The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study

Toward a prognostic model for all-cause mortality among old people with disability in long-term care in China

BACKGROUND

Current prognostic model of all-cause mortality may not be applicable for old people with disability in long-term care due to the absence of injury- and care-related predictors. We aimed to develop a prognostic model specifically tailored to this population, based on comprehensive predictors.

METHOD

We conducted a prospective study involving 41,004 participants aged ≥60 with disability in long-term care across 16 study sites in Southwest China from 2017 to 2021. Participants' demographics, clinical characteristics, disability status, and injury- and care-related information at baseline were used as candidate predictors. We employed a LASSO Cox regression model to develop the prognostic model using the training set (70 % of participants), and the predictive performance was validated in the validation set (30 % of participants). The prognostic index (PI) scores of the prognostic model were used to quantify mortality risk.

RESULTS

At the end of the 4-year follow-up, 17,797 deaths (43.4 %) were observed. The prognostic model revealed several powerful and robust predictors of mortality across the total sample and subgroups, including higher age, living with comorbidities, physical and perceptual disability, and living with pressure sores. Non-professional care was an additional predictor in older participants. The risk of death for participants in the highest quartile of PI scores was approximately four-fold higher compared to those in the lowest quartile.

CONCLUSIONS

We developed and validated a prognostic model that can be practically utilized to identify individuals and populations at risk of death among old people with disability in long-term care.

Toward a Prognostic Model for Mortality Risk in Older People Living With HIV: A Prospective Cohort Study From Southwestern China

OBJECTIVE

The existing prognostic models for mortality risk in people living with HIV (PLWH) may not be applicable for older PLWH because the risk factors were confined to biomarkers and clinical variables. We developed and validated a nomogram for the prognosis of all-cause mortality in older PLWH based on comprehensive predictors.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

We included 824 participants aged ≥50 years (mean age, 64.0 ± 7.6 years) from 30 study sites in Sichuan, China, and followed up from Nov 2018 to Mar 2021.

METHODS

Data on demographics, biomarkers, and clinical indicators were extracted from the registry; mental and social factors were assessed by a survey. Elastic net was used to select predictors. A nomogram was developed based on Cox proportional hazards regression model to visualize the relative effect size (points) of the selected predictors. The prognostic index (PI) was calculated by summing points of all predictors to quantify mortality risk.

RESULTS

Predictive performance of PI from the nomogram was good, with area under the curve of 0.76 for the training set, and 0.77 for the validation set. Change in CD4 count, virological failure in antiretroviral therapy, and living with comorbidities were robust predictors. Depressive symptoms were an important predictor in men, those aged ≥65 years, and those with time of diagnosis <1 year; low social capital was an additional predictor in people aged <65. Mortality risk increased approximately 10-fold among participants whose PI was in the fourth quartile compared with those in the first quartile (hazard ratio, 9.5; 95% CI, 2.9-31.5).

CONCLUSION AND IMPLICATIONS

Although biological and clinical factors are crucial predictors, mental and social predictors are essential for specific groups. The developed nomogram is useful for identifying risk factors and groups at risk of mortality in older PLWH.

Examining the Association Between a Modified Quan-Charlson Comorbidity Index and HIV Viral Suppression: A Cross-Sectional Analysis of DC Cohort Participants

With the advancement of effective antiretroviral therapy, people with HIV live longer, and many are developing non-AIDS comorbidities. It is important to assess how comorbidities are associated with HIV-related health outcomes, such as viral suppression (VS). The aim of this study was to analyze the association between comorbidity burden, measured using a modified Quan-Charlson Comorbidity Index (QCCI), and VS (viral load result of <200 copies/mL). We hypothesized that an increase in QCCI score, indicating a higher risk for mortality, would correlate with lower likelihood of VS because of the burden of comorbidity treatment, possibly leading to worse antiretroviral adherence. Our analysis included participants from the DC Cohort Longitudinal HIV Study in Washington, DC. Eligible participants were aged ≥18 years and enrolled in the cohort as of January 1, 2018 (n = 2,471). A modified QCCI score, which weighs selected comorbidities (not including HIV/AIDS) and predicts mortality, was calculated using International Classification of Disease-9/10 codes from electronic health records. Multivariable logistic regressions were used to characterize the association between QCCI composite scores and VS. Participants were predominantly virally suppressed (89.6%), male (73.9%), non-Hispanic Black (74.7%), and between 18 and 55 years (59.3%). The median QCCI score was 1 (range = 1-12, interquartile range = 0-2), demonstrating predominately low mortality risk. We did not establish a statistically significant association between QCCI score and VS (adjusted odds ratio = 1.06, 95% confidence interval 0.96-1.17). Our findings suggest that a higher QCCI score was not associated with lower VS in this population, which may be partly due to the high retention in care among cohort participants.

Mortality in patients with acquired human immunodeficiency virus infection hospitalized in an intensive care unit during the period 2017-2019

Identify risk factors associated with mortality in HIV patients admitted to an ICU in the city of Bogotá. Retrospective cohort study of patients treated in an ICU during the years 2017–2019. The analysis included descriptive statistics, association tests, and a logistic regression model. A predictive model of mortality at the time of admission to the ICU was developed. 110 HIV patients were identified. Association was found between a Charlson index ≥ 6 and mortality (OR = 2.3, 95% CI 1.0–5.1) and an increase in mortality in the first 21 days of ICU stay (OR = 2.2, 95% CI 1.0–4.9). In the logistic regression analysis, the absence of highly active antiretroviral therapy (HAART) upon admission to the ICU (OR = 2.5 95% CI 1.0–6.1) and the first 21 days of ICU stay (OR = 2.3 95% CI 1.0–5.4) were associated with an increase in mortality. The predictive mortality model established that mortality was higher in patients admitted to the ICU without having previously received HAART than in those who did receive therapy at the time of admission to the ICU. In patients with HIV admitted to the ICU, the absence of HAART will negatively impact mortality during their hospital stay.

HIV, pathology and epigenetic age acceleration in different human tissues

Epigenetic clocks based on patterns of DNA methylation have great importance in understanding aging and disease; however, there are basic questions to be resolved in their application. It remains unknown whether epigenetic age acceleration (EAA) within an individual shows strong correlation between different primary tissue sites, the extent to which tissue pathology and clinical illness correlate with EAA in the target organ, and if EAA variability across tissues differs according to sex. Considering the outsized role of age-related illness in Human Immunodeficiency Virus-1 (HIV), these questions were pursued in a sample enriched for tissue from HIV-infected individuals. We used a custom methylation array to generate DNA methylation data from 661 samples representing 11 human tissues (adipose, blood, bone marrow, heart, kidney, liver, lung, lymph node, muscle, spleen and pituitary gland) from 133 clinically characterized, deceased individuals, including 75 infected with HIV. We developed a multimorbidity index based on the clinical disease history. Epigenetic age was moderately correlated across tissues. Blood had the greatest number and degree of correlation, most notably with spleen and bone marrow. However, blood did not correlate with epigenetic age of liver. EAA in liver was weakly correlated with EAA in kidney, adipose, lung and bone marrow. Clinically, hypertension was associated with EAA in several tissues, consistent with the multiorgan impacts of this illness. HIV infection was associated with positive age acceleration in kidney and spleen. Male sex was associated with increased epigenetic acceleration in several tissues. Preliminary evidence indicates that amyotrophic lateral sclerosis is associated with positive EAA in muscle tissue. Finally, greater multimorbidity was associated with greater EAA across all tissues. Blood alone will often fail to detect EAA in other tissues. While hypertension is associated with increased EAA in several tissues, many pathologies are associated with organ-specific age acceleration.

