this setting. HIV-infected (n=31,015, 97% male, 36% Caucasian, 52% African American, age 48±11 years) and HIV-uninfected veterans (controls, n=105,801, 96% male, 63% Caucasian, 19% African American, age 48±12 years) were included in the analyses. Variables of interest including body weight, weight change at 1, 2 and 5 years after diagnosis (or corresponding baseline visit for controls), ART use and other covariates (age, race, gender). Data were extracted from the VA Corporate Data Warehouse using laboratory values, medications, vital signs and ICD codes. Body weight at baseline was lower in HIV-infected veterans compared to controls (80±17.7 vs. 92.2±19.9 Kg respectively, p<0.01), and the prevalence of overweight (BMI 25-29.9) and obesity (BMI≥30) was higher in controls (34% and 17% in HIV-infected, 38% and 41% in controls respectively). HIV-infected individuals with a BMI <25 gained more weight at 1, 2 and 5 years post-index date compared to controls with most of these gains taking place at year 1 (3.4±7.8 vs. 2.2±7.1 Kg, 3.9±8.6 vs. 3±8 Kg, 4.4±9.8 vs. 4±9.1 Kg change from baseline at 1, 2 and 5 years respectively, all p<0.01). Although this trend was reversed in overweight individuals at 5 years (1.1±7.1 vs. 0.9±5.6 Kg, p=0.06; 1.3±8.1 vs. 1.4±6.5 Kg, p=0.22; 1.7±9.7 vs. 2.3±8.4 Kg, p<0.01 respectively) and in obese individuals at 2 and 5 years (-0.15±9.7 vs. -0.14±8.2 Kg, p>0.9; -0.29±11.2 vs. 0.19±9.2 Kg, p<0.01; -0.03±13 vs. 1.06±11.6 Kg, p<0.01 respectively). Among HIV-infected individuals, those on ART (n=16,028) gained more weight compared to those not on ART (n=4,392) 1, 2 and 5 years after diagnosis (2.3±8.2 vs. 0.88±7.5 Kg, 2.5±9.1 vs. 1.03±8.9 Kg, 2.8±10.6 vs. 1.65±10.2 Kg, respectively, all p<0.01). The weight increase at 1 year was 2.3±8.2 Kg for those exposed to nucleoside reverse-transcriptase inhibitors (NRTI, n=15,853), 2.2±8 Kg for non-NRTI (n=9,237), 2.7±8.6 Kg for protease inhibitors (n=6,961), 2.8±8.2 Kg for integrase inhibitors (n=1895), 0.01±7.1 Kg for fusion inhibitors (n=50), 2.1±8.4 Kg for CCR5 antagonists (n=63) and 2.4±8.8 Kg for pharmacokinetic enhancers (n=499). HIV infection in veterans is associated with lower rates of obesity at diagnosis and significant weight gain for those with a BMI<25 post-diagnosis. Our data also suggest that exposure to ART (perhaps with the exception of fusion inhibitors) is likely to mediate the increase in body weight seen in this setting.

Depression and all-cause mortality risk in HIV-infected and HIV-uninfected US veterans: a cohort study.

The contribution of depression to mortality in adults with and without HIV infection is unclear. We hypothesized that depression increases mortality risk and that this association is stronger among those with HIV infection. Veterans Aging Cohort Study (VACS) data were analysed from the first clinic visit on or after 1 April 2003 (baseline) to 30 September 2015. Depression definitions were: (1) major depressive disorder defined using International Classification of Diseases, Ninth Revision (ICD-9) codes; (2) depressive symptoms defined as Patient Health Questionnaire (PHQ)-9 scores ≥10. The outcome was all-cause mortality. Covariates were demographics, comorbid conditions and health behaviours. Among 129140 eligible participants, 30% had HIV infection, 16% had a major depressive disorder diagnosis, and 24% died over a median follow-up time of 11years. The death rate was 25.3 [95% confidence interval (CI) 25.0-25.6] deaths per 1000 person-years. Major depressive disorder was associated with mortality [hazard ratio (HR) 1.04; 95% CI1.01, 1.07]. This association was modified by HIV status (interaction P-value=0.02). In HIV-stratified analyses, depression was significantly associated with mortality among HIV-uninfected veterans but not among those with HIV infection. Among those with PHQ-9 data (n=7372), 50% had HIV infection, 22% had PHQ-9 scores ≥10, and 28% died over a median follow-up time of 12years. The death rate was 27.3 (95% CI 26.1-28.5) per 1000 person-years. Depressive symptoms were associated with mortality (HR 1.16; 95% CI 1.04, 1.28). This association was modified by HIV status (interaction P-value=0.05). In HIV-stratified analyses, depressive symptoms were significantly associated with mortality among veterans with HIV infection but not among those without HIV infection. Depression was associated with all-cause mortality. This association was modified by HIV status and method of depression ascertainment.

