A challenge for the future: aging and HIV infection

Adults Aged ≥50 Years Reached by the Centers for Disease Control and Prevention's HIV Testing Programs in the United States and US Dependent Areas, 2019

OBJECTIVES

Older adults represent nearly half of people living with HIV in the United States. The objective of this analysis was to describe HIV testing, demographic characteristics, and risks of adults aged ≥50 years (older adults) reached in 2019 by HIV testing programs funded by the Centers for Disease Control and Prevention (CDC).

METHODS

We collected data from 101 CDC-funded community-based organizations and 61 health departments. All funding recipients submitted deidentified program service data for 2019 through a secure online CDC-supported system. We used multivariable robust Poisson regression to assess the association between demographic and risk characteristics and the proportion of tests that resulted in a new diagnosis. We also assessed the proportion of people who received a positive test result, were linked to HIV medical care, and were interviewed for partner services.

RESULTS

During 2019, among 2 452 507 CDC-funded HIV tests provided in the United States, 412 164 (16.8%) were provided to older adults. Among the 1059 (0.26% positivity) older adults with newly diagnosed HIV infection for whom we had data, 582 (68.4%) were linked to HIV medical care within 30 days of diagnosis and 494 (72.1%) were interviewed for partner services. Among the 2858 older adults with previously diagnosed HIV infection, 1321 (46.2%) reported not being in HIV medical care at the time of the test; of those with linkage data, 425 (49.9%) were linked to HIV medical care within 30 days of testing HIV positive.

CONCLUSIONS

More rapid disease progression and higher morbidity and mortality rates among older adults suggest that services are needed to ensure early diagnosis, rapid linkage, and interview for partner services.

Harnessing CD8+ T Cells Under HIV Antiretroviral Therapy

Antiretroviral therapy (ART) has transformed HIV from a fatal disease to a chronic condition. In recent years there has been considerable interest in strategies to enable HIV-infected individuals to cease ART without viral rebound, either by purging all cells infected harboring replication-competent virus (HIV eradication), or by boosting immune responses to allow durable suppression of virus without rebound (HIV remission). Both of these approaches may need to harness HIV-specific CD8⁺ T cells to eliminate infected cells and/or prevent viral spread. In untreated infection, both HIV-specific and total CD8⁺ T cells are dysfunctional. Here, we review our current understanding of both global and HIV-specific CD8⁺ T cell immunity in HIV-infected individuals with durably suppressed viral load under ART, and its implications for HIV cure, eradication or remission. Overall, the literature indicates significant normalization of global T cell parameters, including CD4/8 ratio, activation status, and telomere length. Global characteristics of CD8⁺ T cells from HIV⁺ART⁺ individuals align more closely with those of HIV-seronegative individuals than of viremic HIV-infected individuals. However, markers of senescence remain elevated, leading to the hypothesis that immune aging is accelerated in HIV-infected individuals on ART. This phenomenon could have implications for attempts to prime de novo, or boost existing HIV-specific CD8⁺ T cell responses. A major challenge for both HIV cure and remission strategies is to elicit HIV-specific CD8⁺ T cell responses superior to that elicited by natural infection in terms of response kinetics, magnitude, breadth, viral suppressive capacity, and tissue localization. Addressing these issues will be critical to the success of HIV cure and remission attempts.

Immunosenescence and hurdles in the clinical management of older HIV-patients

People living with HIV (PLWH) who are treated with effective highly active antiretroviral therapy (HAART) have a similar life expectancy to the general population. Moreover, an increasing proportion of new HIV diagnoses are made in people older than 50 y. The number of older HIV-infected patients is thus constantly growing and it is expected that by 2030 around 70% of PLWH will be more than 50 y old. On the other hand, HIV infection itself is responsible for accelerated immunosenescence, a progressive decline of immune system function in both the adaptive and the innate arm, which impairs the ability of an individual to respond to infections and to give rise to long-term immunity; furthermore, older patients tend to have a worse immunological response to HAART. In this review we focus on the pathogenesis of HIV-induced immunosenescence and on the clinical management of older HIV-infected patients.

An assessment of the levels of perceived social support among older adults living with HIV and AIDS in Dublin

Objectives

To determine the level of perceived social support among older adults living with HIV and AIDS in Dublin.

Methods

The study utilized a cross-sectional survey design to collect data from 46 adults aged 50 years or older who are members of open heart house (OHH) in Ireland, a peer support network for people living with HIV and AIDS. Participants completed a set of interviewer-assisted questionnaires, which included the multidimensional measure of perceived social support (PSS) to assess the level of social support.

