The influence of age-associated comorbidities on responses to combination antiretroviral therapy in older people living with HIV

Assessment of Metabolic, Inflammatory, and Immunological Disorders Using a New Panel of Plasma Parameters in People Living with HIV Undergoing Antiretroviral Therapy-A Retrospective Study

Background/Objectives: People living with HIV (PLWH) treated with combined antiretroviral therapy (cART) show a greater predisposition to metabolic and inflammatory disturbances compared to the general population. This study aimed to assess the effect of five years of cART use on the level of selected parameters related to carbohydrate and lipid metabolism and inflammation in PLWH compared to the uninfected. Methods: The levels of sirtuins (-1, -3, -6); irisin (IRS); myostatin (MSTN); peptide YY (PYY); glucagon-like peptide-1 (GLP-1); dipeptidyl peptidase IV (DPP-4); fetuin-A (FETU-A); pentraxin 3 (PTX3); chemokine stromal cell-derived factor 1 (SDF-1); regulated on activation, normal T cell expressed and presumably secreted (RANTES); and interleukins (-4, -7, -15) in the plasma of PLWH and a control group were evaluated by immunoassay methods. The results obtained after five years of antiretroviral therapy were compared with the levels obtained before and one year after cART. Results: Analysis of the parameters after five years of cART showed significantly higher levels in PLWH compared to the control group for SIRT-6, IRS, and IL-4 and significantly lower levels for RANTES and IL-7. There were significantly higher levels of SIRT-6, PYY, GLP-1, and PTX3 obtained after five years of cART compared to the results before therapy and after one year of cART. Conclusions: The results indicated changes occur in the expression of selected parameters during cART use in PLWH. Further research on the clinical usefulness of selected parameters and obtaining new information on the development of HIV-related comorbidities needs to be conducted.

HIV-Induced Thymic Insufficiency and Aging-Related Immunosenescence on Immune Reconstitution in ART-Treated Patients

The mechanisms underlying unsatisfactory immune reconstitution in HIV-1 positive patients under ART have not been fully elucidated, even after years of investigation. Thus, this study aimed to assess the correlation between age and thymic production profile, and its influence on inadequate immunological recovery. Here, 44 ART-treated patients with undetectable plasma HIV-1 load (<40 copies/mL) were classified as 31 immunological responders (IR) and 13 immunological non-responders (INR), according to their CD4+ T-cell count after 18 months of ART. The thymic function was assessed by identifying recent thymic emigrants (RTEs) CD4+ T cells (CD4+/CD45RA+CD31+) in PBMCs using flow cytometry. Clinical data were also analyzed from medical records. The INR group showed a higher age at ART initiation (41 ± 3.0) compared to the IR (33.7 ± 2.1) group (p = 0.041). Evaluating RTE CD4+ T-cells, we observed a lower percentage in the INR group (19.5 ± 6.3) compared to the IR group (29.9 ± 11.5) (p = 0.012). There was a strong negative correlation between age at ART initiation and RTE CD4+ T-cells in INRs (r = -0.784, p = 0.004). Our study has highlighted the thymic insufficiency and aging-related immunosenescence with unsatisfactory immunological recovery during ART in HIV-1 positive patients.

Mortality Risk Factors Among People Living with HIV Receiving Second-line Antiretroviral Therapy in Rural China

BACKGROUND

Second-line antiretroviral therapy (ART) was introduced in Henan Province in 2009. The number of people living with human immunodeficiency virus (HIV) starting this therapy is increasing.

OBJECTIVE

This study aimed to investigate the survival and factors affecting mortality among this group.

METHODS

We conducted a retrospective cohort study of people living with HIV (PLHIV) who switched to second-line ART between May 1, 2010, and May 1, 2016, using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

We followed 3,331 PLHIV for 26,988 person-years, of whom 508 (15.3%) died. The mortality rate was 1.88/100 person-years. After adjusting for confounding factors, we found being a woman (hazard ratio (HR), 0.66; 95% confidence interval (CI) 0.55-0.79), > 50 years old (HR, 2.69; 95% CI, 2.03-3.56), single/widowed (HR, 1.26; 95% CI, 1.04-1.52), having > 6 years of education (HR, 0.78; 95% CI, 0.65-0.94), Chinese medicine (HR, 0.75; 95% CI, 0.52-0.96), liver injury (HR, 1.58; 95% CI, 1.19-2.10), and CD4+ T cell count <200 cells/μl (HR, 1.94; 95% CI, 1.47-2.55), or 200-350 cells/μl (HR, 1.37; 95% CI, 1.03-1.82) were associated with mortality risk.

