Highlight
This study demonstrates that multidimensional social adversity significantly exacerbates mortality and rehospitalization risks among people living with HIV infection and heart failure. Specific domains—such as social support challenges and psychobehavioral instability—show distinct associations with cardiovascular and infection-related mortality. The findings advocate for integrated, domain-specific risk stratification in clinical care.
Background
Heart failure has emerged as a prevalent and serious comorbidity in people with HIV infection due to increased longevity with effective antiretroviral therapy and chronic inflammation. This dual burden complicates clinical management and increases vulnerability to adverse outcomes. Beyond biological factors, social determinants play a crucial role in health outcomes among this population. Social adversity (SA)—encompassing economic hardship, limited healthcare access, unstable living environments, deficient social support, and psychobehavioral instability—may exacerbate risks but remains underexplored in terms of its specific impact on mortality and rehospitalization.
Study Design
The NYC 4H cohort is a prospective observational study of 1044 adults living with HIV and heart failure drawn from the NYC Health + Hospitals system. Multidimensional social adversity at baseline was systematically assessed by licensed clinical social workers using standardized instruments. SA domains were categorized as: economic hardship, healthcare access barriers, environmental instability (including unstable housing), social support challenges, and psychobehavioral instability.
Participants were followed for a mean duration of 3.8 years. The primary endpoints included all-cause mortality, cardiovascular mortality, infection-related mortality, and 6-month rehospitalization risk. Multivariable Cox proportional hazards models and logistic regression analyses were used to estimate adjusted hazard ratios (HRs) and odds ratios (ORs), controlling for confounders.
Key Findings
Of 1044 participants (62.9% male, mean age 61.6 years), 601 (58%) reported at least one aspect of social adversity. The prevalence of SA domains were: economic hardship (12.4%), limited health care access (14.8%), unstable housing/environmental instability (12.4%), social support challenges (17.1%), and psychobehavioral instability (42.0%).
Exposure to any SA was robustly associated with increased mortality risks: 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). Importantly, domain-specific associations were discerned:
- Social support challenges were independently linked to increased cardiovascular mortality (HR 2.19, 95% CI 1.35–3.55) and infection-related mortality (HR 3.09, 95% CI 1.75–5.48).
- Psychobehavioral instability was associated with higher cardiovascular mortality (HR 1.96, 95% CI 1.24–3.11) and increased likelihood of 6-month rehospitalization (adjusted OR 1.75, 95% CI 1.31–2.35).
- Economic hardship correlated with infection-related mortality (HR 2.40, 95% CI 1.22–4.70).
- Environmental instability and social support challenges were linked to elevated rehospitalization risk with adjusted ORs of 1.73 (95% CI 1.15–2.06) and 1.44 (95% CI 1.00–2.06), respectively.
The graded effect of cumulative SA exposure suggests additive risk contributions across domains.
Expert Commentary
This study offers critical insights into how psychosocial vulnerabilities intricately influence clinical trajectories in a medically complex population. It highlights that beyond traditional biomedical risk factors, multidimensional social adversity exerts profound effects on mortality and rehospitalization.
The large, diverse NYC cohort and use of standardized social work evaluations lend credibility and relevance to the findings. Still, residual confounding and potential measurement biases inherent in observational research cannot be fully excluded. Moreover, replication in other geographical and healthcare settings is warranted for generalizability.
Mechanistically, social support challenges and psychobehavioral instability may contribute to poor adherence, delayed care-seeking, and maladaptive stress responses, aggravating cardiovascular risks and susceptibility to infections. Economic and environmental hardships compound barriers to effective chronic disease management.
This work aligns with evolving clinical guidelines that recognize social determinants as vital components of comprehensive care, particularly for vulnerable patients with multimorbidity. Integrated social risk screening and tailored interventions could mitigate adverse outcomes.
Conclusion
The NYC Health + Hospitals 4H cohort analysis robustly associates multidimensional social adversity with elevated mortality and rehospitalization risks in people living with HIV and heart failure. Domain-specific patterns emerged, emphasizing the need for comprehensive social risk assessment in clinical practice. Interventions targeting economic hardship, social support, and psychobehavioral stability may improve outcomes.
Future research should evaluate the effectiveness of integrated social and clinical care models employing multidomain assessments to inform personalized risk stratification, enhance resource allocation, and ultimately reduce excess morbidity and mortality in this high-risk population.
Funding and ClinicalTrials.gov
The study funding sources were not specified in the abstract. The NYC 4H cohort appears embedded within a public hospital system registry. Further details on funding and trial registration would be available in the full article.
References
Chen YY, Borkowski P, Biavati L, et al. Multidimensional Social Adversity and Mortality in People With HIV Infection and Heart Failure: Insights From NYC Health + Hospitals HIV-Heart Failure Cohort. Circulation. 2026;153(24):1903-1914. PMID: 42153290.