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Immunological and Virological Responses in Older HIV-Infected Adults Receiving Antiretroviral Therapy: An Evidence-Based Meta-Analysis. J Acquir Immune Defic Syndr 2020; 83:323-333. [PMID: 31913990 DOI: 10.1097/qai.0000000000002266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Millions of people living with the HIV have received antiretroviral therapy (ART). Older adults make up a significant portion of these individuals; however, the immunological and virological responses to ART for older patients still need to be clarified. DESIGN Meta-analysis. METHODS In this article, we systematically reviewed research articles published between 2001 and 2018 that reported immunological and virological responses and AIDS-related mortality among HIV- infected adults (including individuals aged 50 years and older) receiving ART, using meta-analysis. ART efficiency was measured using 3 outcomes: (1) immunological response, (2) virological response, and (3) mortality. RESULTS We identified 4937 citations, and 40 studies were eventually selected to investigate ART efficiency in older HIV-infected patients, comprising more than 888,151 patients initiating ART. We report that older patients showed poor immunological responses, with CD4 counts and the restoration of CD4 counts after ART initiation being significantly lower than seen in younger patients. However, older patients exhibited better viral suppression rates (risk ratio: 1.04; 95% confidence intervals: 1.01 to 1.08) after 36 months following ART initiation. In addition, older adults had a higher risk of AIDS-related death (adjusted hazard ratio: 1.44, 95% confidence interval: 1.30 to 1.60). CONCLUSIONS Older age after ART initiation was associated with a poorer immunological response and a higher risk of mortality, suggesting the need to increase early diagnosis and treatment among older HIV patients.
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Bogner JR. [Human immunodeficiency virus infection in the elderly]. Z Gerontol Geriatr 2019; 53:179-191. [PMID: 31832770 DOI: 10.1007/s00391-019-01669-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
Due to the excellent efficacy of antiretroviral treatment increasingly more people with human immunodeficiency virus (HIV) infections survive to old age. The national and international definition of older people with HIV infections comprises those aged 50 years and older. Practitioners caring for these patients have to take age-related comorbidities and polypharmacy into account. Cooperation between HIV caregivers and general practitioners as well as geriatric specialists should provide a network that covers topics such as vaccinations, early detection of malignancies and psychosocial aspects, such as loneliness and organization of nursing care. A schedule for preventive measures is presented in this article as well as practical approaches including access to drug interaction databases and HIV treatment guidelines.
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Affiliation(s)
- Johannes R Bogner
- Sektion Klinische Infektiologie, Med. Klinik und Poliklinik IV, Klinikum der Universität München, Pettenkoferstr. 8a, 80336, München, Deutschland.
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Geriatric-HIV Medicine: the geriatrician’s role. Eur Geriatr Med 2018; 10:259-265. [DOI: 10.1007/s41999-018-0144-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/24/2018] [Indexed: 12/21/2022]
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Jourjy J, Dahl K, Huesgen E. Antiretroviral Treatment Efficacy and Safety in Older HIV-Infected Adults. Pharmacotherapy 2016; 35:1140-51. [PMID: 26684554 DOI: 10.1002/phar.1670] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Highly active antiretroviral therapy (ART) and its widespread availability have revolutionized the landscape of HIV care and patient outcomes, transforming infection with HIV into a manageable chronic condition rather than a life-limiting disease. This transformation has created an older patient demographic. The effect that older age has on the outcomes of ART is not completely understood. Limited data are available in older individuals due to underrepresentation in clinical trials. To better understand this relationship, we conducted a literature search to assess the impact of older age on the outcomes of ART in the older HIV-infected population, including immunologic and virologic outcomes, mortality, disease progression, toxicity of ART, and pharmacokinetic considerations. In addition, package inserts of antiretroviral (ARV) medications were reviewed for efficacy, safety, and pharmacokinetic information pertaining to the older population. Most studies in older adults (50 yrs or older) demonstrated slower and blunted CD4 immune recovery but better virologic suppression in response to ART. Higher rates of mortality and faster disease progression have been observed in adults 50 years and older, particularly during the first year after ART initiation. HIV-infected patients aged 50 years and older appear to be at greater risk for certain ART-associated toxicities including nephrotoxicity, decline in bone mineral density and bone fracture, symptomatic peripheral neuropathy, and cardiovascular disease including myocardial infarction. The available literature suggests that clinicians should consider avoiding agents such as tenofovir disoproxil fumarate (TDF) in older patients with risk factors for renal impairment and/or osteoporosis. If TDF is used in patients aged 50 years or older, more frequent monitoring should be considered. Older age was a significant predictor for higher atazanavir exposure and higher lopinavir trough concentration at 24 weeks. The clinical implications of these findings are unknown. It is imperative that future development of novel ARV drug therapies includes a greater proportion of older subjects in clinical trials.
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Affiliation(s)
- Jacqueline Jourjy
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Keelin Dahl
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Emily Huesgen
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
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Abstract
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.
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Affiliation(s)
- Molly A Szerlip
- Internal Medicine Clinic, Department of Medicine, Dwight D. Eisenhower Medical Center, Bldg. 300, Fort Gordon, GA 30905, USA.