CONCLUSIONS

We found lower mortality among PLHIV who switched to second-line ART than most previous studies. The limitations of a retrospective cohort may, therefore, have biased the data, and prospective studies are needed to confirm the results. Moreover, Chinese medicine combined with second-line ART shows potential as a treatment for HIV.

Distinct inflammation-related proteins associated with T cell immune recovery during chronic HIV-1 infection

Chronic inflammation and T cell dysregulation persist in individuals infected with human immunodeficiency virus type 1 (HIV-1), even after successful antiretroviral treatment. The mechanism involved is not fully understood. Here, we used Olink proteomics to comprehensively analyze the aberrant inflammation-related proteins (IRPs) in chronic HIV-1-infected individuals, including in 24 treatment-naïve individuals, 33 immunological responders, and 38 immunological non-responders. T cell dysfunction was evaluated as T cell exhaustion, activation, and differentiation using flow cytometry. We identified a cluster of IRPs (cluster 7), including CXCL11, CXCL9, TNF, CXCL10, and IL18, which was closely associated with T cell dysregulation during chronic HIV-1 infection. Interestingly, IRPs in cluster 5, including ST1A1, CASP8, SIRT2, AXIN1, STAMBP, CD40, and IL7, were negatively correlated with the HIV-1 reservoir size. We also identified a combination of CDCP1, CXCL11, CST5, SLAMF1, TRANCE, and CD5, which may be useful for distinguishing immunological responders and immunological non-responders. In conclusion, the distinct inflammatory milieu is closely associated with immune restoration of T cells, and our results provide insight into immune dysregulation during chronic HIV-1 infection.

Prevalence of and prognosis for poor immunological recovery by virally suppressed and aged HIV-infected patients

Background

Antiretroviral therapy (ART) prolongs lifespan and decreases mortality of HIV infected patients. However, many patients do not achieve optimal immune reconstitution. The influence of non-optimal immune recovery on non-AIDS related diseases is not well defined in aged HIV-infected patients receiving ART.

Methods

A retrospective study was conducted at Tianjin Second People's Hospital, China to evaluate the association of an inadequate immunological response and non-AIDS diseases in HIV infected patients ≥60 years of age and virally suppressed for at least 2 years by ART.

Results

The study included patients (n = 666) who initiated ART between August 2009 and December 2020. The prevalence of patients with an inadequate immunological response was 29.6%. The percentage of non-AIDS diseases such as hypertension, cardiovascular disease (CVD), diabetes, tumor, and chronic kidney disease (CKD) was 32.9, 9.9, 31, 4.1, and 13%, respectively. In addition to baseline CD4+ T cell counts, CVD and tumor were associated with poor immune reconstitution in aged Chinese HIV-1 infected patients. The adjusted odds ratios (95% confidence interval) were AOR 2.45 (95% CI: 1.22-4.93) and 3.06 (95% CI: 1.09-8.56, p = 0.03). Inadequate immunological response was associated with greater mortality (AOR: 2.83, 95% CI: 1.42-5.67, p = 0.003) in this cohort.

Conclusion

These results tend to demonstrate appropriate drug selection at ART initiation and prevention of non-AIDS complications during ART decreased mortality of and an inadequate immunological response in aged HIV infected patients.

The Influence of Age-Associated Comorbidities on Responses to Combination Antiretroviral Therapy Among People Living with HIV, at the ART Clinic of Jimma Medical Center, Ethiopia: A Hospital-Based Nested Case-Control Study

Introduction

Despite the high prevalence of age-associated comorbidities in HIV patients in sub-Saharan Africa, there is a lack of data on their influence on treatment outcomes in HIV patients. Therefore, this study aimed to assess the impact of age-associated comorbidities on responses to antiretroviral therapy (ART) among people living with HIV.