Association of Human Immunodeficiency Virus Infection and Risk of Peripheral Artery Disease.

The effect of human immunodeficiency virus (HIV) on the development of peripheral artery disease (PAD) remains unclear. We investigated whether HIV infection is associated with an increased risk of PAD after adjustment for traditional atherosclerotic risk factors in a large cohort of HIV-infected (HIV+) and demographically similar HIV-uninfected veterans. We studied participants in the Veterans Aging Cohort Study from April 1, 2003 through December 31, 2014. We excluded participants with known prior PAD or prevalent cardiovascular disease (myocardial infarction, stroke, coronary heart disease, and congestive heart failure) and analyzed the effect of HIV status on the risk of incident PAD events after adjusting for demographics, PAD risk factors, substance use, CD4 cell count, HIV-1 ribonucleic acid, and antiretroviral therapy. The primary outcome is incident peripheral artery disease events. Secondary outcomes include mortality and amputation in subjects with incident PAD events by HIV infection status, viral load, and CD4 count. Among 91 953 participants, over a median follow up of 9.0 years, there were 7708 incident PAD events. Rates of incident PAD events per 1000 person-years were higher among HIV+ (11.9; 95% confidence interval [CI], 11.5-12.4) than uninfected veterans (9.9; 95% CI, 9.6-10.1). After adjustment for demographics, PAD risk factors, and other covariates, HIV+ veterans had an increased risk of incident PAD events compared with uninfected veterans (hazard ratio [HR], 1.19; 95% CI, 1.13-1.25). This risk was highest among those with time-updated HIV viral load >500 copies/mL (HR, 1.51; 95% CI, 1.38-1.65) and CD4 cell counts <200 cells/mm3 (HR, 1.91; 95% CI, 1.71-2.13). In contrast, HIV+ veterans with time updated CD4 cell count ≥500 cells/mm3 had no increased risk of PAD (HR, 1.03; 95% CI, 0.96-1.11). Mortality rates after incident PAD events are high regardless of HIV status. HIV infection did not affect rates of amputation after incident PAD events. Infection with HIV is associated with a 19% increased risk of PAD beyond that explained by traditional atherosclerotic risk factors. However, for those with sustained CD4 cell counts <200 cells/mm3, the risk of incident PAD events is nearly 2-fold higher whereas for those with sustained CD4 cell counts ≥500 cells/mm3 there is no excess risk of incident PAD events compared with uninfected people.

Increased Echocardiographic Pulmonary Pressure in HIV-infected and -uninfected Individuals in the Veterans Aging Cohort Study.

The epidemiology and prognostic impact of increased pulmonary pressure among HIV-infected individuals in the antiretroviral therapy era is not well described. To examine the prevalence, clinical features, and outcomes of increased echocardiographic pulmonary pressure in HIV-infected and -uninfected individuals. This study evaluated 8,296 veterans referred for echocardiography with reported pulmonary artery systolic pressure (PASP) estimates from the Veterans Aging Cohort study, an observational cohort of HIV-infected and -uninfected veterans matched by age, sex, race/ethnicity, and clinical site. The primary outcome was adjusted mortality by HIV status. PASP was reported in 2,831 HIV-infected and 5,465 HIV-uninfected veterans (follow-up [mean ± SD], 3.8 ± 2.6 yr). As compared with uninfected veterans, HIV-infected veterans with HIV viral load greater than 500 copies/ml (odds ratio, 1.27; 95% confidence interval [CI], 1.05-1.54) and those with CD4 cell count less than 200 cells/μl (odds ratio, 1.28; 95% CI, 1.02-1.60) had a higher prevalence of PASP greater than or equal to 40 mm Hg. As compared with uninfected veterans with a PASP less than 40 mm Hg, HIV-infected veterans with a PASP greater than or equal to 40 mm Hg had an increased risk of death (adjusted hazard ratio, 1.78; 95% CI, 1.57-2.01). This risk persisted even among participants without prevalent comorbidities (adjusted hazard ratio, 3.61; 95% CI, 2.17-6.01). The adjusted risk of mortality in HIV-infected veterans was higher at all PASP values than in uninfected veterans, including at values currently considered to be normal. HIV-infected people with high HIV viral loads or low CD4 cell counts have a higher prevalence of increased PASP than uninfected people. Mortality risk in HIV-infected veterans increases at lower values of PASP than previously recognized and is present even among those without prevalent comorbidities. These findings may inform clinical decision-making regarding screening and surveillance of pulmonary hypertension in HIV-infected individuals.

