[HIV infection as a cause of accelerated aging and frailty]

"I Thought Cancer was a Tobacco Issue": Perspectives of Veterans with and without HIV on Cancer and Other Health Risks Associated with Alcohol and Tobacco/Nicotine Use

U.S. Veterans and people living with HIV (PWH) experience higher rates of unhealthy alcohol and tobacco/nicotine use than non-Veterans and people without HIV (PWoH). Both groups are susceptible to adverse health outcomes associated with alcohol and tobacco/nicotine use. We explored awareness of alcohol- and tobacco/nicotine-related cancer and immune health risks among Veterans Health Administration (VA) patients with and without HIV. Among a sample of 41 (46% PWH; 73% male; 39% Black) purposively-selected VA patients receiving care 2020-2021 we conducted semi-structured interviews via telephone; interviews were recorded, transcribed and analyzed using a Rapid Assessment Process. Purposive selection was based on HIV status, alcohol and/or tobacco/nicotine use, and demographics. Among participants, 66% reported current smoking, and most screened positive for unhealthy alcohol use. Participants had high awareness of cancer and other health risks related to smoking but low awareness of synergistic risks and cancer risks associated with alcohol use despite awareness of a range of other alcohol-related risks. Awareness of alcohol and/or tobacco/nicotine's impacts on the immune system was variable. Findings did not distinctly differ between PWH and PWoH. Low awareness of alcohol-related cancer risk, risks of co-occurring use, and varying awareness of the impacts of alcohol and tobacco/nicotine on the immune system suggest a need for improved messaging regarding substance use-related cancer and immune risk. This may be especially important among PWH, for whom the prevalence and adverse effects of alcohol and tobacco use, and immune dysfunction are higher.

Cardiac and Renal Comorbidities in Aging People Living With HIV

Contemporary World Health Organization data indicates that ≈39 million people are living with the human immunodeficiency virus. Of these, 24 million have been reported to have successfully accessed combination antiretroviral therapy. In 1996, the World Health Organization endorsed the widespread use of combination antiretroviral therapy, transforming human immunodeficiency virus infection from being a life-threatening disease to a chronic illness characterized by multiple comorbidities. The increased access to combination antiretroviral therapy has translated to people living with human immunodeficiency virus (PLWH) no longer having a reduced life expectancy. Although aging as a biological process increases exposure to oxidative stress and subsequent systemic inflammation, this effect is likely enhanced in PLWH as they age. This narrative review engages the intricate interplay between human immunodeficiency virus associated chronic inflammation, combination antiretroviral therapy, and cardiac and renal comorbidities development in aging PLWH. We examine the evolving demographic profile of PLWH, emphasizing the increasing prevalence of aging individuals within this population. A central focus of the review discusses the pathophysiological mechanisms that underpin the heightened susceptibility of PLWH to renal and cardiac diseases as they age.

Effects of frailty, geriatric syndromes, and comorbidity on mortality and quality of life in older adults with HIV

BACKGROUND

To understand the effects of frailty, geriatric syndromes, and comorbidity on quality of life and mortality in older adults with HIV (OAWH).

METHODS

Cross-sectional study of the FUNCFRAIL multicenter cohort. The setting was outpatient HIV-Clinic. OAWH, 50 year or over were included. We recorded sociodemographic data, HIV infection-related data, comorbidity, frailty, geriatric syndromes (depression, cognitive impairment, falls and malnutrition), quality of life (QOL) and the estimated risk of all-cause 5-year mortality by VACS Index. Association of frailty with geriatric syndromes and comorbidity was evaluated using the Cochran-Mantel-Haenszel test.