Predictors of life-threatening complications in relatively lower-risk patients hospitalized with COVID-19

Older individuals with chronic health conditions are at highest risk of adverse clinical outcomes from COVID-19, but there is widespread belief that risk to younger, relatively lower-risk individuals is negligible. We assessed the rate and predictors of life-threatening complications among relatively lower-risk adults hospitalized with COVID-19. Of 3766 adults hospitalized with COVID-19 to three hospitals in New York City from March to May 2020, 963 were relatively lower-risk based on absence of preexisting health conditions. Multivariable logistic regression models examined in-hospital development of life-threatening complications (major medical events, intubation, or death). Covariates included age, sex, race/ethnicity, hypertension, weight, insurance type, and area-level sociodemographic factors (poverty, crowdedness, and limited English proficiency). In individuals ≥55 years old (n = 522), 33.3% experienced a life-threatening complication, 17.4% were intubated, and 22.6% died. Among those <55 years (n = 441), 15.0% experienced a life-threatening complication, 11.1% were intubated, and 5.9% died. In multivariable analyses among those ≥55 years, age (OR 1.03 [95%CI 1.01–1.06]), male sex (OR 1.72 [95%CI 1.14–2.64]), being publicly insured (versus commercial insurance: Medicare, OR 2.02 [95%CI 1.22–3.38], Medicaid, OR 1.87 [95%CI 1.10–3.20]) and living in areas with relatively high limited English proficiency (highest versus lowest quartile: OR 3.50 [95%CI 1.74–7.13]) predicted life-threatening complications. In those <55 years, no sociodemographic factors significantly predicted life-threatening complications. A substantial proportion of relatively lower-risk patients hospitalized with COVID-19 experienced life-threatening complications and more than 1 in 20 died. Public messaging needs to effectively convey that relatively lower-risk individuals are still at risk of serious complications.

Polypharmacy among HIV infected people aged 50 years or older

Introduction:

Although HAART cannot eradicate HIV, it suppresses viral replication, resulting in a progressive reduction in HIV-related morbidity and mortality. The increase in life expectancy for HIV-infected patients has turned this disease into a chronic disease and, therefore, to the appearance of comorbidities. At the same time there is an increase in the use of concomitant medication, making HIV-infected patient a polymedicated patient.

Objective:

To determine the degree of polypharmacy and to describe clinically relevant drug interactions, as well as the comorbidities and adherence to HAART in HIV + patients over 50 years.

Methods:

Observational, transversal study. Patients ≥50 years on HAART ambulatory were included. The variables were collected: aged, sex, VL, CD4, comorbidities, ARV, concomitant medication, herbal products and adherence. Patients who did not sign informed consent were excluded.

Results:

Were included 154 patients ≥50 years on HAART. The presence of polypharmacy, defined as the use of 5 or more medications including HAART, was 40.3%. 73.4% of the patients had concomitant medication: lipid-lowering agents (33.8%), anxiolytics / sedatives (28.6%), proton-pump inhibitors (26.0%) antihypertensive agents (23.4%). 102 relevant interactions were recorded, finding statistically significant differences in relation to the presence of polypharmacy and pharmacologic drugs classes (p <0.001).

Conclusion:

The prevalence of polypharmacy among HIV+ patients ≥50 years is high. Comorbidities, interactions and drugs associated were similar to those described in the literature. It is necessary to establish priorities in relation to drug interactions with polypharmacy and a correct approach to the pathologies that may develop.

Effect of age at initiation of antiretroviral therapy on treatment outcomes; A retrospective cohort study at a large HIV clinic in southwestern Uganda

BACKGROUND

The prevalence of HIV infection among older persons is increasing yet older age at initiation of antiretroviral therapy (ART) may be associated with poorer treatment outcomes including mortality. However, majority of these studies have been done in the western world and there is limited data in resource limited settings. Our study used routinely collected health facility data to assess trends in age at initiation of ART, the effect of age at ART initiation on mortality and immunological response at a large urban hospital in south western Uganda.

METHODS

We conducted a retrospective records review of patients attending the HIV clinic at Mbarara Regional Referral Hospital in western Uganda. We retrieved records for 8,533 patients who started ART between January 2006 and December 2012. Their data had been collected and stored as part of the larger International Epidemiological Database for the Evaluation of AIDS (IeDEA). Age was stratified into three categories namely; 18-34 (young adults), 35-49 (mid-age) and 50 years or older (older adults). Survival analysis procedures with Kaplan-Meier's plots were used to calculate the survival probability with mortality as the endpoint and Poisson regression analysis used to determine the adjusted relative risks (RR) of mortality.

RESULTS

The proportion of young adults and patients at WHO stage I initiating ART increased steadily over the 7-year period. Older age at ART initiation (> = 50 years) was associated with a higher risk of mortality with adjusted relative risk (RR) at 1.63, (95% CI 1.26-2.11) compared to younger age. Male gender, WHO stages III and IV, lower CD4 count and lower body mass index were also all independently and significantly associated with higher risk for mortality. Older adults also had a poorer immunological response RR = 1.79 (95% CI 0.89-3.58) but was not statistically significant.

CONCLUSIONS

Following ART initiation, older adults compared to the young, have a higher risk of mortality. This age group should be targeted first for 'screen and treat' approach. Optimization of ART treatment regimens for this age group is also required to reduce mortality and improve immunological response.

Terminal differentiation of T cells is strongly associated with CMV infection and increased in HIV-positive individuals on ART and lifestyle matched controls

HIV-1-positive individuals on successful antiretroviral therapy (ART) are reported to have higher rates of age-associated non-communicable comorbidities (AANCCs). HIV-associated immune dysfunction has been suggested to contribute to increased AANCC risk. Here we performed a cross-sectional immune phenotype analysis of T cells in ART-treated HIV-1-positive individuals with undetectable vireamia (HIV-positives) and HIV-1-negative individuals (HIV-negatives) over 45 years of age. In addition, two control groups were studied: HIV negative adults selected based on lifestyle and demographic factors (Co-morBidity in Relation to AIDS, or COBRA) and unselected age-matched donors from a blood bank. Despite long-term ART (median of 12.2 years), HIV-infected adults had lower CD4⁺ T-cell counts and higher CD8⁺ T-cell counts compared to well-matched HIV-negative COBRA participants. The proportion of CD38⁺HLA-DR⁺ and PD-1⁺ CD4⁺ T-cells was higher in HIV-positive cohort compared to the two HIV-negative cohorts. The proportion CD57⁺ and CD27⁻CD28⁻ cells of both CD4⁺ and CD8⁺ T-cells in HIV-positives was higher compared to unselected adults (blood bank) as reported before but this difference was not apparent in comparison with well-matched HIV-negative COBRA participants. Multiple regression analysis showed that the presence of an increased proportion of terminally differentiated T cells was strongly associated with CMV infection. Compared to appropriately selected HIV-negative controls, HIV-positive individuals on ART with long-term suppressed viraemia exhibited incomplete immune recovery and increased immune activation/exhaustion. CMV infection rather than treated HIV infection appears to have more consistent effects on measures of terminal differentiation of T cells.