Comparative Effectiveness of Diabetic Oral Medications Among HIV-Infected and HIV-Uninfected Veterans.

OBJECTIVEType 2 diabetes is increasingly common in HIV-infected individuals. The objective of this study was to compare the glycemic effectiveness of oral diabetic medications among patients with and without HIV infection.RESEARCH DESIGN AND METHODSA longitudinal cohort study was conducted among HIV-infected and uninfected veterans with type 2 diabetes initiating diabetic medications between 1999 and 2010. Generalized estimating equations were used to compare changes in hemoglobin A1c (HbA1c) through the year after medication initiation, adjusting for baseline HbA1c level and clinical covariates. A subanalysis using propensity scores was conducted to account for confounding by indication.RESULTSA total of 2,454 HIV-infected patients and 8,892 HIV-uninfected patients initiated diabetic medications during the study period. The most commonly prescribed medication was metformin (n = 5,647, 50%), followed by a sulfonylurea (n = 5,554, 49%) and a thiazolidinedione (n = 145, 1%). After adjustment for potential confounders, there was no significant difference in the change in HbA1c level among the three groups of new users. HIV infection was not significantly associated with glycemic response (P = 0.24). Black and Hispanic patients had a poorer response to therapy compared with white patients, with a relative increase in HbA1c level of 0.16% (95% CI 0.08, 0.24) [1.7 mmol/mol (0.9, 2.6)] (P < 0.001) and 0.25% (0.11, 0.39) [2.7 mmol/mol (1.2, 4.3)] (P = 0.001), respectively.CONCLUSIONSWe found that glycemic response was independent of the initial class of diabetic medication prescribed among HIV-uninfected and HIV-infected adults with type 2 diabetes. The mechanisms leading to poorer response among black and Hispanic patients, who make up a substantial proportion of those with HIV infection and type 2 diabetes, require further investigation.

Non-medical use of prescription opioids is associated with heroin initiation among US veterans: a prospective cohort study.

To estimate the influence of non-medical use of prescription opioids (NMUPO) on heroin initiation among US veterans receiving medical care. Using a multivariable Cox regression model, we analyzed data from a prospective, multi-site, observational study of HIV-infected and an age/race/site-matched control group of HIV-uninfected veterans in care in the United States. Approximately annual behavioral assessments were conducted and contained self-reported measures of NMUPO and heroin use. Veterans Health Administration (VHA) infectious disease and primary care clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh and Washington, DC. A total of 3396 HIV-infected and uninfected patients enrolled into the Veterans Aging Cohort Study who reported no life-time NMUPO or heroin use, had no opioid use disorder diagnoses at baseline and who were followed between 2002 and 2012. The primary outcome measure was self-reported incident heroin use and the primary exposure of interest was new-onset NMUPO. Our final model was adjusted for socio-demographics, pain interference, prior diagnoses of post-traumatic stress disorder and/or depression and self-reported other substance use. Using a multivariable Cox regression model, we found that non-medical use of prescription opioids NMUPO was associated positively and independently with heroin initiation [adjusted hazard ratio (AHR)=5.43, 95% confidence interval (CI)=4.01, 7.35]. New-onset non-medical use of prescription opioids (NMUPO) is a strong risk factor for heroin initiation among HIV-infected and uninfected veterans in the United States who reported no previous history of NMUPO or illicit opioid use.

