HIV and aging: time for a new paradigm

An internationally generalizable risk index for mortality after one year of antiretroviral therapy

OBJECTIVE

Despite the success of antiretroviral therapy (ART), excess mortality continues for those with HIV infection. A comprehensive approach to risk assessment, addressing multiorgan system injury on ART, is needed. We sought to develop and validate a practical and generalizable mortality risk index for HIV-infected individuals on ART.

DESIGN AND METHODS

The Veterans Aging Cohort Study (VACS) was used to develop the VACS Index, based on age, CD4 cell count, HIV-1 RNA, hemoglobin, aspartate and alanine transaminase, platelets, creatinine and hepatitis C status, and a Restricted Index based on age, CD4 cell count and HIV-1 RNA with an outcome of death up to 6 years after ART initiation. Validation was in six independent cohorts participating in the ART Cohort Collaboration (ART-CC).

RESULTS

In both the development (4932 patients, 656 deaths) and validation cohorts (3146 patients, 86 deaths) the VACS Index had better discrimination than the Restricted Index (c-statistics 0.78 and 0.72 in VACS, 0.82 and 0.78 in ART-CC). The VACS Index also demonstrated better discrimination than the Restricted Index for HIV deaths and non-HIV deaths, in men and women, those younger and older than 50 years, with and without detectable HIV-1 RNA, and with or without HCV coinfection.

CONCLUSIONS

Among HIV-infected patients treated with ART, the VACS Index more accurately discriminates mortality risk than traditional HIV markers and age alone. By accounting for multiorgan system injury, the VACS Index may prove a useful tool in clinical care and research.

Multimorbidity patterns in HIV-infected patients: the role of obesity in chronic disease clustering

BACKGROUND

Increases in multimorbidity and obesity have been noted in HIV-infected populations in the current treatment era. Patterns of multimorbid disease clustering and the impact of obesity on multimorbidity are understudied in this population.

METHODS

We examined obesity and multimorbidity patterns among 1844 HIV-infected patients in the UAB 1917 Clinic. Exploratory factor analysis was used to identify the underlying factor structure responsible for clustering. Patterns among the resulting morbidity factors by body mass index (BMI) category were explored. Multivariable logistic regression models were fit to identify predictors of multimorbidity cluster patterns.

RESULTS

The prevalence of multimorbidity was 65% (1205/1844). Prevalence increased with progressive BMI categories from underweight (64%) to obese (79%). Three multimorbidity clusters were identified: "metabolic," including hypertension, gout, diabetes mellitus, and chronic kidney disease (range, 0.41-0.84; P < 0.001); "Behavioral," including mood disorders, dyslipidemia, chronic obstructive pulmonary disease, chronic ulcer disease, osteoarthritis, obstructive sleep apnea, and cardiac disorders (range, 0.32-0.57; P < 0.001); "Substance Use," including alcohol abuse, substance abuse, tobacco abuse, and hepatitis C (range, 0.53-0.89; P < 0.001). Obesity was associated with increased odds of multimorbidity (obese vs. normal BMI category: OR = 1.52, 95% CI: 1.15 to 2.00).

CONCLUSIONS

Three patterns of disease clustering were identified. Obesity was associated with a higher likelihood of multimorbidity. The management of multimorbidity and obesity will need to be addressed in future clinical practice guidelines to enhance long-term outcomes of HIV-infected patients in the current treatment era.

Predictive accuracy of the Veterans Aging Cohort Study index for mortality with HIV infection: a North American cross cohort analysis

BACKGROUND

By supplementing an index composed of HIV biomarkers and age (restricted index) with measures of organ injury, the Veterans Aging Cohort Study (VACS) index more completely reflects risk of mortality. We compare the accuracy of the VACS and restricted indices (1) among subjects outside the Veterans Affairs Healthcare System, (2) more than 1-5 years of prior exposure to antiretroviral therapy (ART), and (3) within important patient subgroups.

METHODS

We used data from 13 cohorts in the North American AIDS Cohort Collaboration (n = 10, 835) limiting analyses to HIV-infected subjects with at least 12 months exposure to ART. Variables included demographic, laboratory (CD4 count, HIV-1 RNA, hemoglobin, platelets, aspartate and alanine transaminase, creatinine, and hepatitis C status), and survival. We used C-statistics and net reclassification improvement (NRI) to test discrimination varying prior ART exposure from 1 to 5 years. We then combined Veterans Affairs Healthcare System (n = 5066) and North American AIDS Cohort Collaboration data, fit a parametric survival model, and compared predicted to observed mortality by cohort, gender, age, race, and HIV-1 RNA level.

RESULTS

Mean follow-up was 3.3 years (655 deaths). Compared with the restricted index, the VACS index showed greater discrimination (C-statistics: 0.77 vs. 0.74; NRI: 12%; P < 0.0001). NRI was highest among those with HIV-1 RNA <500 copies per milliliter (25%) and age ≥50 years (20%). Predictions were similar to observed mortality among all subgroups.

CONCLUSIONS

VACS index scores discriminate risk and translate into accurate mortality estimates over 1-5 years of exposure to ART and for diverse patient subgroups from North American.

Risk and protective factors associated with health-related quality of life among older gay and bisexual men living with HIV disease

PURPOSE

To identify risk and protective factors associated with mental and physical health-related quality of life, after controlling for key background characteristics, in a population of older gay and bisexual men living with HIV disease. Previous research examining quality of life among persons living with HIV rarely includes older adults.

DESIGN AND METHODS

Survey responses from 226 gay and bisexual men aged 50 and older, and living with HIV disease, which were part of the Caring and Aging with Pride study, were analyzed using multivariate linear regression models.

RESULTS

Findings reveal that comorbidity, limitations in activities, and victimization are significant risk factors for decreased physical and mental health-related quality of life. Stigma and HIV progression did not contribute to the overall outcome variables in multivariate models. Social support and self-efficacy serve as protective factors although social support was only significant with mental health-related quality of life.

IMPLICATIONS

Comorbidity, functional limitations, and lifetime victimization are risks to quality of life among older gay and bisexual men with HIV disease. Self-efficacy and social support represent intrapersonal and interpersonal resources that can be enhanced through interventions to improve health-related quality of life.

Comparison of functional status instruments in HIV-infected adults on effective antiretroviral therapy

BACKGROUND

The best method for assessment of functional status in human immunodeficiency virus type 1 (HIV-1) infected persons is unknown.