Emphysema is associated with thoracic vertebral bone attenuation on chest CT scan in HIV-infected individuals

BACKGROUND

Age-related chronic diseases are prevalent in HIV-infected persons in the antiretroviral therapy (ART) era. Bone mineral density (BMD) loss and emphysema have separately been shown to occur at a younger age and with lesser risk exposure in HIV-infected compared to HIV-uninfected individuals. In non-HIV infected smokers, emphysema has been shown to independently predict low BMD. We hypothesized that emphysema would independently associate with thoracic vertebral bone attenuation, a surrogate for bone mineral density, in HIV-infected individuals.

METHODS

Clinical, pulmonary function, and radiographic data were analyzed for 164 individuals from the University of Pittsburgh's HIV Lung Research Center cohort. Chest CT scans were used to quantify emphysema and compute Hounsfield Unit (HU) attenuation of the 4th, 7th, and 10th thoracic vertebrae. The association between mean HU attenuation values across the three vertebrae and radiographic emphysema, age, sex, body mass index (BMI), steroid use, viral load, CD4 count, and forced expiratory volume in the first second (FEV1) was assessed by univariate and multivariate analyses.

RESULTS

In univariate analysis, mean HU attenuation decreased with increasing age (p<0.001), pack years (p = 0.047), and percent emphysema (p<0.001). In a multivariable model, including pack years, age, sex, ART and steroid use, greater emphysema was independently associated with this surrogate marker of BMD in HIV-infected individuals (p = 0.034).

CONCLUSIONS

The association of emphysema with thoracic bone attenuation in HIV-infected individuals is consistent with previous reports in non-HIV infected smokers. These findings suggest that emphysema should be considered a potential marker of osteoporosis risk in HIV-infected individuals.

Clinical risk factors for in-hospital mortality in older adults with HIV infection: findings from a South African hospital administrative dataset

Introduction

The proportion of older South African adults (aged ≥50 years old) with HIV infection requiring hospitalization is likely to increase in the near future. Clinical risk factors for in-hospital mortality (IHM) in these patients are not well described. We aimed to identify clinical risk factors associated with IHM and their overall contribution towards IHM in older South African adults with HIV infection.

Methods

Clinical data for 690 older adults with HIV infection was obtained from the hospital administrative database at the Hlabisa Hospital in KwaZulu-Natal, South Africa. Logistic regression was used to determine independent clinical risk factors for IHM. Population-attributable fractions (PAFs) were calculated for all independent clinical risk factors identified.

Results

Male gender (p=0.005), CD4 count <350 cells/mm³ (p=0.035), unknown CD4 count (p=0.048), tuberculosis (p=0.033) and renal failure (p=0.013) were independently associated with IHM. Male gender contributed the most to IHM (PAF=0.22), followed by unknown CD4 count (PAF=0.14), tuberculosis (PAF=0.12), renal failure (PAF=0.06) and CD4 count <350 cells/mm³ (PAF=0.01).

Conclusion

Although further research is required to confirm our findings, there is potential for these clinical risk factors identified in our study to be used to stratify patient risk and reduce IHM in older adults with HIV infection.

Correlates of Combination Antiretroviral Adherence Among Recently Diagnosed Older HIV-Infected Adults Between 50 and 64 years

Optimal adherence to combination antiretroviral therapy is essential to the health of older people living with HIV (PLWH), however, the literature on adherence and aging is limited. Using Medicaid data from 29 states (N = 5177), we explored correlates of optimal adherence among older PLWH. The prevalence of optimal adherence was low (32 %) in this study. Males were more adherent than females (APR = 1.11, 95 % CI 1.02-1.21, P = 0.0127); persons with three or more co-morbidities (APR = 0.67, 95 % CI 0.60-0.74, P < 0.001), two co-morbidities (APR = 0.86, 95 % CI 0.75-0.98, P = 0.0319) and one co-morbidity (APR = 0.82, 95 % CI 0.73-0.92, P = 0.0008) were less adherent than those without any co-morbidity; and residents of rural areas (APR = 0.90, 95 % CI 0.63-0.98, P = 0.0385) and small metropolitan areas (APR = 0.82, 95 % CI 0.72-0.94, P = 0.0032) were less adherent than residents of large metropolitan areas. There were no racial differences in optimal adherence. Targeted interventions that provide adherence support, case management, and peer navigation services may be of benefit in achieving optimal adherence in this population.

The Survival Experience of Older and Younger Adults with AIDS

Older people with HIV infection die faster than younger counterparts, but it is notknown whether age-associated survival is changing over time. The authors used theCenters for Disease Control data set of adult cases of AIDS reported from January 1,1981, to December 31, 1994, to study age-associated differences in survival by yearof diagnosis. A total of 433,354 adults with AIDS were reported during this interval.Of these, 10.3% were younger than age 50. In 1983-1984, median survival for olderand younger people was 153 versus 274 days, respectively. By 1991-1992, mediansurvival had improved for both groups-396 and 731 days, respectively. However,the relative and absolute gap in survival grew. While a substantially larger proportionof older adults died within 90 days of diagnosis, the overall trend of an increasingage-associated gap in survival remained when these were excluded from the analysis.Older and younger people with AIDS have achieved prolonged survival, but theage-associated gap in survival has grown.

Middle-Aged and Older People with AIDS

This article explores the stability and changes in national trends related to AIDS rates, transmission routes, and risk factors from the mid-1980s to 1997. The authors show that while the numbers of AIDS cases have grown dramatically for all age groups, the proportion of cases for persons age 50 and older (at diagnosis) has remained a fairly stable 10% of the total case load, resulting in more than 60,000 cases in 1997. Contrary to popular belief, the most prevalent transmission route for middle-aged and older people has always been through sexual contact. While middle-aged and older people may be at reduced risk compared to younger age groups, these data also reveal a disturbing trend. People age 50 and older continue to be less knowledgeable about AIDS risks, perceive themselves to be at lower risk, and, for those with known AIDS-related risks, have made fewer behavioral accommodations to avoid such risksas compared to younger people. With recent data indicating a faster rise in new AIDScases among the 50-plus population, middle-aged and older people can no longer beignored in AIDS prevention or treatment efforts.

Health Care Needs and Services Delivery for Older Persons with HIV/AIDS

This article brings together information on age differences in HIV health care needsand use patterns to shed light on distinctive aspects of health services needs and useby older individuals with HIV. Age differences in social and economic characteristics,medical comorbidity, psychiatric comorbidity, survival, access to medical care, andpatterns in use of inpatient services are examined. Existing literature suggests thatdelayed diagnosis, biologically based differences in progression of HIV disease, andcomorbid health conditions unrelated to HIV all may contribute to the shorter timefrom diagnosis to death among patients. Event history analyses of the hazard andduration of hospitalization among individuals with AIDS in the New Jersey Medicaidprogram indicated that those age 50 and older were hospitalized somewhat less oftenbut for longer stays, suggesting that there may be opportunities to substitute care athome for some care provided in the hospital to older people with HIV.