Risk of Heart Failure With Human Immunodeficiency Virus in the Absence of Prior Diagnosis of Coronary Heart Disease

Whether human immunodeficiency virus (HIV) infection is a risk factor for heart failure (HF) is not clear. The presence of coronary heart disease and alcohol consumption in this population may confound this association. To determine whether HIV infection is a risk factor for incident HF, we conducted a population-based, retrospective cohort study of HIV-infected and HIV-uninfected veterans enrolled in the Veterans Aging Cohort Study Virtual Cohort (VACS-VC) and the 1999 Large Health Study of Veteran Enrollees (LHS) from January 1, 2000, to July 31, 2007. There were 8486 participants (28.2% HIV-infected) enrolled in the VACS-VC who also participated in the 1999 LHS. During the median 7.3 years of follow-up, 286 incident HF events occurred. Age- and race/ethnicity-adjusted HF rates among HIV-infected and HIV-uninfected veterans were 7.12 (95% confidence interval [CI],6.90-7.34) and 4.82 (95% CI,4.72-4.91) per 1000 person-years, respectively. Compared with HIV-uninfected veterans, those who were HIV infected had an increased risk of HF (adjusted hazard ratio [HR], 1.81; 95% CI, 1.39-2.36). This association persisted among veterans who did not have a coronary heart disease event or a diagnosis related to alcohol abuse or dependence before the incident HF event (adjusted HR, 1.96; 95% CI,1.29-2.98). Compared with HIV-uninfected veterans, those who were HIV infected with a baseline Human immunodeficiency virus 1 (HIV-1) RNA level of 500 or more copies/mL had a higher risk of HF (adjusted HR, 2.28; 95% CI,1.57-3.32), while those with baseline and a recent HIV-1 RNA level less than 500 copies/mL did not (adjusted HR, 1.10; 95% CI,0.64-1.89; P<.001 for comparison between high and low HIV-1 RNA groups). Our data suggest that HIV infection is a risk factor for HF. Ongoing viral replication is associated with a higher risk of developing HF.

HIV Infection and Risk for Incident Pulmonary Diseases in the Combination Antiretroviral Therapy Era

In aging HIV-infected populations comorbid diseases are important determinants of morbidity and mortality. Pulmonary diseases have not been systematically assessed in the combination antiretroviral therapy (ART) era. To determine the incidence of pulmonary diseases in HIV-infected persons compared with HIV-uninfected persons. We analyzed data from the Veterans Aging Cohort Study Virtual Cohort, consisting of 33,420 HIV-infected veterans and 66,840 age, sex, race and ethnicity, and site-matched HIV-uninfected veterans. Using Poisson regression, incidence rates and adjusted incidence rate ratios were calculated to determine the association of HIV with pulmonary disease. The Virtual Cohort was merged with the 1999 Veterans Large Health Survey to adjust for self-reported smoking in a nested sample (14%). Incident chronic obstructive pulmonary disease, lung cancer, pulmonary hypertension, and pulmonary fibrosis, as well as pulmonary infections, were significantly more likely among HIV-infected patients compared with uninfected patients in adjusted analyses, although rates of asthma did not differ by HIV status. Bacterial pneumonia and chronic obstructive pulmonary disease were the two most common incident pulmonary diseases, whereas opportunistic pneumonias were less common. Absolute rates of most pulmonary diseases increased with age, although the relative differences between those with and without HIV infection were greatest in younger persons. Chronic obstructive pulmonary disease and asthma, as well as pulmonary infections, were less likely in those with lower HIV RNA levels and use of ART at baseline. Pulmonary diseases among HIV-infected patients receiving care within the Veterans Affairs Healthcare System in the combination ART era reflect a substantial burden of non-AIDS-defining and chronic conditions, many of which are associated with aging.

The association between alcohol consumption and prevalent cardiovascular diseases among HIV-infected and HIV-uninfected men.

