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HIV infection increases the risk of inflammatory bowel disease: a systematic review and meta-analysis

BMC Infectious Diseases volume 24, Article number: 1030 (2024) Cite this article

Abstract

Objective

In order to synthesize available results regarding human immunodeficiency virus (HIV) infection and inflammatory bowel disease (IBD), we conducted a systematic review and meta-analysis to provide quantitative estimates of associated risk.

Methods

A systematic search of four scientific databases, PubMed, the Cochrane Library, EMBASE, and Scopus, was performed. The overall odds ratio (OR) with the corresponding 95% CI was calculated via a random effects model. Sensitivity analyses and tests for publication bias were then performed.

Results

Of the 3046 articles retrieved, seven studies with a cumulative sample size greater than 57,000,000 were included in our analysis. A subsequent meta-analysis based on a random effects model (heterogeneity test, I2 = 99.9) revealed an association between HIV infection and IBD: OR = 2.68 (95% CI: 1.17, 6.13). The funnel plot of this meta-analysis was asymmetric (Egger’s test: P = 0.01), and significant publication bias was found. Sensitivity analysis of the 3 dimensions revealed that the results of this meta-analysis were relatively stable.

Conclusions

A significant correlation may exist between HIV infection and intestinal disease, and more large-scale studies are needed to draw firm conclusions. It is recommended that HIV patients be screened for intestinal diseases.

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Introduction

In recent years, the widespread use of combination antiretroviral therapy (ART) has successfully increased the life expectancy of people living with human immunodeficiency virus (HIV) and significantly decreased HIV/AIDS-related mortality. People living with HIV (PLWH) are aging [1]. According to the statistical data quoted by the Centers for Disease Control and Prevention (CDC) of the United States, nearly half of the PLWH in North America were over the age of 50 in 2019 [2]. Considering the increasing life expectancy of PLWH, chronic conditions, including an increased risk of inflammatory bowel disease (IBD), are a major concern in HIV care [3].

IBDs, including Crohn’s disease and ulcerative colitis, are characterized by chronic and progressive inflammation of the gastrointestinal tract and pose a high disease burden worldwide [4]. The incidence of IBD has reached 396 per 100,000 globally, with the highest incidence reported in North America and Northern and Western Europe [5,6,7]. The causes leading to IBD are complicated and have not yet been fully elucidated. The pathogenesis of IBD is considered to be the result of an interplay between genetic susceptibility [8], immunity [9] and environmental risk factors [10].

The intersection between HIV and IBD, especially the impact of HIV infection on the course of IBD, remains unclear. Studies have noted that HIV infection may affect the prevalence of IBD. Some case series have indicated that IBD symptoms are significantly relieved in PLWH [11,12,13]. However, many studies have reported an increased incidence of IBD in persons living with HIV [11, 14,15,16]. To date, no meta-analysis has been published on the incidence of IBD in PLWH. There is a lack of aggregate evidence on IBD in PLWH. We conducted a meta-analysis to evaluate the association between HIV infection and IBD.

Materials and methods

This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) list. As this study used previously published literature, no ethical issues were involved. In February 2023, our study protocol was registered in the International Prospective Systematic Review under protocol number CRD42023402899.

Data sources and search strategy

We systematically searched the following databases: PubMed, the Cochrane Library, Embase, and Scopus. All the databases were searched from their inception to January 2024. The search terms used were HIV and IBD. Medical subject headings (MeSH) were used to search these databases when available. The supplementary materials list specific search strategies (Table S1).

Study selection

Two reviewers (HW and ZYD) screened the literature according to the inclusion and exclusion criteria, respectively, and any disagreements were resolved by a third researcher (WP). If further details were needed, the reviewers could also contact the corresponding author of the selected article for more information.

Studies meeting all of the following criteria were included: (1) observational studies (prospective studies and retrospective studies), (2) studies that examined the association between HIV and IBD, (3) studies that allowed calculation of the risk of HIV exposure associated with IBD, and (4) conference abstracts. The language was limited to English.

The exclusion criteria were as follows: (1) literature reviews or case reports, (2) nonhuman studies, (3) studies with missing controls (only a description of the current situation), and (4) duplicate populations (articles published with duplicate data). For studies with duplicate published data, studies with larger sample sizes and more recent publication years were selected for further meta-analysis. Notably, all the study selection processes were performed according to the PRISMA Statement.

Data extraction and quality assessment

Data extraction for all included articles was performed by two investigators independently (HW and ZYD), with any disagreements coordinated by a third investigator (WP). The following data were extracted from each study: (1) study design, (2) first author, (3) country, (4) year of publication, (5) age, (6) sex, (7) number of people with and without HIV, (8) sample size, (9) quality of study design and analysis, (10) adjusted variables, and (11) adjusted hazard ratio (HR), crude HR and adjusted OR.

HW and ZYD evaluated the quality of the included literature via the Newcastle‒Ottawa scale (NOS), and those with a total score of ≥ 6 were considered to be of reliable quality. The specific quality assessment strategy is described in the Supplementary Material (Table S2).