Health-Related Quality of Life in Persons Younger and Older than 50 Who are Living with HIV/AIDS

Mortality rates are higher in older persons with AIDS. The Wilson and Cleary health-related quality-of-life model was used to explore whether there were differences on health-related quality-of-life variables between persons aged 50 or older ( n = 73) and younger persons ( n = 640) in a national sample. Depending on the level of the data, either independent t tests or chi-squares were calculated. Older participants reported significantly more medical conditions such as diabetes or hypertension ( p = .000), more limitations in physical functioning ( p = .006), and self-disclosure of HIV infection to fewer people ( p = .000). There were no significant differences on any of the other variables. There are relatively few differences in older as compared to younger persons living with HIV/AIDS, yet mortality rates are higher in older samples. The relationship between the areas where there are differences and whether they affect morbidity and mortality need further exploration.

Predictors of HIV-Infection in Older Adults

This article is a retrospective case-control study of patients from a Veteran’s Affairs Medical Center and an urban public hospital. Patients (53) older than 55 at the time of their HIV diagnosis were age- and gender-matched to 106 HIV-negative controls. Potential predictors of HIV-infection were abstracted from the medical records. HIV-positive patients were more likely to have a history of sexually transmitted diseases, have Hepatitis B+, and have significant differences in their mean globulin, serum sodium, albumin, and hemoglobin levels. The mean albumin to globulin ratio was also statistically, significantly different between the HIV-positive patients and the controls. These data suggest that for patients older than 55, certain medical history parameters may be useful in predicting risk of being HIV-positive. An albumin to globulin ratio < 1.0, especially when combined with a history of alcohol abuse or prior sexually transmitted disease, should prompt all physicians to screen their older patients for HIV.

Predictors of Poor Retention in Care of HIV-infected Patients Receiving Antiretroviral Therapy in Korea: Five-Year Hospital-based Retrospective Cohort Study

Poor retention in care (RIC) is associated with higher antiretroviral therapy (ART) failure and worse survival. Identifying high risk patients for poor RIC is important for targeted intervention. A retrospective cohort study was conducted at a tertiary care hospital in Korea. HIV-infected patients initiating ART during 2002-2008 were included. 5 year-RIC was measured by hospital visit constancy (HVC) at 5 years after initiating ART. Among 247 enrolled patients, 179 (72.5%) remained in care, 20 (8.1%) were transferred to other hospitals, 9 (3.6%) died and 39 (15.8%) were lost to follow-up. We compared the demographic, psychosocial, and clinical characteristics between the groups with 100% HVC (n = 166, 67.2%) and ≤ 50% HVC (n = 33, 13.4%). In multivariable analysis, ART-starting age ≤ 30 years (odds ratio [OR] 4.08 vs. > 50; 95% confidence interval [CI] 1.10-15.15, P = 0.036), no non-HIV related comorbidity (OR 2.94 vs. comorbidity ≥ 1; 95% CI 1.02-8.49, P = 0.046), baseline CD4 cell count > 300 cells/μL (OR 3.58 vs. ≤ 200; 95% CI 1.33-9.65, P = 0.012) were significant predictable factors of poor RIC. HIV/AIDS care-givers should pay attention to young patients with higher baseline CD4 cell counts and no non-HIV related comorbidity.

Mortality and immunological recovery among older adults on antiretroviral therapy at a large urban HIV clinic in Kampala, Uganda

BACKGROUND

We describe older (>50 years) HIV-infected adults after antiretroviral therapy (ART) initiation, evaluating immunological recovery by age category, considering individual trajectories based on the pretreatment CD4. We also describe mortality on ART and its risk factors by age category including the contribution of poor immunological recovery at a large urban clinic in Kampala, Uganda.

METHODS

We performed a cohort analysis of adult (>18 years) HIV-infected patients who initiated ART between January 1, 2004 and January 3, 2012. Immunological response was evaluated using mixed-effects linear regression. We described mortality using Kaplan-Meier survival methods analyzing for risk factors of mortality using multivariate Weibull survival regression stratified by age category.

RESULTS

Among 9806 individuals who initiated ART, mean age was 37 years (SD: 8.8), average follow-up 5.7 years (SD: 1.7), and median baseline CD4 was 115 cells per cubic millimeter (interquartile range: 42-184). Adults younger than 50 years had on average a higher CD4 increase of 45 cells per cubic millimeter (95% confidence interval: 17 to 72; P = 0.001) compared with counterparts aged 60 years and older. Mortality was highest among older adults compared with younger counterparts. Only CD4 count <100 cells per cubic millimeter after 1 year on ART and a CD4 count less than baseline were associated with a statistically significant higher rate of death among older adults.

CONCLUSIONS

Older adults had a slower immunological response, which was associated with mortality, but this mortality was not typically associated with opportunistic infections. Future steps would require more evaluation of possible causes of death among these older individuals if survival on ART is to be further improved.

Patient-centered care for people living with multimorbidity

PURPOSE OF REVIEW

The purpose of this review is to consider a patient-centred approach to the care of people living with HIV (PLWH) who have multimorbidity, irrespective of the specific conditions.

RECENT FINDINGS

Interdisciplinary care to achieve patient-centred care for people with multimorbidity is recognized as important, but the evaluation of models designed to achieve this goal are needed. Key elements of such approaches include patient preferences, interpretation of the evidence, prognosis as a tool to inform patient-centred care, clinical feasibility and optimization of treatment regimens.

SUMMARY

Developing and evaluating the best models of patient-centred care for PLWH who also have multimorbidity is essential. This challenge represents an opportunity to leverage the lessons learned from the care of people with multimorbidity in general, and vice versa.

Psychosocial Predictors and HIV-Related Behaviors of Old Adults Versus Late Middle-Aged and Younger Adults

Objective: We investigated the psychosocial predictors and HIV-related behaviors of old adults versus late middle-aged and younger adults. Method: A demographically representative sample of residents in Italy aged 18 to 75 years ( n = 2,018) was subdivided into three age groups: (a) younger adults (18-49 years), (b) late middle-aged adults (50-59 years), and (c) old adults (60-75 years). Interviews were conducted using computer-assisted telephone survey methodology. Results: Despite reporting similar levels of sexual risk behaviors, late middle-aged and old adults were less likely to use condoms and to have ever had an HIV test. The levels of HIV/AIDS knowledge, risk perception, perceived behavioral control, and behavioral intentions toward condom use were lower among old adults compared with younger adults. Old adults were less likely to have discussed HIV/AIDS with friends, relatives, or health professionals. Discussion: Old adults should be included in prevention efforts targeting knowledge, perceptions, and intentions toward condom use. Future studies should be cautious when overgeneralizing the results to all individuals aged 50 and older.

Treatment of HIV infection in the older patient

The number of HIV patients over the age of 50 years is increasing due to increased longevity in patients treated with highly active antiretroviral therapy (HAART), in addition to new primary infections in older patients. Numerous studies have demonstrated worse HIV disease progression and mortality in older HIV patients compared with younger patients. While HAART therapy has been shown to be effective at reducing HIV-1 RNA, the immunologic benefits in older patients may be reduced compared to younger patients. Older patients are more likely to suffer comorbidities requiring concomitant medications than younger patients. Toxicities from HAART, particularly dyslipdemia, insulin resistance, and pancreatitis may also be worse in older HIV patients. Controlled trials on epidemiology, pathogenesis, and therapeutic and clinical outcomes in the elderly are needed. As the HIV-infected population ages, there is a growing need to better determine the efficacy of HAART in older patients, and to investigate factors associated with a more rapid course of HIV infection in patients over the age of 50 years.