OBJECTIVE

We hypothesized that 3 instruments to assess frailty or disability in elderly populations would perform similarly in HIV-1-infected persons.

METHODS

HIV-infected subjects 45 to 65 years old with plasma HIV-1 RNA <48 copies/mL were classified prospectively as low, moderate, or high function by Fried's frailty phenotype (FFP), the Short Physical Performance Battery (SPPB), and 400-m walk test. Functional instrument agreement was evaluated by weighted kappa statistic, and relationships with demographic or clinical factors were evaluated by odds ratios (OR).

RESULTS

There were 359 participants (85% male, mean age 52 years, mean CD4+ lymphocyte count 551 cells/µL) who were evaluated. Three percent to 8% were low, 31% to 51% were moderate, and 42% to 62% were high function. FFP, SPPB, and 400-m walk test had moderate agreement for functional classification (61%-64%; κ = 0.34-0.41). Across instruments, lower reported physical activity (OR ≯ 5.5; P ≤ .005), no current employment (OR ≯ 4.2; P < .02), arthritis (OR ≯ 6.5; P < .02), neurologic disease (OR ≯ 2.6; P < .05), debilitating pain (OR ≯ 5.4; P < .008), psychiatric disease (OR ≯3.1; P < .03), more comorbidities (OR ≯ 3.6; P ≤ .005), and more non-antiretroviral therapy medications (OR ≯ 3.5; P ≤ .01) were associated with lower function. Current CD4 <200 cells/µL was more likely among low-function (11%) than high-function (2%) persons on FFP (P = .04); other HIV-related characteristics were not significantly different (P > .05) between functional categories on any instrument.

CONCLUSIONS

Moderate functional impairment is common among middle-aged HIV-infected persons, with similar frequencies of impairment detected by 3 instruments. Reduction in comorbid disease, increased physical activity, and improved pain symptom management could reduce functional impairment among persons aging with HIV-infection.

Chronic Care Model Decision Support and Clinical Information Systems interventions for people living with HIV: a systematic review

BACKGROUND

The Chronic Care Model is an effective framework for improving chronic disease management. There is scarce literature describing this model for people living with HIV. Decision Support (DS) and Clinical Information Systems (CIS) are two components of this model that aim to improve care by changing health care provider behavior.

OBJECTIVE

Our aim was to assess the effectiveness of DS and CIS interventions for individuals with HIV, through a systematic literature review.

DESIGN

We performed systematic electronic searches from 1996 to February 2011 of the medical (E.g. Medline, EMBASE, CINAHL) and grey literature. Effectiveness was measured by the frequency of statistically significant outcome improvement. Data and key equity indicator extraction and synthesis was completed.

PARTICIPANTS AND INTERVENTIONS

We included comparative studies of people living with HIV that examined the impact of DS or CIS interventions on outcomes.

MAIN MEASURES

The following measures were assessed: outcome (immunological/virological, medical, psychosocial, economic measures) and health care process/performance measures.

KEY RESULTS

Records were screened for relevance (n = 10,169), full-text copies of relevant studies were obtained (n = 123), and 16 studies were included in the review. Overall, 5/9 (55.6%) and 17/41 (41.5%) process measures and 5/12 (41.7%) and 3/9 (33.3%) outcome measures for DS and CIS interventions, respectively, were statistically significantly improved. DS-explicit mention of implementation of guidelines and CIS-reminders showed the most frequent improvement in outcomes. DS-only interventions were more effective than CIS-only interventions in improving both process and outcome measures. Clinical, statistical and methodological heterogeneity among studies precluded meta-analysis. Primary studies were methodologically weak and often included multifaceted interventions that made assessment of effectiveness challenging.

CONCLUSIONS

Overall, DS and CIS interventions may modestly improve care for people living with HIV, having a greater impact on process measures compared to outcome measures. These interventions should be considered as part of strategies to improve HIV care through changing provider performance.

Pathogenesis and clinical implications of HIV-related anemia in 2013

Anemia is a common feature of HIV-related disease and has been uniformly demonstrated to be an independent predictor of morbidity and mortality. Although anemia often responds to combination antiretroviral therapy, many patients remain anemic despite therapy and such persistent anemia continues to negatively affect prognosis regardless of drug response. Anemia is also a common feature of normal aging. We postulate that the pathophysiology of anemia in HIV, especially that which persists in the face of combination antiretroviral therapy, is a reflection of underlying proinflammatory pathways that are also thought to contribute to anemia in the elderly, as well as other age-related chronic diseases such as cardiovascular disease and chronic obstructive pulmonary disease. This suggests that HIV induces inflammatory pathways that are associated with a pattern of accelerated aging and that anemia is a biomarker of these processes. A better understanding of the pathophysiology of HIV-related anemia may provide important entry points for improving the chronic manifestations of HIV-related disease.

Diabetes and Hypertension among Patients Receiving Antiretroviral Treatment Since 1998 in Senegal: Prevalence and Associated Factors

Cardiovascular risk factors in people on antiretroviral treatment (ART) are poorly documented in resource-constrained settings. A cross-sectional study was conducted in 2009 to assess prevalence of diabetes and hypertension in a sample of 242 HIV-infected patients who had initiated ART between 1998 and 2002 in Dakar, Senegal (ANRS 1215 observational cohort). World Health Organization (WHO) criteria were applied to diagnose diabetes and hypertension. Multiple logistic regressions were used to identify factors associated with diabetes and hypertension. Patients had a median age of 46 years and had received ART for a median duration of about 9 years. 14.5% had diabetes and 28.1% had hypertension. Long duration of ART (≥119 months), older age, higher body mass index (BMI), and higher levels of total cholesterol were associated with higher risks of diabetes. Older age, higher BMI at ART initiation, and higher levels of triglycerides were associated with higher risk of hypertension. This study shows that diabetes and hypertension were frequent in these Senegalese HIV patients on ART. It confirms the association between duration of ART and diabetes and highlights the need to implement programs for prevention of cardiovascular risk factors in HIV patients from resource-constrained settings.

HIV infection, aging, and immune function: implications for cancer risk and prevention

PURPOSE OF REVIEW

Combination antiretroviral therapy (ART) has turned HIV infection into a complex chronic disease. This article documents cancer risk among HIV-infected persons, reviews immune system effects of HIV infection in relation to cancer risk, discusses implications for cancer prevention, and suggests future research directions.