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Immunological and Clinical Responses following the Use of Antiretroviral Therapy among Elderly HIV-Infected Individuals Attending Care and Treatment Clinic in Northwestern Tanzania: A Retrospective Cohort Study. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2016; 2016:5235269. [PMID: 27042375 PMCID: PMC4794567 DOI: 10.1155/2016/5235269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 02/09/2016] [Accepted: 02/14/2016] [Indexed: 11/26/2022]
Abstract
Background. Limited information exists on adults ≥50 years receiving HIV care in sub-Saharan Africa despite their increasing number. We aimed at studying immunologic and clinical responses to ART in this population. Methods. Data of patients who initiated HAART between 30th of June 2004 and 1st of May 2008 at Sekou Toure Care and Treatment Clinic were retrospectively analyzed. Date of ART initiation was used as a baseline and 48 months as a follow-up date. Immune recovery was defined as a CD4 count of ≥350 cells/mm3 at 48 months and late presentation as presentation with WHO stage 3 or 4 at clinic enrollment. Proportions of patients reaching this endpoint were compared between the two groups. Results. A total of 728 patients were included in our study; of these 73 (10.0%) were aged 50 years and above. Late presentation was more common in elderly patients than young patients (65.7% versus 56.1%, P = 0.12). Proportion of patients with CD4 count ≥350 (immune recovery) was higher in younger patients than in elderly patients, although this was not statistically significant (54.5% versus 44.9%, P = 0.2). Median absolute increase in CD4 at 48 months was higher in younger patients than in elderly patients (+241.5 cells/mm3 versus +146 cells/mm3, P = 0.007). Conclusion. Elderly HIV patients have higher rates of late presentation, with lower immune recovery. Strategies to increase HIV testing in this group are required for early diagnosis and treatment to improve outcomes.
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Blanco JR, Caro-Murillo AM, Castaño MA, Olalla J, Domingo P, Arazo P, Gómez-Sirvent JL, Riera M, Pulido F, Vera F, Romero-Palacios A, Aguirrebengoa K, Portilla J, Ferrer P, Pedrol E. Safety, Efficacy, and Persistence of Emtricitabine/Tenofovir Versus Other Nucleoside Analogues in Naive Subjects Aged 50 Years or Older in Spain: The TRIP Study. HIV CLINICAL TRIALS 2014; 14:204-15. [DOI: 10.1310/hct1403-204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Fong R, Cheng AC, Vujovic O, Hoy JF. Factors associated with virological failure in a cohort of combination antiretroviral therapy-treated patients managed at a tertiary referral centre. Sex Health 2014; 10:442-7. [PMID: 24119435 DOI: 10.1071/sh13043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 08/01/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recent antiretroviral regimens are potent and better tolerated, resulting in a low prevalence of treatment failure. It is important to identify the drivers of virological failure, so that patients at risk can be identified early and prevention strategies implemented. METHODS We performed a retrospective case-control study of HIV-positive patients on antiretroviral therapy and managed at The Alfred Hospital during 2010 to evaluate the predictors of virological failure. Controls were matched 3:1 to cases by gender, and by clinical review in the same week as the diagnosis of virological failure in the case. Predictors of virological failure were identified by multivariate conditional logistic regression. RESULTS Thirty-nine patients were identified with treatment failure. In the multivariate model, characteristics associated with virological failure were missed clinic appointments in 1 year before virological failure (odds ratio (OR)=13.1, 95% confidence interval (CI): 2.8-61.1), multiple previous combined antiretroviral therapy regimens (OR =4.2, 95% CI:1.2-15.3), current hepatitis C infection (OR=8.6, 95% CI: 1.9-38.7), older age at HIV diagnosis (OR=1.1, 95% CI: 1.0-1.2), younger age at time of virological failure (OR=0.9, 95% CI: 0.8 to 1.0), and CD4 cell count at virological failure (OR=0.7, 95% CI: 0.5 to 0.9). CONCLUSIONS Targeted and appropriate adherence support should be provided to treatment-experienced patients, particularly those who have missed clinical appointments and those with hepatitis C coinfection. Further elucidation of the barriers to clinic attendance may optimise linkage and retention in care.
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Affiliation(s)
- Raymond Fong
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, Vic. 3004, Australia
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Older HIV-infected patients--an underestimated population in northern Greece: epidemiology, risk of disease progression and death. Int J Infect Dis 2013; 17:e883-91. [PMID: 23639484 DOI: 10.1016/j.ijid.2013.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 02/05/2013] [Accepted: 02/24/2013] [Indexed: 11/20/2022] Open
Abstract
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.
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Pirrone V, Libon DJ, Sell C, Lerner CA, Nonnemacher MR, Wigdahl B. Impact of age on markers of HIV-1 disease. Future Virol 2013; 8:81-101. [PMID: 23596462 PMCID: PMC3625689 DOI: 10.2217/fvl.12.127] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aging is a complicated process characterized by a progressive loss of homeostasis, which results in an increased vulnerability to multiple diseases. HIV-1-infected patients demonstrate a premature aging phenotype and develop certain age-related diseases earlier in their lifespan than what is seen in the general population. Age-related comorbidities may include the development of bone disease, metabolic disorders, neurologic impairment and immunosenescence. Age also appears to have an effect on traditional markers of HIV-1 disease progression, including CD4+ T-cell count and viral load. These effects are not only a consequence of HIV-1 infection, but in many cases, are also linked to antiretroviral therapy. This review summarizes the complex interplay between HIV-1 infection and aging, and the impact that aging has on markers of HIV-1 disease.