Determinants of progression to AIDS and death following HIV diagnosis: a retrospective cohort study in Wuhan, China

OBJECTIVE

To identify determinants associated with disease progression and death following human immunodeficiency virus (HIV) diagnosis.

METHODS

Disease progression data from the diagnosis of HIV infection or acquiring immunodeficiency syndrome (AIDS) to February 29, 2012 were retrospectively collected from the national surveillance system databases and the national treatment database in Wuhan, China. Kaplan-Meier method, Logistic regression and Cox proportional hazards model were applied to identify the related factors of progression to AIDS or death following HIV diagnosis.

RESULTS

By the end of February 2012, 181 of 691 HIV infectors developed to AIDS, and 129 of 470 AIDS patients died among whom 289 cases received concurrent HIV/AIDS diagnosis. Compared with men infected through homosexual behavior, injection drug users possessed sharply decreased hazard ratio (HR) for progression to AIDS following HIV diagnosis [HR = 0.31, 95% confidence interval (CI), 0.18-0.54, P = 4.01×10(-5)]. HIV infectors at least 60 years presented 1.15-fold (HR = 2.15, 95% CI, 1.15-4.03, P = 0.017) increased risk to develop AIDS when compared with those aged 17-29 years. Similarly, AIDS patients with diagnosis ages between 50 and 59 years were at a 1.60-fold higher risk of death (HR = 2.60, 95% CI, 1.18-5.72, P = 0.017) compared to those aged 19-29 years. AIDS patients with more CD4(+) T-cells within 6 months at diagnosis (cell/µL) presented lower risk of death (HR = 0.29 for 50- vs <50, 95% CI, 0.15-0.59, P = 0.001). The highly active antiretroviral therapy (HAART) delayed progression to AIDS from HIV diagnosis (HR = 0.15, 95% CI, 0.07-0.34, P = 6.46×10(-6)) and reduced the risk of death after AIDS diagnosis (HR = 0.02, 95% CI, 0.01-0.04, P = 7.25×10(-25)).

CONCLUSIONS

Progression to AIDS and death following HIV diagnosis differed in age at diagnosis, transmission categories, CD4(+) T-cell counts and HAART. Effective interventions should target those at higher risk for morbidity or mortality, ensuring early diagnosis and timely treatment to slow down the disease progression.

Older HIV-infected patients--an underestimated population in northern Greece: epidemiology, risk of disease progression and death

OBJECTIVES

HIV prevalence among older people is on the increase. The aim of this study was to evaluate the epidemiological and clinical features at diagnosis and survival of older patients.

METHODS

This was a retrospective analysis of the data of 558 newly diagnosed antiretroviral-naïve patients between January 1998 and December 2008. Patients were divided into two groups according to their age at diagnosis: ≥50 years (n=103) and 18-49 years (n=455).

RESULTS

The most common risk factor for older patients was heterosexual contact (p<0.013). Older patients were more likely to suffer from hypertension (33.0% vs. 5.1%, p<0.0005), cardiovascular disease (20.4% vs. 2.9%, p<0.0005), neurological disorders (11.7% vs. 5.5%, p=0.02), renal dysfunction (12.6% vs. 5.3%, p=0.01), and infections (66.0% vs. 49.7%, p=0.003) than their younger counterparts, and to have more hospital admissions during follow-up (47.5% vs. 19.6%, p<0.0005). Older patients had a shorter survival time (p<0.0005). A statistically significant increase in CD4+ cell number through time was observed in both groups (p<0.0005). Younger patients reached higher magnitudes of absolute numbers of CD4+ cells during follow-up (p<0.0005) after the initiation of antiretroviral therapy. The total number of patients with clinical AIDS from baseline throughout the study period was also higher in the older age group (35.9% vs. 25.0%).

CONCLUSIONS

HIV-infected people aged ≥50 years differ in epidemiological and clinical features to younger HIV-infected people. The issue of increasing prevalence of HIV infection is a matter of concern due to existing comorbidities, which probably lead to higher mortality rates and faster progression to clinical AIDS.

Co-morbidities in persons infected with HIV: increased burden with older age and negative effects on health-related quality of life

This study sought to determine the synergistic effects of age and HIV infection on medical co-morbidity burden, along with its clinical correlates and impact on health-related quality of life (HRQoL) across the lifespan in HIV. Participants included 262 individuals across four groups stratified by age (≤40 and ≥50 years) and HIV serostatus. Medical co-morbidity burden was assessed using a modified version of the Charlson Co-morbidity Index (CCI). Multiple regression accounting for potentially confounding demographic, psychiatric, and medical factors revealed an interaction between age and HIV infection on the CCI, with the highest medical co-morbidity burden in the older HIV+cohort. Nearly half of the older HIV+group had at least one major medical co-morbidity, with the most prevalent being diabetes (17.8%), syndromic neurocognitive impairment (15.4%), and malignancy (12.2%). Affective distress and detectable plasma viral load were significantly associated with the CCI in the younger and older HIV-infected groups, respectively. Greater co-morbidity burden was uniquely associated with lower physical HRQoL across the lifespan. These findings highlight the prevalence and clinical impact of co-morbidities in older HIV-infected adults and underscore the importance of early detection and treatment efforts that might enhance HIV disease outcomes.

Cancer and the 'other' noncommunicable chronic diseases in older people living with HIV/AIDS in resource-limited settings: a challenge to success

OBJECTIVE

There is considerable research around the morbidity and mortality related to noncommunicable diseases (NCDs), particularly cardiovascular disease and diabetes, among people living with HIV/AIDS (PLWHA) in resource-richer settings. Less is known about the burden and appropriate management of NCDs, particularly 'other' NCDs including cancer, renal, pulmonary, neurocognitive and mental health conditions, among older PLWHA in resource-limited settings (RLSs). We undertook a literature review of these other NCDs to explore what is currently known about them and identify areas of further research.

METHODS

Systematic literature review of published manuscripts and selected conference abstracts and reports.

RESULTS

Although there is growing recognition of the importance of these NCDs among the aging population of PLWHA in RLSs, significant gaps remain in understanding the epidemiology and risk factors among older PLWHA in these settings. Even more concerning is the limited available evidence for effective and feasible approaches to prevention, screening and treatment of these conditions. The burden of these NCDs is related to both the aging of the population of PLWHA and an increased risk due to HIV infection, other comorbidities associated with HIV infection or transmission risk and underlying risk factors in the general community. Results from resource-richer settings and RLSs highlight malignancies, neurocognitive and mental health as well as renal disease as the most significant challenges currently and likely to increase in the future.

CONCLUSION

Although some lessons can be taken from the growing experience with NCDs in older PLWHA in resource-richer settings, additional research is needed to better understand their risk and impact and identify optimal models of care to effectively address this challenge in the areas where the majority of older PLWHA will be receiving care.

Patient time costs and out-of-pocket costs in hepatitis C

BACKGROUND

Hepatitis C virus (HCV) infection is associated with substantial costs to patients, their caregivers and society.

AIMS

We evaluated time costs (time spent seeking healthcare) and out-of-pocket (OOP) costs for patients with HCV and their caregivers.