RECENT FINDINGS

There has been a shift in the cancer spectrum from AIDS-defining cancers (ADC) to non-ADC, although the burden of ADC remains high. Although a high prevalence of non-HIV cancer risk factors among HIV-infected persons contributes to cancer risk, substantial evidence has accumulated in favor of an independent association between HIV-induced immunodeficiency and elevated risk of many specific cancer types, most of viral cause, although further work is needed to disentangle immunodeficiency and smoking effects for lung cancer, and immunodeficiency and hepatitis virus effects for liver cancer. Relationships between cancer risk and two other immune system hallmarks of HIV infection, chronic inflammation, and immune dysfunction/senescence, remain poorly understood.

SUMMARY

Early, sustained ART is a crucial component of cancer prevention. Continued epidemiologic monitoring is needed to detect possible effects on cancer risk of specific ART classes or medications, long-term exposure to systemic inflammation or immune dysfunction, or earlier or more effective ART.

Prevention of HIV Among Older Adults

Objective:

This study reviews the existing literature on the prevention of HIV among older adults, including universal and indicated prevention programs and prevention strategies.

Method:

A literature search was conducted between September and October of 2011 to identify studies for this review. Several different electronic databases and a combination of keywords were used to conduct the search. In addition, the reference section of each article was reviewed for additional articles.

Results:

A total of 18 articles were identified and reviewed. Three of the articles examined universal prevention, five of the articles examined indicated prevention, and the remainder of the articles provided strategies and recommendations for the prevention of HIV among older adults.

Discussion:

The existing studies document evidence for preventing future cases of HIV/AIDS among older adults. Additional studies and universal and selected interventions are needed in an effort to reduce the number of older adults being diagnosed with HIV.

At the intersection of HIV/AIDS and cancer: a qualitative needs assessment of community-based HIV/AIDS service organizations

Due to advances in treatment, persons living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) are living longer, but with aging, immune deficits, and lifestyle factors, they are at increased risk for cancer. This challenges community-based AIDS service organizations (ASOs) to address the growing cancer needs of persons living with HIV/AIDS (PLWHA). Community-based participatory research was applied to engage ASOs in exploring their capacities and needs for integrating cancer-focused programming into their services. Focus groups were conducted with a community advisory board (CAB) representing 10 community-based organizations serving PLWHA. Three 90-minute, serial focus groups were conducted with a mean number of seven participants. Topics explored CAB members' organizational capacities and needs in cancer prevention, detection, treatment, and survivorship. Transcript analyses identified six themes: (a) agencies have limited experience with cancer-focused programs, which were not framed as cancer specific; (b) agencies need resources and collaborative partnerships to effectively incorporate cancer services; (c) staff and clients must be educated about the relevance of cancer to HIV/AIDS; (d) agencies want to know about linkages between HIV/AIDS and cancer; (e) cancer care providers should be culturally competent; and (f) agencies see opportunities to improve their services through research participation but are wary. Agency capacities were strong in relationships with clients and cultural competency, a holistic view of PLWHA health, expertise in prevention activities, and eagerness to be on the cutting edge of knowledge. Cancer education and prevention were of greatest interest and considered most feasible, suggesting that future projects develop accordingly. These findings suggest a high level of receptivity to expanding or initiating cancer-focused activities but with a clear need for education and awareness building. Qualitative findings will inform a large quantitative survey to validate identified themes, which will be applied in developing interventions to assist ASOs in adopting or expanding cancer-focused activities.

Counting the cost of not costing HIV health facilities accurately: pay now, or pay more later

The HIV pandemic continues to be one of our greatest contemporary public health threats. Policy makers in many middle- and low-income countries are in the process of scaling up HIV prevention, treatment and care services in the context of a reduction in international HIV funding due to the global economic downturn. In order to scale up services that are sustainable in the long term, policy makers and implementers need to have access to robust and contemporary strategic information, including financial information on expenditure and cost, in order to be able to plan, implement, monitor and evaluate HIV services. A major problem in middle- and low-income countries continues to be a lack of basic information on the use of services, their cost, outcome and impact, while those few costing studies that have been performed were often not done in a standardized fashion. Some researchers handle this by transposing information from one country to another, developing mathematical or statistical models that rest on assumptions or information that may not be applicable, or using top-down costing methods that only provide global financial costs rather than using bottom-up ingredients-based costing. While these methods provide answers in the short term, countries should develop systematic data collection systems to store, transfer and produce robust and contemporary strategic financial information for stakeholders at local, sub-national and national levels. National aggregated information should act as the main source of financial data for international donors, agencies or other organizations involved with the global HIV response. This paper describes the financial information required by policy makers and other stakeholders to enable them to make evidence-informed decisions and reviews the quantity and quality of the financial information available, as indicated by cost studies published between 1981 and 2008. Among the lessons learned from reviewing these studies, a need was identified for providing countries with practical guidance to produce reliable and standardized costing data to monitor performance, as countries want to improve programmes and services, and have to demonstrate an efficient use of resources. Finally, the issues raised in this paper relate to the provision of all areas of healthcare in countries and it is going to be increasingly important to leverage the lessons learned from the HIV experience and use resources more effectively and efficiently to improve health systems in general.

HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group

HIV risk behaviors, susceptibility to HIV acquisition, progression of disease after infection, and response to antiretroviral therapy all vary by age. In those living with HIV, current effective treatment has increased the median life expectancy to >70 years of age. Biologic, medical, individual, social, and societal issues change as one ages with HIV infection, but there has been only a small amount of research in this field. Therefore, the Office of AIDS Research of the National Institutes of Health commissioned a working group to develop an outline of the current state of knowledge and areas of critical need for research in HIV and Aging; the working groups' findings and recommendations are summarized in this report. Key overarching themes identified by the group included the following: multimorbidity, polypharmacy, and the need to emphasize maintenance of function; the complexity of assessing HIV versus treatment effects versus aging versus concurrent disease; the inter-related mechanisms of immune senescence, inflammation, and hypercoagulability; the utility of multivariable indices for predicting outcomes; a need to emphasize human studies to account for complexity; and a required focus on issues of community support, caregivers, and systems infrastructure. Critical resources are needed to enact this research agenda and include expanded review panel expertise in aging, functional measures, and multimorbidity, and facilitated use and continued funding to allow long-term follow-up of cohorts aging with HIV.

Projected demographic profile of people living with HIV in Australia: planning for an older generation

BACKGROUND

Advances in HIV antiretroviral therapy (ART) has reduced mortality in people living with HIV (PLHIV), resulting in an ageing population of PLHIV. Knowledge of demographic details such as age, geographical location and sex, will aid in the planning of training and resource allocation to effectively care for the future complex health needs of PLHIV.