Data analysis

Heterogeneity tests and calculations of combined OR values and 95% CIs were performed via Stata 14.0. The adjusted OR/HR was selected if studies reported adjusted ORs/HRs; if the adjusted HR/OR was not reported, the crude HR/OR was calculated on the basis of the available raw data. (1) Effect size merging: OR values from the included studies were merged. (2) Heterogeneity test: If I2 < 50%, multiple similar studies were considered homogeneous, and a fixed-effects model was selected for analysis; conversely, if I2 ≥ 50%, greater heterogeneity was indicated, and a random-effects model was used for merging. (3) The combined OR values and 95% CIs were output and tested for the combined statistic. (4) Egger’s test was used to evaluate publication bias. If the funnel plot appears asymmetric or incomplete, it is considered to have publication bias; symmetry indicates that publication bias is less likely. (5) The purpose of the sensitivity analysis was to understand whether the systematic evaluation results were stable and reliable. The sensitivity analyses were performed in 3 areas: (1) removal of meeting summaries, (2) removal of meeting summaries and ORs, and (3) removal of meeting summaries and unadjusted HR. All the statistical analyses were performed via STATA software version 14.0. The test level was α = 0.05.

Results

Study selection

The PRISMA flow chart is shown in Fig. 1. A comprehensive search of the above databases identified 3046 articles. After removing duplicates, 2427 articles were initially screened for eligibility on the basis of title and abstract. A total of seven articles were ultimately included [17,18,19,20,21,22]. A total of 3042 articles were excluded from this study for the following reasons: (1) duplicate literature (619); (2) review articles and meta-analyses (246); (3) nonhuman studies (137 articles); (4) non-relevant studies (1502) and case reports (278); and (5) insufficient data (356).

Fig. 1
figure 1

Flow chart of the search process

Full size image

Study characteristics

The baseline characteristics are shown in Table 1. The seven studies were published between 2017 and 2022, and all were observational studies. Five were prospective studies [18,19,20, 22], and two were retrospective studies [17, 21]. After the 2 conference [21, 22] abstracts were removed, the total sample size was 56,733,381, with a mean sample size of 11,346,676, ranging from 2892 to 56,218,610. Geographically, four studies [18, 20, 21] were from North America (Canada and the United States), and two studies [17, 19] were from Europe (Switzerland and Denmark).

Table 1 Characteristics of included studies
Full size table

Quality assessment

Table S2 shows the distribution of scores for quality assessment via the NOS. All four studies were of moderate to high quality and were eligible for this meta-analysis. Two conference abstracts were not assessed for quality.

Quantitative synthesis

To compare the relationship between HIV infection and IBD, our preliminary analysis included seven studies [17,18,19,20,21,22]. Our findings suggest an association between HIV infection and IBD. Heterogeneity tests were statistically significant (I2 = 99.9%, P < 0.05), and a meta-analysis based on a random effects model revealed a significant association between HIV infection and IBD, with a combined OR of 2.68 (95% CI: 1.17, 6.13; P = 0.00) (Fig. 2).

Fig. 2
figure 2

Random effects meta-analysis of HIV-induced inflammatory bowel disease

Full size image

The funnel plot of this meta-analysis was asymmetric (Fig. 3; S1 Figure: Egger’s test: P = 0.01), indicating significant publication bias. The results of the sensitivity analysis are shown in Table 2. Sensitivity analyses of the 3 dimensions revealed that the results of this meta-analysis were relatively stable, further demonstrating the stability and reliability of the results of this systematic review. In addition, Alkhayyat’s study affects the stability of the results (S2 Figure).

Fig. 3
figure 3

Funnel plot

Full size image
Table 2 Sensitivity analysis
Full size table

Discussion

Our results revealed that HIV-infected patients had a significantly increased risk of IBD, with an overall OR of 2.68 (95% CI: 1.17, 6.13). Sensitivity analysis of the 3 dimensions revealed that the results of this meta-analysis were relatively stable. To our knowledge, this study is the first meta-analysis to quantify this association in a systematic and comprehensive manner. This study is primarily a preliminary study of the correlation between hiv infection status and inflammatory bowel disease; the viral load and disease remission period are not addressed in this study.

Although the relationship between HIV and IBD has been studied in depth by many scholars, the reported associations and the strength of their associations have been reported inconsistently in different studies and even in opposite cases. Caroline Bähler et al. reported no correlation between HIV and IBD [17]. Nikos Viazis et al. reported that HIV infection has a protective effect on IBD patients, reducing the relapse rate, and indicated that the possible reason for this outcome is the low CD4 + T-cell count [13]. A few studies have noted that a decrease in the CD4 cell count may be associated with IBD remission [12, 13, 23, 24]. However, the absence of a control group in these studies affected the robustness of their results. Some case reports of patients with HIV infection without IBD remission suggest that there may be an association between HIV and IBD [14,15,16, 25,26,27].