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Affiliation(s)
- Vanessa Pirrone
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
| | - David J Libon
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Christian Sell
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Chad A Lerner
- Department of Pathology, Drexel University College of Medicine, Philadelphia, PA 19129, USA
| | - Michael R Nonnemacher
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
| | - Brian Wigdahl
- Department of Microbiology & Immunology, Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
- Drexel University College of Medicine, 245 N 15th Street, New College Building, Philadelphia, PA 19102, USA
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Blanco JR, Jarrín I, Vallejo M, Berenguer J, Solera C, Rubio R, Pulido F, Asensi V, del Amo J, Moreno, and CoRIS S. Definition of advanced age in HIV infection: looking for an age cut-off. AIDS Res Hum Retroviruses 2012; 28:1000-6. [PMID: 22607516 DOI: 10.1089/aid.2011.0377] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The age of 50 has been considered as a cut-off to discriminate older subjects within HIV-infected people according to the Centers for Disease Control and Prevention (CDC). However, the International AIDS Society (IAS) mentions 60 years of age and the Department of Health and Human Services (DHHS) makes no consideration. We aimed to establish an age cut-off that could differentiate response to highly active antiretroviral therapy (HAART) and, therefore, help to define advanced age in HIV-infected patients. CoRIS is an open, prospective, multicenter cohort of HIV adults naive to HAART at entry (January 2004 to October 2009). Survival, immunological response (IR) (CD4 increase of more than 100 cell/ml), and virological response (VR) (HIV RNA less than 50 copies/ml) were compared among 5-year age intervals at start of HAART using Cox proportional hazards models, stratified by hospital and adjusted for potential confounders. Among 5514 patients, 2726 began HAART. During follow-up, 2164 (79.4%) patients experienced an IR, 1686 (61.8%) a VR, and 54 (1.9%) died. Compared with patients aged <25 years at start of HAART, those aged 50-54, 55-59, 60-64, 65-59, and 70 or older were 32% (aHR: 0.68, 95% CI: 0.52-0.87), 29% (aHR: 0.71, 95% CI: 0.53-0.96), 34% (aHR: 0.66, 95% CI: 0.46-0.95), 39% (aHR: 0.61, 95% CI: 0.37-1.00), and 43% (aHR: 0.57, 95% CI: 0.31-1.04) less likely to experience an IR. The VR was similar across all age groups. Finally, patients aged 50-59 showed a 3-fold increase (aHR: 3.58; 95% CI: 1.07-11.99) in their risk of death compared to those aged <30 years. In HIV infection, patients aged ≥50 years have a poorer immunological response to HAART and a poorer survival. This age could be used to define medically advanced age in HIV-infected people.
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Affiliation(s)
| | - Inmaculada Jarrín
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Juan Berenguer
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | | | - Victor Asensi
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Julia del Amo
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
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Reuter S, Oette M, Kaiser R, Lengauer T, Fätkenheuer G, Rockstroh JK, Knechten H, Häussinger D. Risk Factors Associated with Older Age in Treatment-Naive HIV-Positive Patients. Intervirology 2012; 55:147-53. [PMID: 22286885 DOI: 10.1159/000332014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Stefan Reuter
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital, Düsseldorf, Germany.
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Negin J, van Lettow M, Semba M, Martiniuk A, Chan A, Cumming RG. Anti-retroviral treatment outcomes among older adults in Zomba district, Malawi. PLoS One 2011; 6:e26546. [PMID: 22031839 PMCID: PMC3198738 DOI: 10.1371/journal.pone.0026546] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 09/28/2011] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND There are approximately 3 million people aged 50 and older in sub-Saharan Africa who are HIV-positive. Despite this, little is known about the characteristics of older adults who are on treatment and their treatment outcomes. METHODS A retrospective cohort analysis was performed using routinely collected data with Malawi Ministry of Health monitoring tools from facilities providing antiretroviral therapy services in Zomba district. Patients aged 25 years and older initiated on treatment from July 2005 to June 2010 were included. Differences in survival, by age group, were determined using Kaplan-Meier survival plots and Cox proportional hazards regression models. RESULTS There were 10,888 patients aged 25 and older. Patients aged 50 and older (N = 1419) were more likely to be male (P<0.0001) and located in rural areas (P = 0.003) than those aged 25-49. Crude survival estimates among those aged 50-59 were not statistically different from those aged 25-49 (P = 0.925). However, survival among those aged 60 and older (N = 345) was worse (P = 0.019) than among those 25-59. In the proportional hazards model, after controlling for sex and stage at initiation, survival in those aged 50-59 did not differ significantly from those aged 25-49 (hazard ratio 1.00 (95% CI: 0.79 to 1.27; P = 0.998) but the hazard ratio was 1.46 (95% CI: 1.03 to 2.06; P = 0.032) for those aged 60 and older compared to those aged 25-49. CONCLUSIONS Treatment outcomes of those aged 50-59 are similar to those aged 25-49. A better understanding of how older adults present for and respond to treatment is critical to improving HIV services.
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Affiliation(s)
- Joel Negin
- School of Public Health, University of Sydney, Sydney, Australia.
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Maskew M, Brennan AT, MacPhail AP, Sanne IM, Fox MP. Poorer ART outcomes with increasing age at a large public sector HIV clinic in Johannesburg, South Africa. ACTA ACUST UNITED AC 2011; 11:57-65. [PMID: 21951728 DOI: 10.1177/1545109711421641] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As the current HIV-positive population ages, the absolute number of patients >50 years on treatment is increasing. METHODS We analyze the differences in treatment outcomes by age category (18-29, 30-39, 40-49, 50-59, and ≥ 60) among 9139 HIV-positive adults initiating ART in South Africa. RESULTS The adjusted hazard ratios (HRs) for all-cause mortality increased with increasing age, with the strongest association in the first 12 months of follow-up among patients 50 to 59 years (HR 1.67; 95% confidence interval [CI]: 1.24-2.23) versus those <30 years. However, patients 50 to 59 years were less likely to be lost during 24 months on antiretroviral therapy ([ART] HR 0.75; 95% CI: 0.59-0.94) versus patients <30 years. By 6 and 12 months on treatment, older patients were less likely to increase their CD4 count by ≥ 50 cells/mm(3). CONCLUSION Although older patients are at higher risk of mortality and have poorer immunological responses than their younger counterparts, they are more likely to adhere to care and treatment in the first 24 months on ART.