To determine whether alcohol consumption is associated with cardiovascular disease (CVD) among HIV-infected veterans. Using established thresholds for alcohol consumption, we analyzed cross-sectional data from 4743 men (51% HIV infected) from the Veterans Aging Cohort Study, a prospective cohort of HIV-infected veterans and demographically similar HIV-uninfected veterans. Using logistic regression, we estimated the odds ratio (OR) for the association between alcohol consumption and prevalent CVD. Among HIV-infected and HIV-uninfected men, respectively, hazardous drinking (33.2% vs. 30.9%,), alcohol abuse and dependence (20.9% vs. 26.2%), and CVD (14.6% vs. 19.8%) were common. Among HIV-infected men, hazardous drinking [OR = 1.43, 95% confidence interval (CI) = 1.05 to 1.94] and alcohol abuse and dependence (OR = 1.55, 95% CI = 1.07 to 2.23) were associated with a higher prevalence of CVD compared with infrequent and moderate drinking. Among HIV-uninfected men, past drinkers had a higher prevalence of CVD (OR = 1.30, 95% CI = 1.01 to 1.67). For HIV-infected and HIV-uninfected men, traditional risk factors and kidney disease were associated with CVD. Among HIV-infected men, hazardous drinking and alcohol abuse and dependence were associated with a higher prevalence of CVD compared with infrequent and moderate drinking even after adjusting for traditional CVD risk factors, antiretroviral therapy, and CD4 count.

HIV infection and the risk of diabetes mellitus

The influence of HIV infection on the risk of diabetes is unclear. We determined the association and predictors of prevalent diabetes mellitus in HIV infected and uninfected veterans. We determined baseline prevalence and risk factors for diabetes between HIV infected and uninfected veterans in the Veterans Aging Cohort Study. Logistic regression was used to determine the odds of diabetes in HIV infected and uninfected persons. We studied 3227 HIV-infected and 3240 HIV-uninfected individuals. HIV-infected individuals were younger, more likely to be black males, have HCV coinfection and a lower BMI. HIV-infected individuals had a lower prevalence of diabetes at baseline (14.9 vs. 21.4%, P < 0.0001). After adjustment for known risk factors, HIV-infected individuals had a lower risk of diabetes (odds ratio = 0.84, 95% confidence interval = 0.72-0.97). Increasing age, male sex, minority race, and BMI were associated with an increased risk. The odds ratio for diabetes associated with increasing age, minority race and BMI were greater among HIV-infected veterans. HCV coinfection and nucleoside and nonnucleoside reverse transcriptase inhibitor therapy were associated with a higher risk of diabetes in HIV-infected veterans. Although HIV infection itself is not associated with increased risk of diabetes, increasing age; HCV coinfection and BMI have a more profound effect upon the risk of diabetes among HIV-infected persons. Further, long-term ARV treatment also increases risk. Future studies will need to determine whether incidence of diabetes mellitus differs by HIV status.

The Association Between the Receipt of Lipid Lowering Therapy and HIV Status Among Veterans Who Met NCEP/ATP III Criteria for the Receipt of Lipid Lowering Medication

To examine the association between HIV infection status and the receipt of lipid lowering therapy based on National Cholesterol Education Program/Adult Treatment Panel (NCEP/ATP III) guidelines and to assess whether HIV viral load and hepatitis C (HCV) status alters that association. A cross-sectional analysis of survey, laboratory, and pharmacy data from 1,577 male participants (59% HIV infected) of the Veterans Aging Cohort Five-Site Study, a prospective observational cohort of U.S. veterans with and without HIV infection. Receipt of lipid lowering therapy obtained from the VA pharmacy benefits management system was the main outcome. The prevalence of lipid lowering therapy among HIV-infected and HIV-uninfected veterans was 15.4% vs. 37.9%, respectively, p < 0.01. Among veterans who met NCEP/ATP III criteria for lipid lowering therapy, HIV-infected veterans had a significantly lower prevalence for the receipt of lipid lowering therapy (adjusted odds ratio (OR) = 0.43, 95% confidence interval (C.I.) 0.28-0.67) as compared with HIV-uninfected veterans. Among HIV-infected veterans, log HIV viral load (adjusted OR = 0.57, 95% CI, 0.41-0.81) and HIV-HCV co-infection (adjusted OR = 0.31, 95% CI = 0.13-0.75) were negatively associated with receipt of lipid lowering therapy. Exposure to HAART was not associated with receipt of lipid lowering therapy. Among those who met NCEP/ATP III criteria for lipid lowering therapy, HIV-infected veterans, particularly those with high HIV viral loads and HCV co-infection, were significantly less likely to receive lipid lowering therapy. This may be a modifiable mediator of cardiovascular disease among HIV-infected individuals.