Methods

A hospital-based nested case-control study was conducted among adult HIV-infected patients at the Jimma Medical Center from January 3 to June 2, 2022. Data were recorded by interviewing the patients and their medical chart and analyzed using The Statistical Package for Social Science (SPSS) v. 23, and at p <0.05.

The Results

The overall immunological and virologic failure rates were 13.8% and 13.4%, respectively. Being male [AOR = 3.079,95% CI (1.139-8.327)], having age-associated comorbidity [AOR:10.57,95% CI (2.810-39.779)], age ≥ 50 years [AOR = 2.855, 95% CI (1.023-7.9650)], alcohol intake [AOR = 3.648,95% CI (1.118-11.897)], and having a baseline CD4+ count of < 200 cells/uL [AOR:3.862, 95% CI (1.109-13.456) were an independent predictor of immunological failure; Whereas Being alcoholic [AOR:3.11, 95% CI (1.044-9.271)], having a baseline CD4+ count of < 200 cells/uL [AOR:5.11, 95% CI (1.547-16.892)], a low medication adherence [AOR:5.92, 95% CI (1.81-19.36)], bedridden baseline functional status [AOR:3.902, 95% CI (1.237-12.307)], and lack of cotrimoxazole prophylaxis [AOR:2.735,95% CI (1.084-6.902)] were found to be an independent predictor of virologic treatment failure, but being younger (age < 50 years) was protective for virologic failure.

Conclusion

Out of the eight patients who were treated for HIV at least one patient had developed immunological and/or virological failure. Age-associated comorbid chronic non-communicable diseases highly influence immunological outcomes compared with virological outcomes. Health providers should pay attention to age-associated comorbidities, encourage lifestyle modifications, and counsel on medication adherence to improve clinical outcomes in patients with HIV.

Recent advances in poor HIV immune reconstitution: what will the future look like?

Combination antiretroviral therapy has demonstrated proved effectiveness in suppressing viral replication and significantly recovering CD4+ T cell count in HIV type-1 (HIV-1)-infected patients, contributing to a dramatic reduction in AIDS morbidity and mortality. However, the factors affecting immune reconstitution are extremely complex. Demographic factors, co-infection, baseline CD4 cell level, abnormal immune activation, and cytokine dysregulation may all affect immune reconstitution. According to report, 10-40% of HIV-1-infected patients fail to restore the normalization of CD4+ T cell count and function. They are referred to as immunological non-responders (INRs) who fail to achieve complete immune reconstitution and have a higher mortality rate and higher risk of developing other non-AIDS diseases compared with those who achieve complete immune reconstitution. Heretofore, the mechanisms underlying incomplete immune reconstitution in HIV remain elusive, and INRs are not effectively treated or mitigated. This review discusses the recent progress of mechanisms and factors responsible for incomplete immune reconstitution in AIDS and summarizes the corresponding therapeutic strategies according to different mechanisms to improve the individual therapy.

Ageing with HIV in the United States: Changing trends in inpatient hospital stays and comorbidities, 2003-2015

INTRODUCTION

As people with HIV (PWH) age, they experience prolonged exposure to HIV and antiretroviral therapy, increased risks of developing age-related HIV-associated non-AIDS (HANA) comorbidities and higher rates of hospitalization. Few studies have explored the ageing of PWH and its impact on hospital stays in the US. This study examined trends, characteristics and comorbidities associated with hospital stays with HIV (HSWH) as compared with hospital stays without HIV (HSWOH).

METHODS

Thirteen years of pooled National Inpatient Sample (NIS) data from 2003 through 2015 were analysed to describe yearly trends. Trends were evaluated for eight major HANA conditions (cardiovascular disease, cancer, diabetes, liver disease, bone loss, kidney disease, pulmonary disease and neurological disease) across four age groups (18-34, 35-49, 50-64, 65+ years).