The underlying mechanisms regarding HIV and IBD are unclear, but several potential factors might contribute to the association between HIV and IBD. HIV infection leads to a T-cell imbalance, that is, a decrease in CD4 + T cells and an increase in CD8 + T cells. Ulcerative colitis is an antibody-mediated disease, whereas Crohn’s disease is mediated by T cells [28, 29]. The intestine-associated lymphoid tissue, where most T cells are present, is a central site of HIV infection because HIV targets and replicates within CD4 T cells in the lymphoid tissue. In addition, several features of the intestinal mucosa increase susceptibility to viral infection and replication. One of the dependencies of intestinal integrity and function is the gastrointestinal mucosa, whose destruction is a hallmark and risk factor for most intestinal and chronic inflammatory diseases [3]. CD4 + T cells associated with intestinal-associated lymphoid tissue are involved in the mucosal and transmural damage caused by IBD. CD4 + T cells appear to play an important role in the pathogenesis of IBD. After HIV infection, continued viral replication leads to a decrease in CD4 + cells, which can lead to the development of opportunistic infections. Continued viral replication disrupts the protective epithelial barrier, allowing bacterial entry into the underlying tissues and the bloodstream, leading to persistent inflammation, even with antiretroviral drugs [30].

In addition, molecular mimicry between HIV proteins and autoantigens leads to antibody cross-reactivity, which may promote the development of autoimmune disease. The T lymphocyte imbalance caused by HIV has a negative effect on the selection of self-reactive antibody pools and may promote the development of autoimmune diseases [31].

IBD triggers an immune overreaction, and HIV triggers an immune deficiency response, as both have unique inflammatory responses. As a result, the intestinal immune system may be intolerant to symbiotic antigens and other antigens, which can lead to inflammation. Ecological dysbiosis was also noted, with reduced diversity of gut microbial communities in HIV and IBD patients [32]. Several studies have pointed to the occurrence of IBD in HIV-infected individuals [12, 13, 23, 24, 27].

The main strength of this study is that the seven included papers are large national studies with large sample sizes and long follow-up periods. There are several limitations in this study. First, there was publication bias and heterogeneity in this study. Second, the number of included studies in this study was seven in total, so there is low statistical power to confirm or reject the null hypothesis, and more cohort studies are needed in the future to validate our results. This study included only four countries, and more cohort studies in other countries are needed in the future to validate the findings of this study to exclude the effects of race and region. In addition, future studies on HIV and IBD are warranted, and more data and experimental studies are needed to understand the mechanisms of their association. Finally, because the included studies included different sets of confounders in the adjusted model, the choice of effect estimates on the basis of the fully adjusted model was reported not to substantially change the results of the meta-analyses compared with models controlling only for the most common confounders (e.g., sex and age) [33]. Thus, the heterogeneity of the different sets of confounders in the original study did not substantially affect the results.

Conclusions

A significant correlation may exist between HIV infection and intestinal disease, and more large-scale studies are needed to draw firm conclusions. Therefore, future studies on HIV and IBD are warranted. It is recommended that HIV patients be screened for intestinal diseases.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

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Acknowledgements

We thank Wen Fang (the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China) for providing assistance with language editing.

Funding

This work was supported by the Key Research Project of Zhejiang Province for Traditional Chinese Medicine (2019C03076), the National Key Research and Development Program of China (2023YFC3603100 and 2023YFC3603105) and “Leading Goose” R&D Program of Zhejiang (2022C03076-4).

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Author notes

  1. Wei Huang and Yao-dan Zhang contributed equally to this work.

Authors and Affiliations

  1. Department of Emergency Medicine, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310003, Zhejiang, People’s Republic of China

    Wei Huang, Ping Wang, Cong-ying Song, Xuan Lu, Meng-xiao Feng & Yuan-qiang Lu

  2. Zhejiang Key Laboratory for Diagnosis and Treatment of Physic-chemical and Aging-related Injuries, Hangzhou, Zhejiang, People’s Republic of China

    Wei Huang, Ping Wang, Cong-ying Song, Xuan Lu, Meng-xiao Feng & Yuan-qiang Lu

  3. School of Public Health, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China

    Wei Huang, Yao-dan Zhang & Yuan-qiang Lu

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Contributions

Wei Huang: Conceptualization, Formal analysis, Methodology, Software, Writing – original draft. Yao-dan Zhang: Data curation, Writing – original draft. Ping Wang, Cong-ying Song, Xuan Lu, Meng-xiao Feng: Writing – review & editing. Yuan-qiang Lu: Conceptualization, Data curation, Project administration, Writing – review & editing.

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Correspondence to Yuan-qiang Lu.

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Huang, W., Zhang, Yd., Wang, P. et al. HIV infection increases the risk of inflammatory bowel disease: a systematic review and meta-analysis. BMC Infect Dis 24, 1030 (2024). https://doi.org/10.1186/s12879-024-09964-z

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