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Affiliation(s)
- Mhairi Maskew
- 1Department of Medicine, Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Horberg M, Hurley L, Towner W, Gambatese R, Klein D, Antoniskis D, Weinberg W, Kadlecik P, Remmers C, Dobrinich R, Quesenberry C, Silverberg M, Johnson M. HIV quality performance measures in a large integrated health care system. AIDS Patient Care STDS 2011; 25:21-8. [PMID: 21214376 DOI: 10.1089/apc.2010.0315] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
HIV quality performance measurements are critical to evaluating a care program's success in areas of testing, access to and retention in care, care processes and outcomes. Kaiser Permanente (KP) provides care to over 8 million Americans and over 19,000 HIV-infected adults. We undertook a quality performance measurement program to assess the care and outcomes for our HIV-positive patient population. We also examined HIV testing practices among our HIV-uninfected patients presenting with a sexually transmitted infection. Our metrics were extracted electronically (encompassing two time periods: July 1, 2005 through June 30, 2006 and the entire calendar year 2007) and did not require any manual data extraction, which was a primary objective of our strategy. For most individual care measures, improvement over time was noted, with 85% or more performance seen on some measures (accessing care and initiating antiretroviral therapy). Opportunities for improvement were identified on other measures, such as diagnosing HIV at an earlier stage of infection, and more consistent Pneumocystis jiroveci pneumonia prophylaxis. Over 90% of our patients on antiretroviral therapy had maximal viral control, along with high median antiretroviral medication adherence. Our results compare favorably to those of other organizations, with a KP HIV mortality rate less than 50% of the overall U.S. rate. These results have implications for improving our care process going forward, as well as for the new U.S. domestic HIV/AIDS Strategy.
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Affiliation(s)
| | - Leo Hurley
- Kaiser Permanente Northern California, Oakland, California
| | - William Towner
- Kaiser Permanente Southern California, Los Angeles, California
| | - Rebecca Gambatese
- UCDA, Kaiser Permanente Foundation Hospitals and Health Plan, Oakland, California
| | - Daniel Klein
- Kaiser Permanente Northern California, Oakland, California
| | | | | | | | - Carol Remmers
- UCDA, Kaiser Permanente Foundation Hospitals and Health Plan, Oakland, California
| | | | | | | | - Michael Johnson
- UCDA, Kaiser Permanente Foundation Hospitals and Health Plan, Oakland, California
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Abstract
Drug users with HIV infection successfully treated with highly active antiretroviral therapy are now living to older ages. As persons with HIV infection age, they become at risk for comorbidities that occur in any group of aging individuals. However, some of these conditions occur at increased rates, with increasing severity, or pose special problems in older persons with HIV infection. This article discusses the epidemiology of HIV infection in aging drug users, and hormonal, cardiovascular, liver, renal, bone, and cognitive disorders and depression and cancer in these individuals, as well as problems related to taking multiple medications and HIV disease progression.
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Affiliation(s)
- Robert S Klein
- Division of Infectious Diseases and Disease Prevention and Public Health Institute, The Mount Sinai School of Medicine, New York, New York 10029, USA.
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Avelino-Silva VI, Ho YL, Avelino-Silva TJ, Santos SDS. Aging and HIV infection. Ageing Res Rev 2011; 10:163-72. [PMID: 20974294 DOI: 10.1016/j.arr.2010.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 10/12/2010] [Accepted: 10/15/2010] [Indexed: 10/18/2022]
Abstract
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.
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Abstract
OBJECTIVE To determine the impact of age and initial HAART regimen class on virologic and immunologic response within 24 months after initiation. DESIGN Pooled analysis of data from 19 prospective cohort studies in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). METHODS Twelve thousand, one hundred and ninety-six antiretroviral-naive adults who initiated HAART between 1998 and 2008 using a boosted protease inhibitor-based regimen or a nonnucleoside reverse transcriptase inhibitor (NNRTI)-based regimen were included in our study. Discrete time-to-event models estimated adjusted hazard odds ratios (aHOR) and 95% confidence intervals (CIs) for suppressed viral load (≤500 copies/ml) and, separately, at least 100 cells/μl increase in CD4 cell count. Truncated, stabilized inverse probability weights accounted for selection biases from discontinuation of initial regimen class. RESULTS Among 12 196 eligible participants (mean age = 42 years), 50% changed regimen classes after initiation (57 and 48% of whom initiated protease inhibitor and NNRTI-based regimens, respectively). Mean CD4 cell count at initiation was similar by age. Virologic response to treatment was less likely in those initiating using a boosted protease inhibitor [aHOR = 0.77 (0.73, 0.82)], regardless of age. Immunologic response decreased with increasing age [18-<30: ref; 30-<40: aHOR = 0.92 (0.85, 1.00); 40-<50: aHOR = 0.85 (0.78, 0.92); 50-<60: aHOR = 0.82 (0.74, 0.90); ≥60: aHOR = 0.74 (0.65, 0.85)], regardless of initial regimen. CONCLUSION We found no evidence of an interaction between age and initial antiretroviral regimen on virologic or immunologic response to HAART; however, decreased immunologic response with increasing age may have implications for age-specific when-to-start guidelines.