RESULTS

Seven hundred ninety six patients were included. 24.7% were women, mean age was 58.2 (6.3). 14.7% were 65 or over. 517 (65%) patients had ≥3 comorbidities, ≥ 1 geriatric syndrome and/or frailty. There were significant differences in the estimated risk of mortality [(frailty 10.8%) vs. (≥ 3 comorbidities 8.2%) vs. (≥ 1 geriatric syndrome 8.2%) vs. (nothing 6.2%); p = 0.01] and in the prevalence of fair or poor QOL [(frailty 71.7%) vs. (≥ 3 comorbidities 52%) vs. (≥ 1 geriatric syndrome 58.4%) vs. (nothing 51%); p = 0.01]. Cognitive impairment was significantly associated to mortality (8.7% vs. 6.2%; p = 0.02) and depression to poor QOL [76.5% vs. 50%; p = 0.01].

CONCLUSIONS

Frailty, geriatric syndromes, and comorbidity had negative effects on mortality and QOL, but frailty had the greatest negative effect out of the three factors. Our results should be a wake-up call to standardize the screening for frailty and geriatric syndromes in OAWH in the clinical practice.

TRIAL REGISTRATION

NCT03558438.

Association between frailty phenotype, quantification of plasma HIV-1 RNA, CD4 cell count and HAART in HIV-positive subjects: a systematic review and meta-analysis of observational studies

HIV infection causes a constant activation of the immune system and contributes to an enhanced systemic pro-inflammatory cytokine milieu, which has been associated with premature aging and frailty. We performed a systematic review and meta-analysis to analyze whether the HIV-1 RNA load, CD4+ T-lymphocyte counts and exposure to HAART in HIV-positive subjects are associated with frailty phenotype. Searches were performed in PubMed, SCOPUS, Lilacs, Web of Science, Google Scholar, and OpenThesis databases. We used the odds ratio as a measure of the association. We used either a fixed or random-effects model to pool the results of individual studies depending on the presence of heterogeneity. Eleven studies were included in the review. Data from 8035 HIV-positive subjects were analyzed; 2413 of the subjects had viral load detectable, 981 had a CD4T-cell count <350 cells/μL, and 1342 had HAART exposure information. We found an association between frailty and CD4T-cell count <350 cells/μL (OR 2.68, CI 95% 1.68-4.26, I²= 46%), HIV-1 RNA load detectable (OR 1.71, CI 95% 1.38-2.12, I²= 0%), and protease inhibitor-containing HAART regimen (OR 2.21, CI 95% 1.26-3.89, I² = 0%). Further studies are necessary to evaluate the effects of other factors on the development of clinical features related to frailty.

Factors associated to neurocognitive impairment in older adults living with HIV

OBJECTIVE

The HIV infection is a chronic disease that causes neurocognitive impairment (NI) and has been related with early development of frailty. We aimed to study the main risk factors for neurocognitive disorders and frailty in HIV older adults.

MATERIALS AND METHODS

Cross-sectional study with 40 HIV individuals older than 65 years under antiretroviral therapy in Hospital del Mar (Barcelona) recruited between November 2019 and October 2020. Data has been obtained through clinical scores and a blood sample to evaluate NI and frailty and has been analyzed with non-parametric tests and a multivariate logistic regression model.

RESULTS

Among the 40 patients admitted for the study, 14 (35%) had positive screening for NI. We found that HIV individuals with nadir CD4+ T-cell count lower than 350 cells/mm³ had 39.7 more risk for NI (95% CI 2.49-632.10; p = 0.009). Those with a lower education level had 22.78 more risk for neurocognitive disorders (95% CI 2.13-242.71; p = 0.01) and suffering any comorbidity with a punctuation ≥ 1 in the Charlson Comorbidity index had an increased risk of 18.26 of developing NI and frailty (95% CI 1.30-256.33; p = 0.031), among them diabetes was significantly more frequent in NI.

CONCLUSION

We observed that the main risk factors for a positive NI screening in HIV older adults were low education level, a nadir CD4+ T-cell count < 350 cells/mm³ and the presence of any comorbidity, highlighting diabetes among them.