METHODS

We measured costs for 738 HCV outpatients in a tertiary-care clinic using a patient-completed questionnaire. Time and OOP costs were compared across disease stages and sociodemographic categories. We examined the association between cost and disease stage using linear regression adjusting for age, gender, marital status, education, income and Index of Coexistent Disease (ICED) comorbidity score. Costs were expressed in 2007 Canadian dollars.

RESULTS

The mean annual time cost per patient was $2136 (98 h), and ranged from $281 (18 h) in individuals who had cleared the virus to $9416 in transplant recipients (420 h). Caregiver costs were reported in 10% of patients. The mean annual OOP cost per patient was $1326. Patients receiving active treatment and those with late-stage disease spent $2500-2800 per year on HCV-related healthcare, approximately 7% of their annual income. Patients who had cleared the virus had the lowest time and OOP costs. Low income and unemployed patients had higher costs.

CONCLUSIONS

In HCV-infected individuals, OOP and time costs represent a significant economic burden and fall disproportionately upon those least able to afford them. The lower cost burden among those who were successfully treated suggests that wider use of antiviral therapy may reduce economic burden in addition to improving health outcomes.

Predicting adherence to antiretroviral therapy in HIV-infected older adults: the moderating role of gender

This study characterized rates and correlates of ART adherence in 242 HIV-infected persons 50+ years of age. Hierarchical regressions tested a model in which depression mediated the relationships between social support and avoidance coping with ART adherence. Results indicated low rates of consistent and timely adherence in both men (48%) and women (51%). For men and women alike, social support and avoidance coping predicted depression. Although rates of adherence and predictors of depression did not differ by gender, predictors of adherence did. Avoidance coping, social support and depression predicted ART adherence in older men, but not in older women. Contrary to expectations, depression did not mediate the relationships of coping and social support with ART adherence for either gender. These findings suggest that while HIV-infected older men and women share similar paths toward depression, they diverge in predictors of adherence. Adherence interventions may be more efficacious if they are sensitive to gender differences, although more research is first needed to identify factors related to adherence in HIV-infected older women.

The effect of comorbidity on the competing risk of sudden and nonsudden death in an ambulatory heart failure population

BACKGROUND

Sudden death (SD) and non-sudden cardiac death are responsible for the majority of deaths in patients with heart failure. We sought to identify the influence of comorbid illness (Charlson Comorbidity Index [CCI]) on competing modes of death in heart failure.

METHODS

A retrospective analysis of 824 patients followed in a tertiary care heart failure clinic was performed. We analyzed the cumulative incidence of sudden and nonsudden death. Competing risk regression was used to examine the association between medical comorbidities and mode of death. The outcomes of interest were overall mortality, SD, SD and/or appropriate implantable cardioverter-defibrillator therapy (ICD), and non-SD.

RESULTS

Mean age of the study population was 64.1 ± 14.7 years, 68.6% were male, and mean ejection fraction was 32.8% ± 13.5%. Over a mean follow-up of 4.4 years, 229 patients (27.8%) died. SD accounted for 33 deaths (14.4%), whereas SD/appropriate ICD therapy occurred in 56 patients (24.5%). The risk of non-SD and total mortality increased (P < .0001) as the CCI increased, whereas the risk of SD decreased (P = .03). The cumulative incidence of SD, SD and/or ventricular tachycardia/fibrillation, and non-SD at 5 years was 5.6%, 9.1%, and 27.8%, respectively. In multivariate competing risk analysis, advancing age, New York Heart Association class, and a CCI >4 were significantly associated with non-SD.

CONCLUSION

Patients with heart failure with significant comorbidities are much more likely to sustain non-SD. These findings may have implications in optimal selection of patients with heart failure for interventions such as prophylactic ICD therapy.

Aging and HIV infection

INTRODUCTION

Population aging has become a global phenomenon, and HIV infection among older individuals is also increasing. Because age can affect the progression of HIV infection, we aimed to evaluate the present knowledge on HIV infection in older patients.

METHODS

Literature review of the last 20 years.

RESULTS

Older HIV-infected patients have lower CD4(+) T cell counts, higher viral load and are more frequently symptomatic at diagnosis. The infection progresses more rapidly, with higher morbidity and lethality rates. However, older patients are more compliant to antiretroviral treatment; they experience a better virologic response, and treatment represents a positive clinical impact. Aging affects the complex interaction between HIV infection and the immune system. Both conditions contribute to the dysfunction of immune cells, including a decrease in the phagocytes' microbicidal capability, natural killer cells' cytolytic function, expression of toll-like receptors and production of interleukin-12. Chronic immune activation responsible for the depletion of CD4(+) and CD8(+) T cells in HIV infection appears to worsen with senescence. Older patients also exhibit a less robust humoral response, with the production of less avid and specific antibodies.

CONCLUSION

Both HIV and aging contribute to immune dysfunction, morbidity and mortality. However, highly active antiretroviral therapy (HAART) is beneficial for older patients, and treatment of older patients should not be discouraged.

HIV and aging

Approximately one in five individuals living with HIV infection in the United States is 50 years of age or older. This proportion continues to increase as HIV incidence remains stable and potent antiretroviral therapy has reduced the morbidity and mortality associated with HIV infection. Newly identified HIV-seropositive older individuals are proportionately more likely than younger persons to have AIDS at the time of diagnosis. Clinicians have to think about the possibility of HIV infection in older persons to avoid delays in diagnosis and treatment. Immunologic recovery in older individuals initiated on combination antiretroviral therapy is less robust in some studies compared with younger individuals. However, virologic suppression on treatment in young versus old antiretroviral naïve patients is comparable. Co-morbid conditions and their treatment pose a special challenge to health care providers with regard to drug metabolism and interactions with HIV medications. HIV prevention should be discussed with all at risk individuals. The HIV epidemic will only worsen if medical practitioners neglect to discuss sexual risk behavior with their older patients.

Prevalence and patient awareness of medical comorbidities in an urban AIDS clinic

Mortality in HIV-positive persons is increasingly due to non-HIV-related medical comorbidities. There are limited data on the prevalence and patient awareness of these comorbid conditions. Two hundred subjects at an urban HIV clinic were interviewed in 2005 to assess their awareness of 15 non-HIV-related medical comorbidities, defined as medical problems that are neither AIDS-defining by standard definitions, nor a direct effect of immune deficiency. Medical charts were subsequently reviewed to establish prevalence and concordance between self-report and chart documentation. Eighty-four percent of subjects self-reported at least 1 of 15 medical comorbidities and 92% had at least 1 condition chart-documented. The top 5 chart-documented conditions were hepatitis C (51.5%), pulmonary disease (28.5%), high blood pressure (27%), high cholesterol (24.5%), and obesity (22.5%). In multivariate analysis, higher number of non-HIV-related medical comorbidities was associated with older age, female gender, and intravenous drug use as route of HIV transmission. Across self-reported non-HIV-related medical comorbidities, the absolute concordance rate ranged from 67% to 96%, the sensitivity ranged from 0% to 79%; the positive predictive value ranged from 0% to 100%. While the vast majority of largely urban minority HIV-positive subjects were diagnosed with non-HIV-related medical comorbidities, there is significant room for improvement in patient awareness. In order to help patients optimally access and adhere to medication and medical care for these non-HIV-related medical comorbidities, interventions and educational campaigns to improve patient awareness that take cultural background, literacy, and educational level into account should be developed, implemented, and evaluated.