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Rhee MS, Greenblatt DJ. Pharmacologic consideration for the use of antiretroviral agents in the elderly. J Clin Pharmacol 2009; 48:1212-25. [PMID: 18812611 DOI: 10.1177/0091270008322177] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Martin S Rhee
- Tufts Medical Center, 800 Washington Street, Box 41, Boston, MA 02111; e-mail:
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20
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Brañas F, Serra JA. [HIV Infection in the elderly]. Rev Esp Geriatr Gerontol 2009; 44:149-154. [PMID: 19443084 DOI: 10.1016/j.regg.2008.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2008] [Revised: 12/17/2008] [Accepted: 12/18/2008] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Fátima Brañas
- Servicio de Geriatría, Hospital Infanta Leonor, Madrid, España.
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21
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Gebo KA. Epidemiology of HIV and response to antiretroviral therapy in the middle aged and elderly. ACTA ACUST UNITED AC 2008; 4:615-627. [PMID: 19915688 DOI: 10.2217/1745509x.4.6.615] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Kelly A Gebo
- Johns Hopkins University School of Medicine, 1830 E Monument St, Room 435, Baltimore, MD 21287, USA
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22
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Increasing age at HIV seroconversion from 18 to 40 years is associated with favorable virologic and immunologic responses to HAART. J Acquir Immune Defic Syndr 2008; 49:40-7. [PMID: 18667932 DOI: 10.1097/qai.0b013e31817bec05] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Studies evaluating the effect of age on response to highly active antiretroviral therapy (HAART) have been limited by their inability to control for duration of human immunodeficiency virus (HIV) infection. We examined the effect of age at HIV seroconversion on response to HAART. METHODS A retrospective analysis of a longitudinal US military cohort of HIV-infected subjects. Time to and maintenance of viral suppression, rate of CD4 cell increase, and rate of progression to acquired immunodeficiency syndrome or death were compared across age groups using time-to-event methods. RESULTS Five hundred sixty-three HIV-infected adults who seroconverted after January 1, 1996, and started HAART were included. Increasing age at seroconversion was significantly associated with faster time to viral suppression (P = 0.002). Increasing age also correlated with duration of suppression, with a 35% reduction in risk of viral rebound for every 5-year increase in age above 18 years (hazard ratio: 0.65, 95% confidence interval 0.55 to 0.75). The rate of CD4 cell increase from 6 to 84 months post-HAART was significantly greater in those who seroconverted at older ages (P = 0.0002). Rates of progression to acquired immunodeficiency syndrome or death did not differ between groups. CONCLUSIONS Increasing age at seroconversion was associated with shorter time to and longer maintenance of viral suppression and a faster increase in CD4 cell count.
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23
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Lacerda HR, Kitner D. Mortality of the elderly is still exceedingly high at diagnosis of AIDS despite favourable outcomes after highly active antiretroviral therapy in Recife, Brazil. Int J STD AIDS 2008; 19:450-4. [PMID: 18574115 DOI: 10.1258/ijsa.2008.007317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- H R Lacerda
- Postgraduate Course in Sciences of Health, Federal University of Pernambuco, Brazil.
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Effros RB, Fletcher CV, Gebo K, Halter JB, Hazzard WR, Horne FM, Huebner RE, Janoff EN, Justice AC, Kuritzkes D, Nayfield SG, Plaeger SF, Schmader KE, Ashworth JR, Campanelli C, Clayton CP, Rada B, Woolard NF, High KP. Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 2008; 47:542-53. [PMID: 18627268 PMCID: PMC3130308 DOI: 10.1086/590150] [Citation(s) in RCA: 396] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Highly active antiretroviral treatment has resulted in dramatically increased life expectancy among patients with HIV infection who are now aging while receiving treatment and are at risk of developing chronic diseases associated with advanced age. Similarities between aging and the courses of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome suggest that HIV infection compresses the aging process, perhaps accelerating comorbidities and frailty. In a workshop organized by the Association of Specialty Professors, the Infectious Diseases Society of America, the HIV Medical Association, the National Institute on Aging, and the National Institute on Allergy and Infectious Diseases, researchers in infectious diseases, geriatrics, immunology, and gerontology met to review what is known about HIV infection and aging, to identify research gaps, and to suggest high priority topics for future research. Answers to the questions posed are likely to help prioritize and balance strategies to slow the progression of HIV infection, to address comorbidities and drug toxicity, and to enhance understanding about both HIV infection and aging.