RESULTS

Although overall rates of hospitalization reduced across all age groups, the proportion of HIV-related hospitalization increased among older Americans. The average number of chronic conditions was higher for HSWH among all age groups and disproportionately increased for older PWH. Although age-adjusted rates of cardiovascular disease, cancer, bone loss and pulmonary disease were lower for HSWH relative to HSWOH, rates increased disproportionately over the study period. The prevalence of all major HANA conditions except cancer and diabetes increased among the elderly (65+), and the prevalence of cardiovascular disease, cancer, bone loss, kidney disease and pulmonary disease also increased among patients aged 50-64 years.

CONCLUSIONS

Higher rates of hospitalizations and HANA comorbidities were observed among older HIV patients. The ageing of PWH suggests increased future hospital resource utilization for HSWH. Appropriate training of healthcare providers is essential to managing increased comorbidity burdens of older PWH during hospital stays in the US.

Factors associated with viremia in people living with HIV on antiretroviral therapy in Guatemala

INTRODUCTION

Viral suppression prevents HIV transmission and disease progression, but socio-economic and clinical factors can hinder the goal of suppression. We evaluated factors associated with viral non suppression (VNS) and persistent viremia (PV) in people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in Guatemala.

METHODS

We conducted a cross sectional analysis using data from an ongoing cohort of PLHIV attending the largest HIV clinic in Guatemala. Univariable and multivariable analyses were conducted between PLHIV with viral suppression and detectable viremia. VNS was defined as most recent HIV RNA ≥ 200 copies/ml and PV as two consecutive HIV RNA ≥ 200 copies/ml.

RESULTS

Of 664 participants, 13.3% had VNS and 7.1% had PV. In univariable analysis disaggregated by gender, low income, poor education, perceived difficulty attending healthcare, and alcohol use were associated with VNS in men while low CD4 at diagnosis, multiple prior ART regimens and treatment interruptions were significant in both genders. Multiple prior ART regimens (adjusted Odds Ratio (aOR) 2.82, [95% confidence interval (CI) 1.59, 4.99], p < 0.01), treatment interruptions (aOR 4.51, [95% CI 2.13, 9.58], p < 0.01), excessive alcohol consumption (aOR 2.56, [95% CI 1.18, 5.54], p < 0.05) perceived difficulty attending healthcare (aOR 2.07, [ 95% CI 1.25, 3.42], p < 0.01) and low CD4 at diagnosis (aOR 2.34, 95% [CI 1.30, 4.20], p < 0.01) were independently associated with VNS on multivariable regression.

CONCLUSIONS

We conclude that socio-economic and clinical factors influence viral suppression in our cohort and vary between men and women. Gender specific approaches are necessary to achieve the 90% suppression goal.

Incomplete immune reconstitution in HIV/AIDS patients on antiretroviral therapy: Challenges of immunological non-responders

The morbidity and mortality of HIV type-1 (HIV-1)-related diseases were dramatically diminished by the grounds of the introduction of potent antiretroviral therapy, which induces persistent suppression of HIV-1 replication and gradual recovery of CD4⁺ T-cell counts. However, ∼10-40% of HIV-1-infected individuals fail to achieve normalization of CD4⁺ T-cell counts despite persistent virological suppression. These patients are referred to as "inadequate immunological responders," "immunodiscordant responders," or "immunological non-responders (INRs)" who show severe immunological dysfunction. Indeed, INRs are at an increased risk of clinical progression to AIDS and non-AIDS events and present higher rates of mortality than HIV-1-infected individuals with adequate immune reconstitution. To date, the underlying mechanism of incomplete immune reconstitution in HIV-1-infected patients has not been fully elucidated. In light of this limitation, it is of substantial practical significance to deeply understand the mechanism of immune reconstitution and design effective individualized treatment strategies. Therefore, in this review, we aim to highlight the mechanism and risk factors of incomplete immune reconstitution and strategies to intervene.

The impact of data quality and source data verification on epidemiologic inference: a practical application using HIV observational data

BACKGROUND

Data audits are often evaluated soon after completion, even though the identification of systematic issues may lead to additional data quality improvements in the future. In this study, we assess the impact of the entire data audit process on subsequent statistical analyses.