Polypharmacy, Medication-Related Burden and Antiretroviral Therapy Adherence in People Living with HIV Aged 50 and Above: A Cross-Sectional Study in Hunan, China

PURPOSE

People living with HIV (PLWHIV) are susceptible to non-communicable diseases (NCDs) because of aging and infections. This means that the number of non-HIV medications increases, along with issues of polypharmacy and medication-related burden. The purpose of this study was to identify the current situation of polypharmacy and medication-related burden among PLWHIV aged 50 and above, as well as the relation between medication-related burden and antiretroviral therapy (ART) adherence.

PATIENTS AND METHODS

A cross-sectional study was conducted with 185 participants recruited from two HIV clinics in Yuelu District Center for Disease Control (CDC) and Changsha First Hospital in Hunan, China. Participants filled questionnaires about comorbidities, polypharmacy, medication-related burden, ART adherence and sociodemographic characteristics.

RESULTS

Among the participants, 40% were receiving polypharmacy, and PLWHIV, who were female (β = 5.946; 95% CI = 1.354, 10.541), had a lower monthly income (β = -4.777; 95% CI = -6.923, -2.632), and took more drugs (β = 2.200; 95% CI = 1.167, 3.233) were more likely to report a higher level of medication-related burden. The score of ART adherence was negatively associated with medication-related burden (r_s = -0.250 p = 0.001).

CONCLUSION

The findings suggest that more attention should be paid to the issues of polypharmacy and targeted interventions should be developed to reduce medication-related burden among older PLWHIV.

Spinal Epidural Abscess Patients Have Higher Modified Frailty Indexes Than Back Pain Patients on Emergency Room Presentation: A Single-Center Retrospective Case-Control Study

OBJECTIVE

Spinal epidural abscess (SEA) patients have increased medical comorbidities and risk factors for infection compared with those without SEA. However, the association between frailty and SEA patients has not been documented.

METHODS

A total of 46 SEA patients were randomly paired and matched by age and sex with a control group of patients with back pain who had presented to our emergency department from 2012 to 2017. Statistical analysis identified the risk factors associated with SEA and frailty using the modified frailty index (mFI), and the patients were stratified into robust, prefrail, and frail groups. We examined the value of the mFI as a prognostic predictor and evaluated the classic risk factors (CRFs).

RESULTS

The SEA patients had higher mFIs and CRFs (P = 0.023 and P < 0.001, respectively) and a longer length of stay (22.89 days vs. 1.72 days; P < 0.001). Of the mFI variables, only diabetes had a significant association with SEA (odds ratio [OR], 3.60; P = 0.012). Among the stratified mFI subgroups, a frail ranking (mFI >2) was the strongest risk factor for SEA (OR, 5.18; P = 0.003). A robust ranking (mFI, 0-1) was a weak negative predictor for SEA (OR, 0.41; P = 0.058). The robust patients were also more likely to be discharged to home (OR, 7.58; P = 0.002). Of the CRF variables, only intravenous drug use had a statistically significant association with SEA (OR, 10.72; P = 0.015).

CONCLUSIONS

Patients with SEA were more frail compared with the control back pain patients. Frailty was determined to be an independent risk factor for SEA, outside of the CRFs. The use of the mFI could be potentially useful in predicting the diagnosis, prognosticating, and guiding SEA treatment.

High Prevalence of Frailty and Prefrailty Status in Brazilian Patients Living with HIV

Frailty is associated with an increased probability of serious adverse health outcomes in the geriatric general population. People living with HIV have a higher prevalence of frailty. However, the magnitude of this problem in younger patients in South America is unknown. We aimed to determine the prevalence and factors associated with frailty. This is a cross-sectional study from the Brazilian cohort HIV-AIDS (CoBRA) developed between March and November of 2018, on patients ≥18 years of age. Frailty phenotype was assessed by original Fried criteria. The results were analyzed using descriptive statistics, while identification of factors related to frailty was assessed by using multivariate logistic regression. We enrolled 231 patients; all, but 2 were on antiretroviral therapy (ART). Median age was 45.6 interquartile range (36.7-52.1) years, 136 (58.9%) were male, and 86.7% self-identified as non-white. Mean CD4 count was 660 (±345) cells/mm³ and 83.5% had undetectable HIV plasma viral load (<50 copies/mL). Prevalence of frailty and prefrailty was 10.4% and 52.4%, respectively. A CD4 count <200 cells/mm³, depression, low income, and use of third-line ART were variables significantly associated with a greater risk to present frail or prefrail status. Frailty prevalence increases with age and is an important health problem to health care in HIV aging patients. It requires proper strategies to its early detection, prevention, and management.