METHODS

An agent-based, stochastic, geographical model was developed to determine the current and future demographic of PLHIV in Australia. Data and parameters were sourced from Australia's National HIV Registry and peer reviewed literature. Processes that were simulated include progression to AIDS, mortality and internal migration.

FINDINGS

The model estimates the mean age of PLHIV in Australia is increasing at a rate of 0.49 years each year. The expected proportion of PLHIV in over 55 years is estimated to increase from 25.3% in 2010 to 44.2% in 2020. Median age is lower in inner-city areas of the capital cities than in rural areas. The areas with the highest prevalence of HIV will continue to be capital cities; however, other areas will have greater percentage growth from 2010 to 2020.

CONCLUSIONS

The age of the population of people living with HIV is expected to increase considerably in the future. As the population of PLHIV ages, specialist clinical training and resource provision in the aged care sector will also need to be addressed.

Lessons learned from the first wave of aging with HIV

In this perspective piece, the authors consider what has been learned and is being studied about aging with HIV in resource-rich settings. The authors argue that although there is much that will be different about aging with HIV in other parts of the globe, there are common themes and approaches to care. These include the observation that most patients have more than one health condition, and the need to assess individual risk, prioritize care, and consider the total burden of disease when considering further testing and treatment.

Prevalence of HIV and chronic comorbidities among older adults

OBJECTIVES

Limited evidence is available on HIV, aging and comorbidities in sub-Saharan Africa. This article describes the prevalence of HIV and chronic comorbidities among those aged 50 years and older in South Africa using nationally representative data.

DESIGN

The WHO's Study of global AGEing and adult health (SAGE) was conducted in South Africa in 2007-2008. SAGE includes nationally representative cohorts of persons aged 50 years and older, with comparison samples of those aged 18-49 years, which aims to study health and its determinants.

METHODS

Logistic and linear regression models were applied to data from respondents aged 50 years and older to determine associations between age, sex and HIV status and various outcome variables including prevalence of seven chronic conditions.

RESULTS

HIV prevalence among adults aged 50 and older in South Africa was 6.4% and was particularly elevated among Africans, women aged 50-59 and those living in rural areas. Rates of chronic disease were higher among all older adults compared with those aged 18-49. Of those aged 50 years and older, 29.6% had two or more of the seven chronic conditions compared with 8.8% of those aged 18-49 years (P < 0.0001). When controlling for age and sex among those aged 50 and older, BMI was lower among HIV-infected older adults aged 50 and older (27.5 kg/m2) than in HIV-uninfected individuals of the same age (30.6) (P < 0.0001). Grip strength among HIV-infected older adults was significantly (P=0.004) weaker than among similarly-aged HIV-uninfected individuals.

CONCLUSION

HIV-infected older adults in South Africa have high rates of chronic disease and weakness. Studies are required to examine HIV diagnostics and treatment instigation rates among older adults to ensure equity of access to quality care, as the number and percentage of older adults living with HIV is likely to increase.

The impact of antiretroviral treatment on the age composition of the HIV epidemic in sub-Saharan Africa

INTRODUCTION

Antiretroviral treatment (ART) coverage is rapidly expanding in sub-Saharan Africa (SSA). Based on the effect of ART on survival of HIV-infected people and HIV transmission, the age composition of the HIV epidemic in the region is expected to change in the coming decades. We quantify the change in the age composition of HIV-infected people in all countries in SSA.

METHODS

We used STDSIM, a stochastic microsimulation model, and developed an approach to represent HIV prevalence and treatment coverage in 43 countries in SSA, using publicly available data. We predict future trends in HIV prevalence and total number of HIV-infected people aged 15-49 years and 50 years or older for different ART coverage levels.

RESULTS

We show that, if treatment coverage continues to increase at present rates, the total number of HIV-infected people aged 50 years or older will nearly triple over the coming years: from 3.1 million in 2011 to 9.1 million in 2040, dramatically changing the age composition of the HIV epidemic in SSA. In 2011, about one in seven HIV-infected people was aged 50 years or older; in 2040, this ratio will be larger than one in four.

CONCLUSION

The HIV epidemic in SSA is rapidly ageing, implying changing needs and demands in many social sectors, including health, social care, and old-age pension systems. Health policymakers need to anticipate the impact of the changing HIV age composition in their planning for future capacity in these systems.

HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries

Although health systems in most low-income countries largely provide episodic care for acute symptomatic conditions, many HIV programs have developed effective, locally owned and contextually appropriate policies, systems and tools to support chronic care services for persons living with HIV (PLWH). The continuity of care provided by such programs may be especially critical for older PLWH, who are at risk for more rapid progression of disease and are more likely to have complications of HIV and its treatment than their younger counterparts. Older PLWH are also more likely to have other chronic noncommunicable diseases (NCDs), including hypertension, diabetes, cancers and chronic lung disease. As the number of older PLWH rises, enhanced chronic care systems will be required to optimize their health and wellbeing. These systems, lessons and resources can also be leveraged to support the burgeoning numbers of HIV-negative individuals with chronic NCD in need of ongoing care.

Sensibility assessment of the HIV Disability Questionnaire

PURPOSE

Our purpose was to assess the sensibility of the human immunodeficiency virus (HIV) Disability Questionnaire (HDQ), the first HIV-specific disability questionnaire.

METHODS

We administered the HDQ, a sensibility questionnaire and a structured qualitative interview to 22 adults living with HIV and five experienced clinicians. We considered the HDQ sensible if median scores on the sensibility questionnaire were ≥5 for adults living with HIV and ≥4 for clinicians for at least 80% of the items. We analyzed the interview data using directed qualitative content analytical techniques.

RESULTS

Questionnaire scores were ≥5 for 88% (15/17) of the items and ≥4 for 100% (17/17) of the items for adults living with HIV and clinicians, respectively. The interview analysis indicated participants felt the HDQ possessed face and content validity in all disability dimensions, had adequate response options, was easy to complete, and adequately captured the episodic nature of disability. Participants had mixed responses about the questionnaire title and provided recommendations to refine item wording and response options.

CONCLUSIONS

The HDQ appears sensible for use with adults living with HIV. Next steps include further measurement property assessment. The HDQ may be used by rehabilitation clinicians and researchers to assess disability experienced by adults living with HIV.