METHODS

We conducted on-site audits of datasets from nine international HIV care sites. Error rates were quantified for key demographic and clinical variables among a subset of records randomly selected for auditing. Based on audit results, some sites were tasked with targeted validation of high-error-rate variables resulting in a post-audit dataset. We estimated the times from antiretroviral therapy initiation until death and first AIDS-defining event using the pre-audit data, the audit data, and the post-audit data.

RESULTS

The overall discrepancy rate between pre-audit and audit data (n = 250) across all audited variables was 17.1%. The estimated probability of mortality and an AIDS-defining event over time was higher in the audited data relative to the pre-audit data. Among patients represented in both the post-audit and pre-audit cohorts (n = 18,999), AIDS and mortality estimates also were higher in the post-audit data.

CONCLUSION

Though some changes may have occurred independently, our findings suggest that improved data quality following the audit may impact epidemiological inferences.

Performance of fracture risk assessment tool in HIV-positive male individuals aged ≥45 years on suppressive antiretroviral therapy

INTRODUCTION

An age-specific evaluation and management algorithm for reduced bone mineral density (BMD) is suggested for HIV-positive patients without major risk factors. Whether combination of BMD and the Fracture Risk Assessment Tool (FRAX) may detect more individuals for therapeutic interventions remains unclear. We aimed to determine the prevalence of middle-aged or older HIV-positive males fitting the criteria of therapeutic interventions with different approaches.

METHODS

From July 2016 to February 2018, HIV-positive male patients aged ≥45 years receiving suppressive antiretroviral therapy were recruited in a cross-sectional study, at two designated hospitals for HIV care in northern Taiwan. Patients with malignancy, AIDS, pre-existing bone disease or immobilization were excluded. Information on clinical and demographic characteristics, FRAX questionnaire, activity questionnaire, BMD and serum 25(OH)D was obtained. FRAX scores combined with BMD (FRAX/BMD) and without BMD (FRAX) were calculated. The data were analysed on the basis of major risk factors for fragility fracture and age stratification, FRAX score and BMD results respectively.

RESULTS

We enrolled 330 patients with a mean age of 51.6 years and CD4 610 cells/μL, in whom 98.1% (n = 324) underwent BMD assessment of one site or more. By FRAX, 6.7% (n = 22) reached treatment thresholds (10-year risk of major osteoporotic fracture ≥20% and/or hip fracture ≥3%). The prevalence of osteopenia (-2.5

CONCLUSIONS

With FRAX as a screening approach among HIV-positive male patients aged ≥45 years, addition of BMD assessment may detect more candidates for therapeutic management.

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Key Words

• ageing
• bone mineral density
• combination antiretroviral therapy
• osteopenia
• osteoporosis

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MESH Headings

• Adult
• Algorithms
• Anti-HIV Agents/therapeutic use
• Bone Density
• Cross-Sectional Studies
• Fractures, Bone/etiology
• HIV Seropositivity/complications
• HIV Seropositivity/drug therapy
• HIV Seropositivity/epidemiology
• Hip Fractures/etiology
• Humans
• Male
• Middle Aged
• Osteoporosis/etiology
• Osteoporotic Fractures/etiology
• Prevalence
• Risk Factors
• Surveys and Questionnaires
• Taiwan/epidemiology

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Affiliation(s)

Mao‐Song Tsai Department of Internal MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan School of MedicineCollege of MedicineFu Jen Catholic UniversityNew Taipei CityTaiwan
Jun‐Yu Zhang Center of Infection ControlNational Taiwan University HospitalTaipeiTaiwan
Hsin‐Yun Sun Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan
Wen‐Chun Liu Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan
Pei‐Ying Wu Center of Infection ControlNational Taiwan University HospitalTaipeiTaiwan
Chia‐Jui Yang Department of Internal MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
Chien‐Ching Hung Department of Internal MedicineNational Taiwan University Hospital and NationalTaiwan University College of MedicineTaipeiTaiwan Department of Tropical Medicine and ParasitologyNational Taiwan University College of MedicineTaipeiTaiwan

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