Depression Symptoms and Treatment Among HIV Infected and Uninfected Veterans

Depression is one of the most common comorbid conditions affecting persons with HIV. We compared depressive symptoms and depression treatment using data from the Veterans Aging Cohort Study (VACS), a prospective cohort of HIV-infected and uninfected subjects. We identified subjects with a Patient Health Questionnaire score of 10 or greater. Treatment was defined as prescription of a selective serotonin reuptake inhibitor (SSRI) or mental health counseling. Overall, 16% of 4,480 subjects had depressive symptoms, and HIV-infected patients were more likely to have had depressive symptoms (OR = 1.38, 95% CI = 1.18, 1.62). Geographic site of care and having a mental health provider at the clinic was associated with treatment. In multivariable models restricted to 732 patients with depressive symptoms, receipt of depression treatment did not differ by HIV status (Adjusted OR = 1.11, 95% CI = 0.80, 1.54). Non-Hispanic whites were more likely to receive treatment (Adjusted OR = 2.09, 95% CI 1.04, 4.24). Primary care and HIV providers were equally unlikely to treat active depressive symptoms. Treatment variation by race, site, and availability of a mental health provider, suggests targets for intervention.

Do Patterns of Comorbidity Vary by HIV Status, Age, and HIV Severity?

Patterns of comorbidity among persons with human immunodeficiency virus (HIV) are not well described. We compared comorbidity among veterans with and without HIV infection. The sample consisted of 33,420 HIV-infected veterans and 66,840 HIV-uninfected veterans. We identified and clustered 11 comorbid conditions using validated International Classification of Diseases, 9th Revision, Clinical Modification codes. We defined multimorbidity as the presence of conditions in all clusters. Models restricted to HIV-infected veterans were adjusted for CD4 cell count and viral load. Comorbidity was common (prevalence, 60%-63%), and prevalence varied by HIV status. Differences remained when the veterans were stratified by age. In multivariable analyses, older HIV-infected veterans were more likely to have substance use disorder and multimorbidity. Renal, vascular, and pulmonary diseases were associated with CD4 cell count <200 cells/mm(3); hypertension was associated with CD4 cell count >200 cells/mm(3). Comorbidity is the rule, and multimorbidity is common among veterans with HIV infection. Patterns of comorbidity differ substantially by HIV status, age, and HIV severity. Primary care guidelines require adaptation for persons with HIV infection.

Alcohol Problems and Health Care Services Use in Human Immunodeficiency Virus (HIV)-Infected and HIV-Uninfected Veterans

Although alcohol problems are common in human immunodeficiency virus (HIV)-infected patients, their impact on health care services use in HIV-infected patients is not well understood. We sought to examine the association between alcohol problems and health care services use in HIV-infected and HIV-uninfected patients. We undertook a prospective analysis of 16,048 HIV-infected veterans and 32,096 age-, race-, gender-, and region-matched HIV-uninfected controls identified through the national Veterans Affairs electronic administrative medical record database. We identified subjects with alcohol problems using ICD-9-CM codes for alcohol diagnoses and/or alcohol-related complications. We measured outpatient visits, emergency department visits, and inpatient hospitalizations over 12 months of follow-up. In adjusted analyses, HIV-infected veterans with alcohol problems were significantly more likely than HIV-uninfected veterans without alcohol problems to have at least 1 outpatient visit and at least 1 inpatient hospitalization and, among those with any health services use, to have significantly greater rates for outpatient visits (Incidence rate ratio [IRR] 2.17; 95% confidence interval [CI] 2.06-2.28; P < 0.001), emergency department visits (IRR 1.46; 95% CI 1.35-1.58; P < 0.001), and inpatient hospitalizations (IRR 1.46; 95% CI 1.30-1.64; P < 0.001). The incidence rates for outpatient visits, mental health visits, emergency department visits, and inpatient hospitalizations were significantly higher in HIV-infected veterans with alcohol problems than in HIV-infected veterans without alcohol problems. We did not find a consistent interaction effect between alcohol problems and HIV status. Alcohol problems are associated with greater outpatient, emergency department, and inpatient health care utilization in HIV-infected and HIV-uninfected veterans. However, alcohol does not appear to have a stronger effect on health services use in HIV-infected veterans compared with HIV-uninfected veterans.