IMPLICATIONS FOR REHABILITATION

• As people with HIV infection live longer, individuals may face a range of health-related challenges due to the disease, concurrent health conditions and the potential adverse effects of treatment. Together, these health-related challenges may be termed disability. • The HIV Disability Questionnaire (HDQ) is the first HIV-specific instrument developed to describe the presence, severity and episodic nature of the disability experienced by adults living with HIV. The HDQ is comprised of four domains including symptoms and impairments, uncertainty about future health, difficulties carrying out day-to-day activities, and challenges to social inclusion. • The HDQ appears sensible for use with adults living with HIV, possessing face and content validity and ease of use in all four domains as well as describing the daily episodic nature of disability. • The HDQ may be used by rehabilitation clinicians and researchers to assess disability experienced by adults living with HIV.

Perception of vulnerability to HIV infection among older people in Nairobi, Kenya: a need for intervention

It is evident that sexual activity tends to decrease with age. Nonetheless, it is still prevalent enough to be considered a risk factor for the spread of HIV among older people. This paper uses quantitative data for 2053 individuals to examine HIV risk perception and correlates of perceived risk among older people aged 50 years and older living in Nairobi slums. It emerged that a majority of older people did not consider themselves at risk of infection. Of those who felt at risk, a greater proportion sensed only a small chance of contracting HIV. Women cited 'no sexual activity' while men mentioned 'having only one and/or a faithful sexual partner' as the primary reasons for perceiving minimal risk of HIV infection. There were no differences by sex in the basis for perceiving moderate-to-great risk of infection. Religion is a key factor in risk perception with Muslims perceiving higher levels of risk and, conversely, devotees irrespective of faith perceiving lower levels of risk. Older people willing to be tested for HIV had a decreased likelihood of perceived risk compared with those unwilling to be tested. This paper recommends evaluation of older people's perception of risk in order to better inform interventions aimed at minimizing their vulnerability to HIV infection.

Lenalidomide enhancement of human T cell functions in human immunodeficiency virus (HIV)-infected and HIV-negative CD4 T lymphocytopenic patients

Suppressed T cell functions in human immunodeficiency virus (HIV) infection were identified and corrected by lenalidomide in middle-aged HIV-infected patients. Chemotaxis of T cells from HIV-infected men (n = 6, mean 43 years) to sphingosine 1-phosphate (S1P) and CCL21 was significantly lower than that of HIV-negative men (n = 6, mean 41 years), and was enhanced significantly up to control levels by 100 and 1000 nM lenalidomide. Generation of interleukin (IL)-2, but not interferon (IFN)-γ, by T cells of middle-aged HIV-infected men was significantly lower than that for controls and was increased significantly by 10-1000 nM lenalidomide up to a maximum of more than 300%. CD4 and CD8 T cells isolated from healthy middle-aged men and reconstituted in vitro at a low CD4 : CD8 ratio typical of HIV infection had depressed chemotaxis to S1P, but not CCL21, and generation of IL-2, but not IFN-γ. Significant enhancement of chemotaxis to S1P and CCL21 was induced by 100-1000 nM lenalidomide only for normal T cells at a low CD4 : CD8 ratio. T cells from HIV-negative middle-aged CD4 T lymphocytopenic patients (n = 3), with a CD4 : CD8 ratio as low as that of HIV-infected patients, had similarly diminished chemotaxis to S1P and CCL21, and depressed generation of IL-2, but not IFN-γ. Lenalidomide at 30-1000 nM significantly enhanced chemotaxis to S1P and IL-2 generation for T cells from HIV-negative CD4 T lymphocytopenic patients as from HIV-infected patients, with less effect on CCL21-elicited chemotaxis and none for IFN-γ generation. Defects in functions of T cells from middle-aged HIV-infected men are partially attributable to CD4 T lymphocytopenia and are corrected by lenalidomide.

Immunosenescence and HIV

PURPOSE OF REVIEW

The present review discusses the interplay between HIV infection and other environmental factors (e.g. co-infection with CMV) in the acceleration of the aging process of the immune system, leading to 'immunosenescence.'

RECENT FINDINGS

Basic studies in cell biology demonstrate that replicative senescence is a common pathway of many cell lineages, including those of the immune system, characterized by activation of a unique pro-inflammatory secretory program. In the setting of HIV disease, this process is accelerated, resulting in an immunosuppressed state that diminishes the ability of the immune system to contain virus while at the same time facilitating viral replication and spread. Clinically, these changes result in a lower capacity to respond to new infections as well as an increased frequency of age-associated end-organ disease (e.g. cardiovascular complications, cancer, and neurologic disease).

SUMMARY

Accelerated immunosenescence in the setting of HIV disease is associated with increased morbidity and mortality, prompting the need for more investigation into its causes, diagnosis, and treatment.

Patient-reported symptoms on the antiretroviral regimen efavirenz/emtricitabine/tenofovir

Most patients (80-90%) newly diagnosed with HIV are started on the antiretroviral regimen efavirenz, emtricitabine, and tenofovir (EFV/FTC/TDF). Existing studies of patient tolerability, however, are limited. We compared symptom experiences of patients on EFV/FTC/TDF, and the subsequent impact on health-related quality of life, with those of patients on other combination antiretroviral therapy (cART). We conducted a cross-sectional analysis of the Veterans Aging Cohort Study from February 2008 to August 2009 to compare the symptom experiences of patients on EFV/FTC/TDF vs. other cART, unadjusted and then adjusted for treatment characteristics, and comorbid disease severity. We then assessed the association between EFV/FTC/TDF use and health-related quality of life. Among the 1,759 patients in our analytic sample, EFV/FTC/TDF use was associated with fewer symptoms than was other cART. The use of EFV/FTC/TDF was independently associated with health-related quality of life, and this association was at least partially explained by symptom burden.