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Affiliation(s)
- Rita B. Effros
- David Geffen School of Medicine at the University of California, Los Angeles
| | | | - Kelly Gebo
- Johns Hopkins University School of Medicine, Baltimore
| | | | | | | | - Robin E. Huebner
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Edward N. Janoff
- Mucosal and Vaccine Research Program Colorado, University of Colorado School of Medicine, Denver
| | | | - Daniel Kuritzkes
- Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Susan F. Plaeger
- National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | | | | | | | | | - Beth Rada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Nancy F. Woolard
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kevin P. High
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
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25
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Effros R, Fletcher C, Gebo K, Halter J, Hazzard W, Horne F, Huebner R, Janoff E, Justice A, Kuritzkes D, Nayfield S, Plaeger S, Schmader K, Ashworth J, Campanelli C, Clayton C, Rada B, Woolard N, High K. Aging and Infectious Diseases: Workshop on HIV Infection and Aging: What Is Known and Future Research Directions. Clin Infect Dis 2008. [DOI: https:/doi.10.1086/590150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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26
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Navarro G, Nogueras MM, Segura F, Casabona J, Miro JM, Murillas J, Tural C, Ferrer E, Jaén A, Force L, Vilaró J, García I, Masabeu A, Altés J, Esteve A, Sued O, Riera M, Clotet B, Podzamczer D, Gatell JM. HIV-1 infected patients older than 50 years. PISCIS cohort study. J Infect 2008; 57:64-71. [PMID: 18572247 DOI: 10.1016/j.jinf.2008.05.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 05/09/2008] [Accepted: 05/10/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The aim of this study is to characterize the ways in which older HIV-infected people differ from younger HIV-infected people. METHODS Prospective cohort study. PISCIS cohort includes newly attended HIV-infected subjects since January 1, 1998. Naive patients were selected. Two groups were defined: G1 (>or=50 years at time of diagnosis, n=493) and G2 (18-49 years, n=4511). Statistical analysis was performed using chi(2), Student's t test, Cox regression and linear mixed models. RESULTS G1 had different features: males (G1: 84% vs. G2: 75%, p<0.001), sexual transmission (52% vs. 32%, p<0.001), AIDS at first visit (38% vs. 22%, p<0.001). The follow-up was 6 years. Ninety-five percent of patients in G1 and 92% in G2 presented a detectable viral load (>or=500 copies/mm(3)) at the first visit (p=0.016). G1 presented lower CD4 levels with respect to G2 throughout the period but the increase of CD4 in G1 at the end of the study period was 254 cells/mm(3) whereas for G2 it was 196 cells/mm(3) (p<0.001). Mortality was 9% for G1 and 4% for G2 (p<0.001). CONCLUSIONS HIV-infected people diagnosed at the age of 50 years or older showed different features. They showed good viral and immunological response to HAART.
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Affiliation(s)
- G Navarro
- Corporación Sanitaria Parc Tauli, Sabadell, Barcelona, Spain.
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27
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Abstract
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.
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Affiliation(s)
- Vera P Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157-1042, USA.
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Cuzin L, Delpierre C, Gerard S, Massip P, Marchou B. Immunologic and clinical responses to highly active antiretroviral therapy in patients with HIV infection aged >50 years. Clin Infect Dis 2007; 45:654-7. [PMID: 17683004 DOI: 10.1086/520652] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 05/01/2007] [Indexed: 12/16/2022] Open
Abstract
We analyzed the effect of age on highly active antiretroviral therapy efficacy and tolerance in 639 patients with human immunodeficiency virus (HIV) infection (99 of whom were aged >50 years, and 540 of whom were aged <50 years). Late testing, which was more frequent in the older age group, was the only independent factor associated with immunologic and clinical evolution of infection. Age >50 years was associated with earlier treatment discontinuation.
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Affiliation(s)
- Lise Cuzin
- Department of Infectious and Tropical Diseases, Hopital Purpan, Toulouse, France.
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29
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Nogueras M, Navarro G, Antón E, Sala M, Cervantes M, Amengual M, Segura F. Epidemiological and clinical features, response to HAART, and survival in HIV-infected patients diagnosed at the age of 50 or more. BMC Infect Dis 2006; 6:159. [PMID: 17087819 PMCID: PMC1654166 DOI: 10.1186/1471-2334-6-159] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 11/06/2006] [Indexed: 11/12/2022] Open
Abstract
Background Over the last years, the mean age of subjects with HIV infection and AIDS is increasing. Moreover, some epidemiological and clinical differences between younger and older HIV-infected individuals have been observed. However, since introduction of HAART therapy, there are controversial results regarding their response to HAART. The aim of the present study is to evaluate epidemiological and clinical features, response to HAART, and survival in elderly HIV-infected patients with regard to younger HIV-infected patients. Methods A prospective cohort study (1998–2003) was performed on patients from Sabadell Hospital, in Northeast of Spain. The cohort includes newly attended HIV-infected patients since January 1, 1998. For the purpose of this analysis, data was censured at December 31, 2003. Taking into account age at time of diagnosis, it was considered 36 HIV-positive people aged 50 years or more (Group 1, G1) and 419 HIV-positive people aged 13–40 years (Group 2, G2). Epidemiological, clinical, biological and therapy data are recorded. Statistical analysis was performed using Chi-squared test and Fisher exact test, Mann-Whitney U test, Kaplan-Meier, Log Rank test, and Two-Way ANOVA from random factors. Results G1 showed higher proportion of men than G2. The most common risk factors in G1 were heterosexual transmission (P = 0.01) and having sex with men or women (P < 0.001). G1 and G2 show parallel profiles through the time regarding immunological response (P = 0.989) and virological response (P = 0.074). However, older people showed lower CD4 cell counts at first clinic visit (P < 0.001) and, eventually, they did not achieve the same counts as G2. G1 presented faster progression to AIDS (P < 0.001) and shorter survival (P < 0.001). Conclusion Older patients have different epidemiological features. Their immunological and virological responses are good. However, older patients do not achieve the same CD4 cell counts likely due to they have lower counts at first clinic visit. Thus, it is essential physicians know older HIV-infected patients features to consider the possibility of HIV infection in these patients with the aim of treatment would not be delayed.
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Affiliation(s)
- MaMercedes Nogueras
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Gemma Navarro
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Esperança Antón
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Montserrat Sala
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Manel Cervantes
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - MaJosé Amengual
- UDIAT Diagnosis Centre, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
| | - Ferran Segura
- Infectious Diseases Program, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, Spain
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Abstract
HIV/AIDS continues to increase among adults older than 50 years of age. Racial and ethnic minorities are still disproportionately affected by HIV/AIDS. The misconception that older adults are not at high risk for acquiring HIV/AIDS stems from a false impression that older adults are not sexually active and do not participate in risky behaviors that could result in HIV/AIDS. Studies show that older adult men and women engage in sexual intercourse--or some form of sexual behavior--at least weekly, and identify that risk factors for HIV/AIDS among adults older than 50 years of age include multiple sex partners, a high-risk partner, receipt of blood products between 1974 and 1984, or injection drug use. The development of new diagnostic resources, antimicrobial treatments, and antiretroviral therapy have made HIV/AIDS more chronic in nature, so that morbidity and mortality rates related to HIV/AIDS have declined. With this decline, HIV/AIDS has become a disease of chronicity rather than an acute illness.