Characterization of CD31 expression in CD4+ and CD8+T cell subpopulations in chronic untreated HIV infection

BACKGROUND

The platelet endothelial cell adhesion molecule-1 (PECAM-1) or CD31 has been involved in regulation of T-cell tolerance, activation, survival and homing in mice cells. However, there is limited knowledge about the expression pattern and role of this molecule in human T cells, particularly in conditions of chronic immune activation.

OBJECTIVES

We explored CD31 expression in T cell differentiation subsets of individuals with untreated HIV infection and in non-HIV-infected controls. We also assessed phenotypic differences between CD31+ and CD31- subsets in memory and terminally differentiated (TEMRA) CD4+ and CD8 + T cells.

METHODS

Forty-one individuals with untreated HIV infection and 34 non-HIV-infected controls were included in the study. We compared the expression of CD31 in CD4+ and CD8 + T cells across stages of differentiation in the two study groups by flow cytometry. We also analyzed the expression of CD57 (a marker of senescence), Ki67 (a marker of cycling cells), PD-1 (a marker of exhaustion), and CD38/HLA-DR (a marker of immune activation) on memory and TEMRA CD31+ and CD31- T cells.

RESULTS

CD31 expression was significantly higher in CD8 + T cells than in CD4 + T cells, measured as frequency, absolute numbers and median fluorescence intensity (MFI), in both study groups (p < 0.0001 in all cases). Intermediate differentiation subsets of CD4+ and CD8 + T cells expressed higher levels of CD31 in the context of HIV infection (p < 0.001 in all cases). CD31 expression frequency decreased with cellular differentiation of CD4+ and CD8 + T cells in both groups, but this decrease was steeper in individuals without HIV infection (CD4+: p < 0.001 and CD8+: p < 0.0001). As expected, memory and TEMRA CD4+ and CD8 + T cells expressed significantly higher levels of CD57, PD-1, Ki67 and CD38/HLA-DR in HIV-infected compared to non-HIV-infected individuals (p < 0.01 in all cases). CD31 expression was associated with lower activation of memory (but not TEMRA) CD4 + T cells in non-HIV-infected persons, an effect not observed in the HIV-infected group. CD31 expression on memory CD8 + T cells of HIV-infected individuals was associated higher levels of PD-1 (p = 0.0019) and CD38/HLADR (p = 0.0345), and higher PD-1 expression on CD8 + TEMRA (p = 0.0024), an effect not observed in non-HIV-infected individuals.

CONCLUSION

In the context of HIV-associated chronic immune activation, specifically on memory CD8 + T cells, CD31 expression was associated with higher PD-1 and CD38/HLA-DR co-expression, suggesting that CD31 expression may result from an insufficient attempt to contain T cell exhaustion and activation. CD31-targeted therapies may contribute to modulate these cellular responses.

Infections in the older population: what do we know?

The incidence of infections increases with age and results in a higher risk of morbidity and mortality. This rise is not mainly related to chronological age per se but has been linked mostly to individual factors such as immunosenescence; the presence of comorbidities; the occurrence of geriatric syndromes such as poor nutrition, polypharmacy, and cognitive disorders; and the presence of functional impairment concomitant with environmental, healthcare-related and microbiological factors such as the increasing risk of multidrug-resistant microorganisms. The geriatric concept of frailty introduces a new approach for considering the risk of infection; this concept highlights the importance of functional status and is a more comprehensive and multicomponent approach that may help to reverse the vulnerability to stress. The aim of this article is to provide some typical hallmarks of infections among older adults in comparison to younger individuals. The main differences among the older population that are presented are an increased prevalence of infections and potential risk factors, a higher risk of carrying multidrug-resistant microorganisms, an increase in barriers to a prompt diagnosis related to atypical presentations and challenges with diagnostic tools, a higher risk of under- and over-diagnosis, a worse prognosis with a higher risk of acute and chronic complications and a particular need for better communication among all healthcare sectors as they are closely linked together.