The converging and diverging characteristics of HIV-positive and HIV-negative gay men in the Australian Gay Community Periodic Surveys, 2000-2009

To assess the changing health promotion needs of human immunodeficiency virus (HIV)-positive gay men in Australia, we analysed the social and behavioural characteristics of HIV-positive men in the Australian Gay Community Periodic Surveys. We looked at change over time in the characteristics of HIV-positive men (from 2000-2001 to 2008-2009) and compared HIV-positive men with their HIV-negative peers within each time period. Multivariate logistic regression analysis was used to assess independent changes over time within each HIV status group. A total of 21,620 responses were included in the analyses; 10,537 in 2000-2001 and 11,083 in 2008-2009. Between the two time periods, HIV-positive and HIV-negative men became more similar in the following areas: paid employment, sexual identity, number of male sex partners, the likelihood of having a regular male partner and having a seroconcordant regular male partner. The two groups diverged in these areas: age, ethnicity, educational level, social engagement with gay men, types of relationship with regular male partners, likelihood of unprotected anal intercourse with casual male partners and likelihood of HIV disclosure to casual male partners. Workforce participation and educational attainment have improved among HIV-positive gay men since 2000, but they still lag behind their HIV-negative peers in these areas. Because HIV-positive men are an ageing cohort, support services will need to increasingly address issues of HIV, sexuality and ageing with HIV-positive men. The increase in unprotected anal intercourse and HIV disclosure with casual partners means that education and support services will increasingly need to address effective HIV disclosure and non-condom-based risk reduction strategies with both HIV-positive and HIV-negative gay men.

Summary report from the Human Immunodeficiency Virus and Aging Consensus Project: treatment strategies for clinicians managing older individuals with the human immunodeficiency virus

By 2015, most of the people living with the human immunodeficiency virus (HIV) in the United States will be aged 50 and older. Many will have known their HIV status for at least a decade, and most will have received antiretroviral therapy for some, if not all, of the time since testing positive. As these individuals advance in years, they frequently acquire diseases more commonly associated with aging than with HIV. This represents a unique challenge for today's medical providers. Although these individuals may appear considerably older than their chronological age, they are typically too young to see a geriatrician. An HIV specialist, although knowledgeable in the nuances of antiretroviral therapy, may be less comfortable managing multiple age-related illnesses. Similarly, a geriatrician experienced in managing multiple, age-related conditions may be less familiar with adjusting HIV-related therapies. In this era of caring for older adults with HIV, these two medical disciplines are finding they have much to learn from each other.

Does an index composed of clinical data reflect effects of inflammation, coagulation, and monocyte activation on mortality among those aging with HIV?

BACKGROUND

When added to age, CD4 count and human immunodeficiency virus type 1 (HIV-1) RNA alone (Restricted Index), hemoglobin, FIB-4 Index, hepatitis C virus (HCV), and estimated glomerular filtration rate improve prediction of mortality. Weighted and combined, these 7 routine clinical variables constitute the Veterans Aging Cohort Study (VACS) Index. Because nonroutine biomarkers of inflammation (interleukin 6 [IL-6]), coagulation (D-dimer), and monocyte activation (sCD14) also predict mortality, we test the association of these indices and biomarkers with each other and with mortality.

METHODS

Samples from 1302 HIV-infected veterans on antiretroviral therapy were analyzed. Indices were calculated closest to date of collection. We calculated Spearman correlations stratified by HIV-1 RNA and HCV status and measured association with mortality using C statistics and net reclassification improvement (NRI).

RESULTS

Of 1302 subjects, 915 had HIV-1 RNA <500 copies/mL and 154 died. The VACS Index was more correlated with IL-6, D-dimer, and sCD14 than the Restricted Index (P < .001). It was also more predictive of mortality (C statistic, 0.76; 95% confidence interval [CI], .72-.80) than any biomarker (C statistic, 0.66-0.70) or the Restricted Index (C statistic, 0.71; 95% CI, .67-.75). Compared to the Restricted Index alone, NRI resulted from incremental addition of VACS Index components (10%), D-dimer (7%), and sCD14 (4%), but not from IL-6 (0%).

CONCLUSIONS

Among HIV-infected individuals, independent of CD4, HIV-1 RNA, and age, hemoglobin and markers of liver and renal injury are associated with inflammation. Addition of D-dimer and sCD14, but not IL-6, improves the predictive accuracy of the VACS Index for mortality.

The structure of coping among older adults living with HIV/AIDS and depressive symptoms

One-third of adults living with HIV/AIDS are over the age of 50. This study evaluated the structure of coping among 307 older adults living with HIV/AIDS. Participants completed 61 coping items and measures of anxiety, depression, loneliness, and coping self-efficacy. Exploratory factor analyses retained 40 coping items loading on five specific first order factors (Distancing Avoidance, Social Support Seeking, Self-Destructive Avoidance, Spiritual Coping, and Solution-Focused Coping) and two general second order factors (Active and Avoidant Coping). Factors demonstrated good reliability and validity. Results suggest that general coping factors should be considered with specific factors when measuring coping among older adults.

'Got a room for me?' Housing experiences of older adults living with HIV/AIDS in Ottawa

HIV/AIDS and aging is an important emerging topic with relevance to gerontology. Currently, little is known about the housing experiences of older adults within the context of HIV/AIDS. This article explores the issue and examines interview data concerning the housing experiences of 11 older adults (52 to 67 years old) living with HIV/AIDS in Ottawa, Ontario. Participants' stories revealed concerns relating to three major themes: acceptance into retirement homes and long-term care communities, barriers to accessing subsidized housing services, and homelessness. Participants reported feeling that they lacked recognition and experienced confusion about their future housing prospects. These data suggest that a shift may be occurring in the housing needs of people aging with HIV/AIDS. This emerging population presents challenges to mainstream ideas of aging. We conclude that increased attention is needed in research, policy, and practice to address housing issues among this age group of people living with HIV/AIDS.

Mechanisms of immunosenescence: lessons from models of accelerated immune aging

With increasing age, the ability of the adaptive immune system to respond to vaccines and to protect from infection declines. In parallel, the production of inflammatory mediators increases. While cross-sectional studies have been successful in defining age-dependent immunological phenotypes, studies of accelerated immune aging in human subpopulations have been instrumental in obtaining mechanistic insights. The immune system depends on its regenerative capacity; however, the T cell repertoire, once established, is relatively robust to aging and only decompensates when additionally stressed. Such stressors include chronic infections such as CMV and HIV, even when viral replication is controlled, and autoimmune diseases. Reduced regenerative capacity, chronic immune activation in the absence of cell exhaustion, T cell memory inflation, and accumulation of highly potent effector T cells in these patients synergize to develop an immune phenotype that is characteristic of the elderly. Studies of accelerated immune aging in autoimmune diseases have identified an unexpected link to chronic DNA damage responses that are known to be important in aging, but so far had not been implicated in immune aging.