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Affiliation(s)
- Sharon Wallace Stark
- Marjorie K. Unterberg School of Nursing and Health Studies, Monmouth University, West Long Branch, NJ, USA.
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31
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Abstract
Between 2001 and 2004, the percentage of all HIV cases in patients aged >or=50 years increased from 17% to 23%. This concerning increase is expected to continue over the next decade. The increasing prevalence of HIV in these patients is a result of increased longevity in patients treated with highly active antiretroviral therapy (HAART) as well as new primary infections in older patients. While older patients may achieve virological suppression at the same rate as younger patients, the immunological benefit of HAART in older patients may be reduced compared with younger patients. In addition, the toxicities associated with HAART may be worse in older HIV patients, particularly those with underlying renal or hepatic insufficiency. All previous studies evaluating the virological and immunological benefits of HAART in older patients have had relatively small sample sizes and none has compared efficacy or rates of toxicity by HAART treatment class. Co-morbidities are more common in older than in younger patients and can impact on the management of HIV in these patients. Providers must be cognisant of drug-drug interactions and potential adverse effects of HAART regimens when selecting an ideal antiretroviral regimen for older HIV patients. Given the increased longevity and rates of malignancies in HIV-infected patients, providers should also be particularly vigilant in maintaining routine health screening in older HIV patients. Controlled trials on HIV epidemiology, pathogenesis, and therapeutic and clinical outcomes are also needed in older patients. As the HIV-infected population ages, there is a growing need to better determine the effectiveness of HAART in older patients, and to investigate factors associated with a more rapid course of HIV infection in patients aged >50 years.
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Affiliation(s)
- Kelly A Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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Grabar S, Weiss L, Costagliola D. HIV infection in older patients in the HAART era. J Antimicrob Chemother 2005; 57:4-7. [PMID: 16284223 DOI: 10.1093/jac/dki411] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An increasing number of patients over 50 years of age are now living with HIV, owing to highly active antiretroviral therapy (HAART) that prolongs survival on the one hand and to late diagnosis of patients living with occult HIV infection on the other hand. Most studies have shown that compared with younger patients, patients over 50 generally have a slower immunological response to HAART and experience more rapid clinical progression, despite a better virological response. Low thymic output probably plays a role in the poorer CD4 cell response in patients initiating HAART over 50 years. Management of HIV infection in older patients is particularly complex, mainly because they are more likely to have co-morbidities necessitating specific medications that may interact with antiretroviral drugs. More controlled studies of HAART efficacy and tolerability in such patients are needed to establish specific management guidelines. Information campaigns targeting older patients and their doctors are also needed to ensure timely diagnosis of HIV infection and antiretroviral treatment initiation.
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Affiliation(s)
- Sophie Grabar
- Service de Biostatistique et Informatique Médicale, Université Paris-Descartes, Faculté de Médecine, Hôpital Cochin, Paris, France.
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Uphold CR, Mkanta WN. Review: use of health care services among persons living with HIV infection: state of the science and future directions. AIDS Patient Care STDS 2005; 19:473-85. [PMID: 16124841 DOI: 10.1089/apc.2005.19.473] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.
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Affiliation(s)
- Constance R Uphold
- Rehabilitation Outcomes Research Center, University of Florida, Gainesville, Florida 32608-1197, USA.
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Antón E, Sala M, Mallolas J, Navarro G, Cervantes M, Gatell JM, Segura F. [Clinical and epidemiological study of a series of HIV-infected patients over 50 years old]. Enferm Infecc Microbiol Clin 2005; 23:145-8. [PMID: 15757586 DOI: 10.1157/13072164] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The epidemiology of human immunodeficiency virus (HIV) infection has changed in recent years. Cases in persons over the age of 50 have increased, and the most frequent mode of transmission is sexual contact. The objective of this study is to analyse the epidemiological, clinical and evolution characteristics of a clinical series of HIV-infected patients over 50 years old at the time of diagnosis. METHODS 165 HIV-infected patients over the age of 50, attended at Hospital Clinic (Barcelona) and Corporació Parc Taulí (Sabadell) during the period of 1985 to 2001, were studied. RESULTS Among the total, 81% of the patients were men, mean age at the time of diagnosis was 58.5 years, and 81.8% had acquired the disease by sexual contact. The median initial CD4 T cell count was 216 cells/microl. Initial viral load was 1,000-100,000 copies/ml in 45.2% of the patients, whereas 52.3% had > 100,000 copies/ml. At the time of diagnosis, 30.9% had an AIDS-defining disease. The main opportunistic diseases were pulmonary tuberculosis, Kaposi's sarcoma, P. jiroveci (before carinii) pneumonia and non-Hodgkin lymphoma. Mortality due to AIDS was 32.7%. CONCLUSIONS Subjects over 50 years old diagnosed with HIV-infection were predominantly men, who acquired the infection by sexual contact. A high percentage of patients were diagnosed with the development of an opportunistic disease.
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Affiliation(s)
- Esperança Antón
- Servicio de Medicina Interna, Corporació Parc Taulí, Sabadell, Barcelona, Spain.