Development of an HIV risk reduction intervention for older seropositive African American men

The purpose of this study was to assess the feasibility and acceptability of an HIV risk reduction intervention to increase consistent condom use in a sample of older HIV-positive African American men who have sex with men (MSM). Repeated measures were used at baseline, immediate postintervention, and 3 months postintervention to collect data. The development of the intervention was implemented in four phases: focus groups, pilot testing of the questionnaire, modifying the intervention, and executing the intervention. Sixty HIV-positive African American MSM were randomized to either an HIV risk condition or a health condition. Each condition consisted of four 120-minute sessions delivered over a 4-week period in a classroom-like setting using interactive approaches. The primary outcome was consistent condom use during every instance of anal intercourse. In unadjusted analyses, men in the risk reduction group were twice as likely to use condoms consistently (odds ratio [OR] = 2.04; 95% confidence interval [CI] = 0.48-8.77; p = 0.336), although this did not reach statistical significance. All participants reporting consistent condom use at baseline reported consistent use at 3 months giving perfect prediction for the sample. Among men not reporting consistent condom use at baseline, those in the risk reduction group were 5 times more likely to report consistent condom use at 3 months than were those in the health condition (OR = 5.18; 95% CI = 0.97-27.78; p = 0.054). The findings suggest that an HIV risk-reduction condition may increase consistent condom use among HIV-positive African American MSM 50 years and older.

Pharmacologic consideration for the use of antiretroviral agents in the elderly

The prevalence of human immunodeficiency virus (HIV) infection among people older than 50 years is increasing. HIV-infected patients require lifelong treatment with antiretroviral agents to suppress viral replication and maintain immune function. The use of antiretroviral agents in the elderly can be complicated by multiple chronic comorbidities and coadministered non-HIV medications. The pharmacokinetics of antiretroviral agents may be altered due to age-related decrements in hepatic and renal function. The elderly may be more sensitive than younger people to antiretroviral drug toxicity. A better understanding of the pharmacokinetics of antiretroviral agents in the elderly is of importance for the successful management of complex antiretroviral regimens in this population.

[HIV Infection in the elderly]

HIV infection is increasingly common in the elderly. This population is a heterogeneous group with particular epidemiologic characteristics and often with associated comorbidities, which frequently delay diagnosis and lead to poor immunological status at the start of highly active antiretroviral therapy (HAART). There are no differences between elderly and young HIV infected patients in the recommended antiretroviral regimens. Tolerance to treatment is good and the virological and immunological response to HAART is positive, although immunological response is slower and lower than in younger patients. Treatment adherence, which has been shown to be the only protective independent factor related to virological failure, is better in the elderly.

Does cirrhosis affect quality of life in hepatitis C virus-infected patients?

BACKGROUND

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and is associated with impairments in health-related quality of life.

AIMS

To evaluate quality of life (QOL) in cirrhotic (compensated and decompensated) and non-cirrhotic patients with chronic HCV infection, using preference-based (utilities) and non-preference-based methods of evaluating QOL.

METHODS

In a tertiary care setting, 271 patients completed a self-administered time trade-off utility instrument, the Health Utility Index Mark 2 and Mark 3, and the Hepatitis Quality of Life Questionnaire Version 2. Mean QOL scores were compared across HCV disease stages and sociodemographical categories. We examined the association between QOL and disease stage using linear regression adjusting for age, education, marital status, log income and Charlson comorbidity scores. Mean utility scores were compared across disease stages using a propensity score method.

RESULTS

Mean utilities were lower than general population norms (0.81-0.92) and ranged from 0.62 to 0.82 in non-cirrhotic patients (n=197), 0.56-0.84 in compensated cirrhotic patients (n=17) and 0.55-0.76 for decompensated cirrhotic patients (n=57). No significant association found was between disease stage and utility for current health status. Higher income, fewer comorbidities and living in a married or common-law relationship were significantly associated with higher utilities and better QOL. No significant difference in utilities was found between disease stages using propensity score matching.

CONCLUSIONS

Our study confirms that changes in HCV disease stage explain only small changes in QOL and suggests that factors such as underlying comorbidities, income and marital status have a greater effect on QOL than disease stage.

County-level socioeconomic status and survival after HIV diagnosis, United States

PURPOSE

To estimate relative survival (RS) after human immunodeficiency virus (HIV) diagnosis, by race/ethnicity and county-level socioeconomic status (SES).

METHODS

We estimated 5-year RS by age, race/ethnicity, transmission category, sex, diagnosis year, CD4 count, and by county-level SES variables from the U.S. Census. Data, from the national HIV/AIDS Reporting System, were for HIV-infected persons ages > or =13 years (diagnosis during 1996-2003 and follow-up through 2005). We calculated RS proportions by using a maximum likelihood algorithm and modeled the relative risk of excess death (RR) using generalized linear models, with poverty as a random effect.

RESULTS

For men, RS was worse in counties with larger proportions of people living below the 2000 U.S. poverty level (87.7% for poverty of > or =20% vs. 90.1% for poverty of <5.0%) and where unemployment was greater (87.8% where unemployment > 7.1% vs. 90.5% where unemployment < 4.0%). The effects of county-level SES on RS of women were similar. In multilevel multivariate models, RR for men and women within 5 years after an HIV diagnosis was significantly worse in counties where 10.0-19.9% (compared with <5.0%) lived below the poverty level (RR = 1.3 [95% CI 1.2-1.5] and RR = 1.8 [95% CI 1.4-2.2], respectively).

CONCLUSIONS

RS was worse in lower SES areas. To help address the impact of county-level SES, resources for HIV testing, care, and proven economic interventions should be directed to areas with concentrations of economically disadvantaged people.

Epidemiology of HIV and response to antiretroviral therapy in the middle aged and elderly

HIV is increasing in prevalence in the middle aged and older population owing to both increased longevity, and new infections in these populations. Highly active antiretrorival therapy (HAART) therapy may be less effective at restoring immune function in older patients compared with younger patients. There are significant toxicities associated with HAART therapy that, combined with decreased renal and liver function in older patients, may be more problematic in older HIV-infected patients. Comorbid disease is becoming an increasing problem with coadministration of multiple drugs and significant drug-drug interactions. Psychosocial issues in the older patient are often different than those in younger HIV-infected patients and providers should try to address these issues early. Finally, future research should work to identify the ideal timing and type of HAART regimens for older HIV-infected individuals.

Mortality of the elderly is still exceedingly high at diagnosis of AIDS despite favourable outcomes after highly active antiretroviral therapy in Recife, Brazil

This study aimed to compare the outcome of an elderly group of AIDS patients with that of a younger group and their features at the time of the diagnosis of AIDS. We evaluated 58 patients aged >60 years and 114 aged 20-39 years, followed for 35.3 months. There was an obvious delay in diagnosing the elderly as they had more AIDS-defining diseases at diagnosis and their most frequent opportunistic infection was pulmonary tuberculosis. Mortality at the time of the diagnosis of AIDS was four times higher in the elderly (24.1% versus 6.1%, P < 0.001). However, when comparing only those submitted to highly active antiretroviral therapy, there was a similar frequency of favourable outcomes; 76.9% in the elderly against 83.1% in the young (P = 0.455). Mean CD4 lymphocyte was 438 cells/mm(3) at the end of follow up in the young when compared with 442 cells/mm(3) in the elderly (P = 0.945). The types of antiretroviral schema and the number of antivirals per patient were similar in both groups.