Lung Disease in Older Patients with HIV

Successful treatment of HIV with combination antiretroviral therapy (ART) has resulted in an aging HIV-infected population. As HIV-infected patients are living longer, noninfectious pulmonary diseases are becoming increasingly prevalent with a proportional decline in the incidence of opportunistic infections (OIs). Pulmonary OIs such as Pneumocystis jirovecii pneumonia (PCP) and tuberculosis are still responsible for a significant proportion of pulmonary diseases in HIV-infected patients. However, bacterial pneumonia (BP) and noninfectious pulmonary diseases such as chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary arterial hypertension (PAH), and interstitial lung disease (ILD) account for a growing number of pulmonary diseases in aging HIV-infected patients. The purpose of this chapter is to discuss the spectrum and management of pulmonary diseases in aging HIV-infected patients, although limited data exists to guide management of many noninfectious pulmonary diseases in HIV-infected patients. In the absence of such data, treatment of lung diseases in HIV-infected patients should generally follow guidelines for management established in HIV-uninfected patients.

Telephone-administered motivational interviewing reduces risky sexual behavior in HIV-positive late middle-age and older adults: a pilot randomized controlled trial

By 2014, 50% of all adults living with HIV/AIDS will be 50-plus years of age. This pilot randomized controlled trial assessed the efficacy of two telephone-delivered motivational interviewing (MI) interventions to reduce risky sexual behavior in HIV-infected adults 45-plus years old. Eligible participants reported engaging in at least one occasion of unprotected anal and/or vaginal intercourse in the 3 months prior to study enrollment. Participants were randomly assigned to receive four sessions of telephone-delivered MI, one session of telephone-delivered MI, or no MI. Relative to 4-session MI participants, Controls reported approximately three times as many episodes of unprotected sex at 3- and 6-month follow-up, while 1-session MI participants reported four times as many unprotected sex acts at 3- and 6-month follow-up. No differences in condom use were observed between 1-session MI and Control participants. Additional large-scale studies that evaluate this intervention approach are warranted.

Anti-retroviral treatment outcomes among older adults in Zomba district, Malawi

BACKGROUND

There are approximately 3 million people aged 50 and older in sub-Saharan Africa who are HIV-positive. Despite this, little is known about the characteristics of older adults who are on treatment and their treatment outcomes.

METHODS

A retrospective cohort analysis was performed using routinely collected data with Malawi Ministry of Health monitoring tools from facilities providing antiretroviral therapy services in Zomba district. Patients aged 25 years and older initiated on treatment from July 2005 to June 2010 were included. Differences in survival, by age group, were determined using Kaplan-Meier survival plots and Cox proportional hazards regression models.

RESULTS

There were 10,888 patients aged 25 and older. Patients aged 50 and older (N = 1419) were more likely to be male (P<0.0001) and located in rural areas (P = 0.003) than those aged 25-49. Crude survival estimates among those aged 50-59 were not statistically different from those aged 25-49 (P = 0.925). However, survival among those aged 60 and older (N = 345) was worse (P = 0.019) than among those 25-59. In the proportional hazards model, after controlling for sex and stage at initiation, survival in those aged 50-59 did not differ significantly from those aged 25-49 (hazard ratio 1.00 (95% CI: 0.79 to 1.27; P = 0.998) but the hazard ratio was 1.46 (95% CI: 1.03 to 2.06; P = 0.032) for those aged 60 and older compared to those aged 25-49.

CONCLUSIONS

Treatment outcomes of those aged 50-59 are similar to those aged 25-49. A better understanding of how older adults present for and respond to treatment is critical to improving HIV services.

Premature age-related comorbidities among HIV-infected persons compared with the general population

BACKGROUND

Human immunodeficiency virus (HIV)-infected patients may have a greater risk of noninfectious comorbidities (NICMs) compared with the general population. We assessed the prevalence and risk factors for NICMs in a large cohort of HIV-infected adults and compared these findings with data from matched control subjects.

METHODS

We performed a case-control study involving antiretroviral therapy (ART)-experienced HIV-infected patients treated at Modena University, Italy, from 2002 through 2009. These patients were compared with age-, sex-, and race-matched adults (control subjects) from the general population included in the CINECA ARNO database. NICMs included cardiovascular disease, hypertension, diabetes mellitus, bone fractures, and renal failure. Polypathology (Pp) was defined as the concurrent presence of ≥2 NICMs. Logistic regression models were constructed to evaluate associated predictors of NICMs and Pp.

RESULTS

There were 2854 patients and 8562 control subjects. The mean age was 46 years, and 37% were women. Individual NICM and Pp prevalences in each age stratum were higher among patients than among controls (all P <.001). Pp prevalence among patients aged 41-50 years was similar to that among controls aged 51-60 years (P value was not statistically significant); diabetes mellitus, cardiovascular disease, bone fractures, and renal failure were statistically independent after adjustment for sex, age, and hypertension. Logistic regression models showed that independent predictors of Pp in the overall cohort were (all P < .001) age (odds ratio [OR], 1.11), male sex (OR, 1.77), nadir CD4 cell count <200 cells/μL (OR, 4.46), and ART exposure (OR, 1.01).

CONCLUSIONS

Specific age-related NICMs and Pp were more common among HIV-infected patients than in the general population. The prevalence of Pp in HIV-infected persons anticipated Pp prevalence observed in the general population among persons who were 10 years older, and HIV-specific cofactors (lower nadir CD4 cell count and more prolonged ART exposure) were identified as risk factors. These data support the need for earlier screening for NICMs in HIV-infected patients.

Predictors of immune recovery and the association with late mortality while on antiretroviral treatment in Cambodia

The objectives of this study were to examine the association of the on-treatment CD4 cell count with late mortality (after >6 months of antiretroviral treatment [ART]) and to identify the determinants of the long-term CD4 cell count evolution after treatment initiation. We conducted a retrospective analysis including all antiretroviral (ARV)-naïve adults initiating ART in a tertiary hospital in Phnom Penh, Cambodia from 2003-2010. We used Cox proportional hazards modelling (mortality analysis), including time-updated CD4 counts, and mixed-effects modelling (CD4 response over time). Overall, 2840 patients were included (47% male, median age: 34 years, median baseline CD4 count: 78 cells/μL). The median time on ART was 2.5 years (IQR 1.1-4.3); 71 patients died after >6 months of ART. The baseline CD4 count was the main determinant of the on-treatment CD4 cell count. Time-updated CD4 cell counts was the strongest determinant of late mortality with a HR of 0.32 (95% CI 0.16-0.63) and 0.29 (95% CI 0.11-0.71) for CD4 values of 200-350 cells/μL and 350-500 cells/μL respectively. We conclude that baseline CD4 counts strongly determine the long-term immune recovery, which critically affects late mortality. This calls for increased efforts for early ART initiation and availability of CD4 count testing in low-income countries.