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Tumbarello M, Rabagliati R, de Gaetano Donati K, Bertagnolio S, Montuori E, Tamburrini E, Tacconelli E, Cauda R. Older age does not influence CD4 cell recovery in HIV-1 infected patients receiving highly active antiretroviral therapy. BMC Infect Dis 2004; 4:46. [PMID: 15530169 PMCID: PMC533877 DOI: 10.1186/1471-2334-4-46] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2004] [Accepted: 11/06/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnosis of HIV infection is recently occurring with increasing frequency in middle-aged and in older individuals. As HAART became available, a minimal beneficial effect on immunological outcome in older in respect of younger subjects has been reported. In fact, both the intensity and the rapidity of the immunological response appeared to be reduced in elderly subjects. On the contrary, only few reports have indicated a similar immunological outcome both in older and younger HIV-positive subjects. Interestingly, older age did not seem to significantly affect the long-term virological outcome of HAART treated subjects. METHODS To characterise epidemiological and clinical features of older HIV+ subjects, a prospective case-control study was performed: 120 subjects >/= 50 and 476 between 20 and 35 years were initially compared. Subsequently, to better define the impact of HAART on their viro-immunological response, 81 older were compared with 162 younger subjects. RESULTS At baseline cases presented significantly lower TCD4+ cell number and were more frequently affected by comorbid conditions. Under HAART a statistically significant increase in TCD4+ cell number was observed in cases and controls. At multivariate analysis, there was no statistically significant difference between cases and controls regarding viro-immunological response. CONCLUSIONS Although older subjects present a more severe HIV infection, they can achieve, under HAART, the same viro-immunological success as the younger individuals.
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Affiliation(s)
- Mario Tumbarello
- Department of Infectious Diseases, Catholic University, Rome, Italy
| | - Ricardo Rabagliati
- On leave of absence from the Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | | | - Eva Montuori
- Department of Infectious Diseases, Catholic University, Rome, Italy
| | | | | | - Roberto Cauda
- Department of Infectious Diseases, Catholic University, Rome, Italy
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Grabar S, Kousignian I, Sobel A, Le Bras P, Gasnault J, Enel P, Jung C, Mahamat A, Lang JM, Costagliola D. Immunologic and clinical responses to highly active antiretroviral therapy over 50 years of age. Results from the French Hospital Database on HIV. AIDS 2004; 18:2029-38. [PMID: 15577624 DOI: 10.1097/00002030-200410210-00007] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To study immunologic and clinical responses to HAART in patients over 50 years old. DESIGN AND METHODS A prospective cohort study which included 68 hospitals in France. A total of 3015 antiretroviral-naive patients, 401 of whom were aged 50 years or over, were enrolled following initiation of HAART. The influence of age on the mean CD4 cell count increase on HAART was studied by using a two-slope mixed model. Progression, defined by the occurrence of a new AIDS-defining event (ADE) or death, was studied by Cox multivariate analyses. RESULTS Among patients with baseline HIV RNA above 5 log copies/ml, CD4 mean increase during the first 6 months on HAART was +42.9 x 10(6) cells/l per month in patients under 50 years and +36.9 x 10(6) cells/l per month in patients over 50 years (P < 0.0001); subsequently, the respective monthly changes were +17.9 and +15.6 x 10(6) cells/l per month (P < 0.0001). Similar trends were observed in patients with baseline HIV RNA below 5 log copies/ml, and also after stratification for the baseline CD4 cell count. After a median follow-up of 31.5 months, 263 patients had a new ADE and 44 patients died. After adjustment for baseline characteristics, older patients had a significantly higher risk of clinical progression (hazard ratio (HR) = 1.52 [95% confidence interval (CI), 1.15-2.00]) and were more likely to achieve a viral load below 500 copies/ml [HR = 1.23, (95% CI, 1.11-1.38)]. CONCLUSION Patients over 50 years of age have an immunologic response to HAART. However, their CD4 cell reconstitution is significantly slower than in younger patients, despite a better virologic response. This impaired immunologic response may explain their higher risk of clinical progression.
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Affiliation(s)
- Sophie Grabar
- Department of Biostatistics, Cochin Hospital, University Paris V, Paris, France.
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Adeyemi OM, Badri SM, Max B, Chinomona N, Barker D. HIV infection in older patients. Clin Infect Dis 2003; 36:1347. [PMID: 12746785 DOI: 10.1086/374871] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Perez JL, Moore RD. Greater effect of highly active antiretroviral therapy on survival in people aged > or =50 years compared with younger people in an urban observational cohort. Clin Infect Dis 2003; 36:212-8. [PMID: 12522755 DOI: 10.1086/345669] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2002] [Accepted: 10/08/2002] [Indexed: 11/03/2022] Open
Abstract
Although human immunodeficiency virus-infected people aged > or =50 years have a blunted CD4 cell recovery when receiving highly active antiretroviral therapy (HAART), there are few data on mortality. Mortality rates were studied for 253 individuals aged > or =50 years and a younger group of 535 people in a retrospective cohort; for untreated persons in each age group, the proportions surviving at 3 years were 83% and 70% (P<.01), respectively. No significant difference in the survival rate was found between the older (83%) and younger (89%) patients who received HAART (P=.29). The hazard ratio for death in the older untreated group was 2.4 (95% confidence interval [CI], 1.4-3.9) when exposed to HAART. However, compared with older untreated patients, the hazard ratio for death decreased to 0.28 (95% CI, 0.15-0.52) for treated older adults. The effect of HAART substantially improves the survival rate for older individuals and supports the importance of treatment in this group.
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Affiliation(s)
- John L Perez
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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