Physician specialization and women's primary care services in an urban HIV clinic

To compare adherence to published primary care guidelines by general internal medicine and infectious diseases (ID) specialist physicians treating HIV-positive women we conducted a retrospective patient record review of 148 female HIV-positive patients seen at the Nathan Smith Clinic in New Haven, Connecticut, in 2001 and 2002. Four quality measures were defined to evaluate physician practices: annual cervical cancer screening, influenza vaccination and hyperlipidemia screening, and biennial mammography. Main outcome was the frequency of meeting each measure by generalist and ID-specialist physicians, and the two physician types were compared after controlling for patient clustering, age, and CD4 cell count. Among all measures, the rates of cervical cancer screening in 2001 were lowest among generalists (55%) and ID-specialists (47%) but not significantly different (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.78 to 1.90), and the rates of hyperlipidemia screening in 2002 were highest for both generalists (98%) and ID-specialists (93%), but again not significant (OR 2.86, CI 0.30 to 27.6). No statistically significant differences were found between physician types for any quality measure, nor were significant differences found in the CD4 cell counts of patients of each physician type who received each service. Our results show potential for improvements in care among both generalist and ID-specialist physicians treating HIV-positive women.

Aging and infectious diseases: do patterns of comorbidity vary by HIV status, age, and HIV severity?

Patterns of comorbidity among persons with human immunodeficiency virus (HIV) are not well described. We compared comorbidity among veterans with and without HIV infection. The sample consisted of 33,420 HIV-infected veterans and 66,840 HIV-uninfected veterans. We identified and clustered 11 comorbid conditions using validated International Classification of Diseases, 9th Revision, Clinical Modification codes. We defined multimorbidity as the presence of conditions in all clusters. Models restricted to HIV-infected veterans were adjusted for CD4 cell count and viral load. Comorbidity was common (prevalence, 60%-63%), and prevalence varied by HIV status. Differences remained when the veterans were stratified by age. In multivariable analyses, older HIV-infected veterans were more likely to have substance use disorder and multimorbidity. Renal, vascular, and pulmonary diseases were associated with CD4 cell count <200 cells/mm(3); hypertension was associated with CD4 cell count >200 cells/mm(3). Comorbidity is the rule, and multimorbidity is common among veterans with HIV infection. Patterns of comorbidity differ substantially by HIV status, age, and HIV severity. Primary care guidelines require adaptation for persons with HIV infection.

Negative influence of age on CD4+ cell recovery after highly active antiretroviral therapy in naive HIV-1-infected patients with severe immunodeficiency

OBJECTIVE

To study the effect of age on several outcomes among 187 antiretroviral-naive infected patients who started highly active antiretroviral therapy (HAART) with <or=200 CD4(+)/microl.

METHODS

We carried out a retrospective study to determine the hazard ratio (HR) to reach an outcome in patients who experienced a change from the baseline in CD4(+) counts of at least +100, +200, +300, +400 and +500 cells/microl at any moment during the follow-up and the odds ratio (OR) of achieving and maintaining a CD4(+) value above a certain setpoint during at least 6, 12 or 18 months.

RESULTS

The adjusted HR for an increase of +400 CD4(+)/microl and +500 CD4(+)/microl were 1.3 (95% CI: 1.1; 1.5) and 1.3 (95% CI: 1.1; 1.6) times slower for each additional 5 years of age at baseline. In addition, for every 5 years of extra age, the adjusted OR to achieve an absolute CD4(+) cell count >500/microl at 6, 12 and 18 months after the initiation of HAART were 2.2 (95% CI: 1.5; 3.2), 1.8 (95% CI: 1.2; 2.6), and 1.8 (95% CI: 1.2; 2.9) times less likely, respectively. We also found that patients >or=45 years old had worse complete CD4(+) recovery (CD4(+)>500 cells/microl) than patients <45 years old.

CONCLUSION

The CD4(+) recovery after HAART is a prolonged and continuous process which extends for several years. Age at baseline is inversely correlated with the magnitude and speed of CD4(+) recovery among HIV-1 infected patients.

HIV infection in the elderly

In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis. While HIV infection is commonly thought to affect younger adults, there are an increasing number of patients over 50 years of age living with the condition. UNAIDS and WHO estimate that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older. With the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, survival following HIV diagnosis has risen dramatically and HIV infection has evolved from an acute disease process to being managed as a chronic medical condition. As treated HIV-infected patients live longer and the number of new HIV diagnoses in older patients rise, clinicians need to be aware of these trends and become familiar with the management of HIV infection in the older patient. This article is intended for the general clinician, including geriatricians, and will review epidemiologic data and HIV treatment as well as provide a discussion on medical management issues affecting the older HIV-infected patient.

HIV infection in older adults

The incidence and prevalence of HIV infection in older adults is rising, with disproportionate increases in women and minorities. Compared with younger adults, older patients who have HIV often are diagnosed later in the course of the disease and may have an accelerated decline in immune function. Although the prognosis for older adults has improved with the initiation of highly active antiretroviral therapy, there remains a higher risk for comorbid illness. Additional efforts to diagnose and prevent HIV infection in this older age group are necessary to decrease the transmission of HIV and to reduce the morbidity and mortality associated with this infection.

Antiretroviral treatment and age-related comorbidities in a cohort of older HIV-infected patients

BACKGROUND

The availability of several therapeutic regimens has transformed HIV infection from a life-threatening disease into a chronic condition. Older patients (>50 years old) with HIV infection constitute a new treatment challenge in terms of the cumulative effects of ageing and antiretroviral therapy (ART).

METHODS

The immunovirological effects and metabolic interactions of 48 weeks of ART in older patients followed up in three Infectious Diseases Units in Milan, Italy since 1994 were compared with those in younger controls aged 25-35 years.

RESULTS

The 159 older patients and 118 controls enrolled in the study were comparable for HIV stage, baseline CD4 cell count and viral load but differed for mode of HIV transmission, comorbid conditions and related chronic treatments. Mean viral load decreased after 48 weeks of treatment by 2.6 log(10) HIV RNA copies/mL and CD4 count increased by 137.5 cells/microL in older patients, and similar values for immunovirological effects were obtained in the young controls. The relative risk (RR) of an abnormal test in older patients was 7.33 [95% confidence interval (CI) 4.36-12.36] for glucose, 1.73 (95% CI 1.45-2.07) for total cholesterol, 1.56 (95% CI 1.22-2.0) for high-density lipoprotein cholesterol, 1.26 (95% CI 1.02-1.56) for triglycerides, 6.48 (95% CI 4.36-9.66) for serum creatinine, and 0.45 (95% CI 0.35-0.58) for ALT. Moderate/severe liver and renal toxicities were recorded in the older patients but not in the controls. The tolerability of ART did not differ between the older patients and the controls. Thirty-nine new cardiovascular, endocrine-metabolic and neuralgic disorders (24.52 per 100 person-years) were diagnosed in the older patients and four (3.39 per 100 person-years) in the controls (P<0.0001).

CONCLUSIONS

Diseases induced by, or related to, the toxic effects of antiretrovirals interact with age-specific health profiles, raising new questions and challenges. Comparative epidemiological studies, research studies addressing specific questions and surveillance are needed to answer the questions that arise in clinical monitoring.