Results

Levels of PSS among participants were observed as follows: 54 % had low PSS, 33 % had a moderate PSS and 13 % had high PSS. A fifth of the study participants had a history of injection drug use (IDU) and this group reported higher PSS scores in general than non-IDU’s (H = 79.500, Z = −2.678, p = 0.006). PSS scores were observed to be higher in general among participants with longer duration of infection [H(2) = 7.856, p = 0.020].

Conclusion

Despite its limitations, this study provides vital information about the level of social support among older people living with HIV and AIDS at OHH Dublin. An unexpected but interesting finding was the positive relationship between IDU and PSS level. Formulation of strategies to enable older PLHA to be more proactive members of their community through a peer support network sponsored volunteer services should be encouraged.

Factors associated with undernourishment among people 20 years old or over with HIV/AIDS, attending public health services in the São Paulo municipality, Brazil

The study evaluated the nutritional status of 629 people living with HIV/AIDS attended at 12 specialized services of São Paulo's Municipal Health Department, Brazil. Data were obtained from medical records and through interviews during nutritional consultation. We used the classification criteria established by World Health Organization to assess malnourished individuals, a BMI < 18.5kg/m2. The prevalence of malnutrition in people with AIDS is 3.12 times that observed among people with HIV, and among people with co-infection it is 3.41 times that obtained among people without co-infection. This indicates how these conditions can harm the maintenance of the nutritional status, and shows that they demand a comprehensive understanding of the mechanisms involved in this phenomenon, as well as the development of strategies to improve the health care of individuals at nutritional risk.

Poor functional immune recovery in aged HIV-1-infected patients following successfully treatment with antiretroviral therapy

Aging is now a well-recognized characteristic of the HIV-infected population and both AIDS and aging are characterized by a deficiency of the T-cell compartment. The objective of the present study was to evaluate the impact of antiretroviral (ARV) therapy in recovering functional response of T cells to both HIV-1-specific ENV peptides (ENV) and tetanus toxoid (TT), in young and aged AIDS patients who responded to ARV therapy by controlling virus replication and elevating CD4(+) T cell counts. Here, we observed that proliferative response of T-cells to either HIV-1-specific Env peptides or tetanus toxoid (TT) was significantly lower in older antiretroviral (ARV)-treated patients. With regard to cytokine profile, lower levels of IFN-γ, IL-17 and IL-21, associated with elevated IL-10 release, were produced by Env- or TT-stimulated T-cells from older patients. The IL-10 neutralization by anti-IL-10 mAb did not elevate IFN-γ and IL-21 release in older patients. Finally, even after a booster dose of TT, reduced anti-TT IgG titers were quantified in older AIDS patients and it was related to both lower IL-21 and IFN-γ production and reduced frequency of central memory T-cells. Our results reveal that ARV therapy, despite the adequate recovery of CD4(+) T cell counts and suppression of viremia, was less efficient in recovering adequate immune response in older AIDS patients.

Reduction in Size and Number of Plantar Verrucae in Human Immunodeficiency Virus-Infected Individuals After the Implementation of Highly Active Antiretroviral Therapy

BACKGROUND

Implementation of highly active antiretroviral therapy (HAART) significantly increased the life expectancy of those living with human immunodeficiency virus (HIV). Except for prevalence, scientific reports regarding clinical manifestations of plantar verrucae in the post-HAART era are lacking. The objective of this study was to compare clinical manifestations of plantar verrucae between HIV-infected and noninfected individuals and then to compare these findings with those observed before the implementation of HAART.

METHODS

Nineteen patients with plantar verrucae (ten with HIV and nine without HIV) were examined to determine the size, number, and clinical type of verrucae present. The two groups were first compared with each other and then with previously collected data from a similar analysis conducted in 1995, before the implementation of HAART. Statistical significance was determined using the Fisher exact test or the Wilcoxon rank sum test.

RESULTS

No significant differences were observed in the size, number, or clinical type of verrucae between HIV-negative and HIV-positive patients. Compared with the 1995 data, there was a significant decrease in the number of verrucae lesions per individual and a nonsignificant decrease in the average size of verrucae in HIV-positive patients.

CONCLUSIONS

Study results indicate that the implementation of HAART has impacted the clinical manifestations of plantar verrucae in HIV-positive individuals. Further analyses with a larger number of patients are required to confirm and substantiate these findings.

CD4:CD8 ratio as a frontier marker for clinical outcome, immune dysfunction and viral reservoir size in virologically suppressed HIV-positive patients

Introduction

Absolute CD4 T cell count and plasma viral load have been established as predictors of HIV disease progression, and CD4 T cell count is used as an indicator for initiation of antiretroviral therapy. Following long-term therapy, patients generally present with significant CD4 T cell recovery contrasting with persistently elevated CD8 T cell counts, which leads to a partial restoration of CD4:CD8 ratio. This review focuses on the relevance of the CD4:CD8 ratio on clinical outcomes, immune dysfunction and HIV reservoir size in long-term treated patients.