Efavirenz, atazanavir, and ritonavir disrupt sarcoplasmic reticulum Ca2+ homeostasis in skeletal muscles

While muscle fatigue, pain and weakness are common co-morbidities in HIV-1 infected people, their underlying cause remain poorly defined. To this end, we evaluated whether the common antiretroviral drugs efavirenz (EFV), atazanavir (ATV) and ritonavir (RTV) could be a contributing factor by pertubating sarcoplasmic reticulum (SR) Ca²⁺ cycling. In live-cell imaging, EFV (6.0 μM), ATV (6.0 μM), and RTV (3.0 μM) elicited Ca²⁺ transients and blebbing of the plasma membranes of C2C12 skeletal muscle myotubes. Pretreating C2C12 skeletal muscle myotubes with the SR Ca²⁺ release channel blocker ryanodine (50 μM), slowed the rate and amplitude of Ca²⁺ release from and reuptake of Ca²⁺ into the SR. EFV, ATV and RTV (1 nM - 20 μM) potentiated and then displaced [³H] ryanodine binding to rabbit skeletal muscle ryanodine receptor Ca²⁺ release channel (RyR1). These drugs at concentrations 0.25-31.2 μM also increased and or decreased the open probability of RyR1 by altering its gating and conductance. ATV (≤5 μM) potentiated and >5μM inhibited the ability of sarco (endo)plasmic reticulum Ca²⁺-ATPase (SERCA1) to hydrolyze ATP and transport Ca²⁺. RTV (2.5-31.5 μM) dose-dependently inhibited SERCA1-mediated, ATP-dependent Ca²⁺ transport. EFV (0.25-31.5 μM) had no measurable effect on SERCA1's ability to hydrolyze ATP and transport Ca²⁺. These data support the notion that EFV, ATV and RTV could be contributing to skeletal muscle co-morbidities in PLWH by modulating SR Ca²⁺ homeostasis.

Supplementing Glycine and N-acetylcysteine (GlyNAC) in Aging HIV Patients Improves Oxidative Stress, Mitochondrial Dysfunction, Inflammation, Endothelial Dysfunction, Insulin Resistance, Genotoxicity, Strength, and Cognition: Results of an Open-Label Clinical Trial

Background: Patients with HIV (PWH) develop geriatric comorbidities, including functional and cognitive decline at a younger age. However, contributing mechanisms are unclear and interventions are lacking. We hypothesized that deficiency of the antioxidant protein glutathione (GSH) contributes to multiple defects representing premature aging in PWH, and that these defects could be improved by supplementing the GSH precursors glycine and N-acetylcysteine (GlyNAC). Methods: We conducted an open label clinical trial where eight PWH and eight matched uninfected-controls were studied at baseline. PWH were studied again 12-weeks after receiving GlyNAC, and 8-weeks after stopping GlyNAC. Controls did not receive supplementation. Outcome measures included red-blood cell and muscle GSH concentrations, mitochondrial function, mitophagy and autophagy, oxidative stress, inflammation, endothelial function, genomic damage, insulin resistance, glucose production, muscle-protein breakdown rates, body composition, physical function and cognition. Results: PWH had significant defects in measured outcomes, which improved with GlyNAC supplementation. However, benefits receded after stopping GlyNAC. Conclusions: This open label trial finds that PWH have premature aging based on multiple biological and functional defects, and identifies novel mechanistic explanations for cognitive and physical decline. Nutritional supplementation with GlyNAC improves comorbidities suggestive of premature aging in PWH including functional and cognitive decline, and warrants additional investigation.