Developing clinical practice guidelines in HIV rehabilitation: process recommendations and guiding principles

Our purpose was to develop process recommendations and guiding principles for future clinical practice guidelines in HIV rehabilitation. We conducted a scoping study that included focus group and interview consultations with 28 participants including people living with HIV, researchers, clinicians, educators, and policy stakeholders with expertise in HIV and rehabilitation. We used qualitative content analysis techniques to identify emergent themes related to the development of clinical practice guidelines. Results included seven recommendations for the process of developing clinical practice guidelines in HIV rehabilitation that spanned areas of flexibility, scope, adopting existing evidence from concurrent health conditions, format, interprofessional approach to development and implementation, terminology, and knowledge translation. Three guiding principles emerged to inform the philosophical approach for guideline development. These findings serve as a foundation for the development of clinical practice guidelines in HIV rehabilitation to enhance the care and treatment of people living with HIV.

HIV knowledge and attitudes among providers in aging: results from a national survey

Within 5 years, half the U.S. HIV-infected population will be over age 50, and providers caring for older adults must deal with this reality. This study assessed attitudes toward people with HIV/AIDS and knowledge of HIV/AIDS among physicians with a geriatrics specialty, and nurses and social workers who specialize in gerontology. A survey mailed in 2008 to a random sample of U.S. providers yielded a 60% response rate. Main outcome measures included: Knowledge of HIV/AIDS, attitudes toward people with HIV/AIDS, and knowledge of issues related to HIV in older adults. General knowledge of HIV/AIDS was good with scores of 89%, 84%, and 81% for physicians, nurses, and social workers, respectively; groups differed significantly (F(2, 483)=18.626, p<0.0005). Attitudes were positive, with a significant main effect of profession on the attitude subscales (F(4, 952)=6.84, p<0.0005). Eighty-three percent of the sample were unaware that dementia due to HIV may be reversible; no significant differences by profession (χ(2)=4.50, p=0.105). The sample had difficulty ranking the four most common risk factors for HIV infection in older adults, with no significant differences among the professions (F(2, 483)=1.22, p=0.296). Only 6% of the sample correctly ranked all four risk factors. Estimates of the percent of U.S. AIDS cases in people over age 50 varied widely; few answered correctly, with no significant differences by professional group (F(2,319)=2.82, p=0.06). These findings highlight the need for further education among providers who specialize in aging.

Ageing with HIV in South Africa

We used an established microsimulation model, quantified to a rural South African setting with a well developed antiretroviral treatment programme, to predict the impact of antiretroviral therapy on the HIV epidemic in the population aged over 50 years. We show that the HIV prevalence in patients aged over 50 years will nearly double in the next 30 years, whereas the fraction of HIV-infected patients aged over 50 years will triple in the same period. This ageing epidemic has important consequences for the South African healthcare system, as older HIV patients require specialized care.

What do we know about older adults and HIV? A review of social and behavioral literature

The fastest growing segment of the United States HIV population is people aged 50 and older. This heterogeneous group includes people with diverse pathways into HIV positive status in later life, including aging with the disease as well as later life-acquired infections. As people with HIV live into older ages, solving problems of successful secondary prevention and ongoing treatment requires more specific knowledge of the particular aging-related contextual sociocultural, psychosocial, and personal factors salient to the situations of persons living with HIV. Greater knowledge of these factors will help solve challenges to reducing psychological burden and promoting health maintenance for people with HIV. Yet, the current literature on aging and HIV remains nascent. To assess the state of knowledge of the sociocultural and behavioral factors associated with aging with HIV, we conducted a systematic critical content review of peer-reviewed social and behavioral research on aging and HIV to answer the question, "How have older age, and social, cultural, and behavioral aspects of the intersection of HIV and age been addressed in the literature?" We searched First Search, Proquest, Psych Info, Pub Med, Wilson Select Plus, and World Cat and identified 1549 articles. We then reviewed these to select peer-reviewed articles reporting results of research on the social and behavioral aspects of living with HIV at age 50 and older. Fifty-eight publications were identified that met study inclusion criteria. While few publications reported clear age-related differences, there were significant ethnic differences in living with HIV in later life and also differences among older people when groups were defined by mode of transmission. Findings are discussed in light of constructs from gerontology which may contribute to clarifying how later life, life course stage, and psychological development intersect with, influence, and are influenced by HIV disease and long-term anti-retroviral therapy use.

HIV infection, inflammation, immunosenescence, and aging

Although antiretroviral therapy for HIV infection prevents AIDS-related complications and prolongs life, it does not fully restore health. Long-term treated patients remain at higher than expected risk for a number of complications typically associated with aging, including cardiovascular disease, cancer, osteoporosis, and other end-organ diseases. The potential effect of HIV on health is perhaps most clearly exhibited by a number of immunologic abnormalities that persist despite effective suppression of HIV replication. These changes are consistent with some of the changes to the adaptive immune system that are seen in the very old ("immunosenescence") and that are likely related in part to persistent inflammation. HIV-associated inflammation and immunosenescence have been implicated as causally related to the premature onset of other end-organ diseases. Novel therapeutic strategies aimed at preventing or reversing these immunologic defects may be necessary if HIV-infected patients are to achieve normal life span.

Health care system and policy factors influencing engagement in HIV medical care: piecing together the fragments of a fractured health care delivery system

Grounded in a socio-ecological framework, we describe salient health care system and policy factors that influence engagement in human immunodeficiency virus (HIV) clinical care. The discussion emphasizes successful programs and models of service delivery and highlights the limitations of current, fragmented health care system components in supporting effective, efficient, and sustained patient engagement across a continuum of care. A fundamental need exists for improved synergies between funding and service agencies that provide HIV testing, prevention, treatment, and supportive services. We propose a feedback loop whereby actionable, patient-level surveillance of HIV testing and engagement in care activities inform educational outreach and resource allocation to support integrated "testing and linkage to care plus" service delivery. Ongoing surveillance of programmatic performance in achieving defined benchmarks for linkage of patients who have newly diagnosed HIV infection and retention of those patients in care is imperative to iteratively inform further educational efforts, resource allocation, and refinement of service delivery.