Method

We conducted a comprehensive literature review of publications in English language using major electronic databases. Our search was focused on factors contributing to CD4:CD8 T cell ratio and clinical outcome in adult HIV-positive patients in the context of treated infection.

Discussion

Low CD4:CD8 ratio has been linked to ageing and acts as a predictor of mortality in the general population. This ratio may represent the combined effects of inflammation and immunological changes called “inflammaging.” Although the mechanisms underlying partial correction of the CD4:CD8 ratio and persistently elevated CD8 T cell count in long-term treated patients remain poorly understood, it has been recently indicated that patients with optimal CD4 T cell recovery and low CD4:CD8 ratio still harbour increased immune activation, an immune senescent phenotype and have a higher risk of non-AIDS morbidity and mortality. This review reconsiders CD4:CD8 ratio in the light of advances in the understanding of immune dysfunction and examines its pathophysiological features and implications on clinical outcome and HIV reservoir size in long-term treated HIV-positive adults.

Conclusion

The CD4:CD8 ratio can contribute to the immunological evaluation of treated patients in a long-term follow-up and may be applied for monitoring both immune dysfunction and viral reservoir size in immune-based clinical trials.

HIV/AIDS in the Puerto Rican elderly: immunological changes between gender and body mass index

PURPOSE

Human immunodeficiency virus (HIV) in the elderly population has serious repercussions. The elderly are underdiagnosed for HIV and the costs associated with their late-stage care represent a financial burden to the public health system. The purpose is to analyze various profiles among a cohort of elderly patients with HIV/AIDS.

METHODS

This is a baseline cohort 60 years or older seen in the Retrovirus Research Center between January 2000 to December 2011. We present the profiles of our cohort stratified by gender and body mass index viewed as a covariate of interest.

RESULTS

A total of 266 people (68% males and 32% females) seen at the Center were older than 60 years of age. Males were significantly more often overweight (p<.05). Females were significantly more underweight with chronic conditions (p<.05). Women had higher CD4 count and lower HIV viral loads (p<.05). Underweight elderly males were more heavily affected with the burden of HIV infection compared with women.

A review of cardiovascular and renal function monitoring: a consideration of older adults with HIV

The prevalence of human immunodeficiency virus (HIV) infection in older and elderly adults is significant worldwide. This population poses new challenges and opportunities in the management of HIV. In addition to the risks affecting HIV patients of all ages, including risk of opportunistic infection and medication resistance, age-related changes in physiology, higher comorbidity burdens, increased use of medications, and potential adverse drug reactions to HIV medications all factor into the care of older adults with HIV. The risk and progression of cardiovascular and renal comorbidities may be higher in the older adult HIV population and in patients taking specific HIV medications. Understanding these risks is essential when managing a new type of patient: the older adult with HIV.

Viral, host and therapeutic factors affecting T-cell recovery in virologically controlled HIV patients

Despite suppressive combination antiretroviral therapy, a considerable proportion of HIV-infected patients do not achieve adequate immune recovery in terms of the CD4+ T-cell count, although they have controlled viremia values. Many questions remain for clinicians in the management of these patients, defined as immunological nonresponders, including questions about the mechanisms underlying the lack of immune restoration and possible therapeutic approaches to this particular group of patients.

High IL-10 production by aged AIDS patients is related to high frequency of Tr-1 phenotype and low in vitro viral replication

This work aims to elucidate the effects of age and HIV-1 infection on the frequency and function of T cell subsets in response to HIV-specific and non-specific stimuli. As compared with the younger AIDS group, the frequencies of naive and central memory T cells were significantly lower in aged AIDS patients. Although there was also a dramatic loss of classical CD4(+)FoxP3(+)CD25(+)Treg cells in this patient group, high frequencies of IL-10-producing CD4(+)FoxP3(-) T cells were observed. In our system, the increased production of IL-10 in aged AIDS patients was mainly derived from Env-specific CD4(+)FoxP3(-)CD152(+) T cells. Interestingly, while the blockade of IL-10 activity by monoclonal antibody clearly enhanced the release of IL-6 and IL-1β by Env-stimulated PBMC cultures from aged AIDS patients, this monoclonal antibody enhanced in vitro HIV-1-replication. In conclusion, HIV infection and aging undoubtedly contribute synergistically to a complex immune dysfunction in T cell compartment of HAART-treated older HIV-infected individuals.

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.