HIV infection in older patients

Systemic Arterial Hypertension in people living with HIV/AIDS: integrative review

OBJECTIVE

To analyze scientific productions about the relationship between HIV and Systemic Arterial Hypertension (SAH) in people living with HIV/AIDS (PLWHA).

METHOD

Integrative literature review in six databases, held in March 2016. "AIDS" and "hypertension" were the keywords used in Portuguese, English and Spanish languages. We found 248 articles and selected 17. The categories formulated were "prevalence of SAH in PLWHA," "risk factors for SAH in PLWHA" and "adverse events of antiretroviral therapy (ART) that contribute to HAS."

RESULTS

There is no consensus whether HIV and ART influence the SAH development, but there are several risk factors for SAH among PLWHA. It was observed that protease inhibitors medicines influence SAH the most.

CONCLUSION

Guidelines for SAH prevention must be performed in all individuals, however, in PLWHA, they must focus on characteristic risk factors of this population.

Motor function declines over time in human immunodeficiency virus and is associated with cerebrovascular disease, while HIV-associated neurocognitive disorder remains stable

HIV-associated neurocognitive disorders (HAND) remain prevalent in the combined antiretroviral therapy (CART) era, especially the milder forms. Despite these milder phenotypes, we have shown that motor abnormalities persist and have quantified them with the HIV Dementia Motor Scale (HDMS). Our objectives were to replicate, in an independent sample, our prior findings that the HDMS is associated with cognitive impairment in HIV, while adding consideration of age-associated comorbidities such as cerebrovascular disease, and to examine the longitudinal trajectories of cognitive and motor dysfunction. We included all participants enrolled in the Manhattan HIV Brain Bank (MHBB) from January 2007 to May 2017 who had complete baseline data (N = 164). MHBB participants undergo standardized longitudinal assessments including documentation of comorbidities and medications, blood work, the HDMS, and neurocognitive testing. We found that motor dysfunction, cognitive impairment, and cerebrovascular disease were significantly associated with each other at baseline. Cerebrovascular disease independently predicted cognitive impairment in a multivariable model. Longitudinal analysis in a subset of 78 participants with ≥ 4 years of follow-up showed a stable cognition but declining motor function. We conclude that the HDMS is a valid measurement of motor dysfunction in HIV-infected patients and is associated with cognitive impairment and the presence of cerebrovascular disease. Cognitive impairment is mild and stable in CART-treated HIV; however, motor function declines over time, which may be related to the accrual of comorbidities such as cerebrovascular disease. Further research should examine the mechanisms underlying motor dysfunction in HIV and its clinical impact.

Level of adherence and HIV RNA suppression in the current era of highly active antiretroviral therapy (HAART)

The need to achieve ≥95 % adherence to HAART for treatment effectiveness may be a barrier for universal initiation at early stages of HIV. Using longitudinal data collected from 2006 to 2011 from cohort studies of MSM (MACS) and IDUs (ALIVE study), we estimated the minimum adherence needed to achieve HIV RNA suppression (<50 copies/mL), defined as the level at which at least 80 % were virally suppressed, and the odds of suppression was not significantly different than that observed with ≥95 % adherence. In the MACS, ≥80 % suppression was observed with 80-84 % adherence and the odds ratio for suppression (vs. ≥95 % adherence) was 1.43 (0.61, 3.33). In the ALIVE study where <35 % were on newer drugs, only 71.4 % were suppressed among those who reported ≥95 % adherence. Although IDUs on older HAART regimens may need to be ≥95 % adherent, concerns related to non-adherence may be less of a barrier to initiation of modern HAART regimens.

HIV prevalence and sexual behaviour at older ages in rural Malawi

Research on HIV infection and sexual behaviour in sub-Saharan Africa typically focuses on individuals aged 15-49 years under the assumption that both become less relevant for older individuals. We test this assumption using data from rural Malawi to compare sexual behaviour and HIV infection for individuals aged 15-49 with individuals aged 50-64 and 65 and over years. Although general declines with age were observed, levels of sexual activity and HIV remained considerable: 26.7% and 73.8% of women and men aged 65+ reported having sex in the last year, respectively; men's average number of sexual partners remained above one; and HIV prevalence is significantly higher for men aged 50-64 (8.9%) than men aged 15-49 (4.1%). We conclude that older populations are relevant to studies of sexual behaviour and HIV risk. Their importance is likely to increase as access to antiretrovirals in Africa increases. We recommend inclusion of adults aged over 49 years in African HIV/AIDS research and prevention efforts.

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 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.

HIV-1 infected patients older than 50 years. PISCIS cohort study

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.

Epidemiological and clinical features, response to HAART, and survival in HIV-infected patients diagnosed at the age of 50 or more

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.

Provision of general and HIV-specific health maintenance in middle aged and older patients in an urban HIV clinic

Given the increased prevalence of HIV infection in older individuals, we evaluated the adequacy of HIV-specific health maintenance, age-appropriate cancer screening, and diabetes management in an urban HIV clinic. We randomly selected 222 HIV-positive patients 40 years or older followed at the Johns Hopkins University Moore Clinic between 1999 and 2002. Demographic, clinical, and pharmaceutical data were abstracted from clinic charts. Outcomes of interest were vaccinations, annual rapid plasmin reagin (RPR) testing, and Papanicoloau smears and mammography in women. Logistic regression analyses were performed to identify variables significantly associated with being up to date on vaccinations. The sample was 56% female and 82% African American with a mean age of 50.9 years. Sixty-five percent used tobacco, 10% used alcohol, and 13% used illicit drugs daily. At the time of evaluation, 87% had received the pneumococcal vaccine. Of nonimmune patients, 66% were vaccinated for hepatitis B and 28% for hepatitis A. Eighty-two percent of women were referred for Papanicoloau smears and 56% for mammography. Only 59% completed the Papanicoloau smear, and 31% had mammography. Forty-two percent of patients with diabetes underwent quarterly foot examinations, and 33% had microalbuminuria screening. Risk factors for missed vaccinations include prior AIDS diagnosis (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.55, 3.13), CD4+ cell count less than 50 cells/mm(3) at the time of visit (OR 6.31, 95% CI 1.74, 22.9), and a history of chronic obstructive pulmonary disease (COPD) or asthma (OR 2.54, 95% CI 1.03, 6.28). In summary, HIV-positive patients are more likely to receive HIV-specific primary care interventions, especially vaccinations that can be given in clinic, than routine health maintenance screening that required referral and evaluation elsewhere. This suggests that if health maintenance screening can be delivered in the same clinic, usage rates are likely to increase.

HIV and Aging

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.

[Clinical and epidemiological study of a series of HIV-infected patients over 50 years old]

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.

Older age does not influence CD4 cell recovery in HIV-1 infected patients receiving highly active antiretroviral therapy

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.

HIV infection and advanced age emerging epidemiological, clinical, and management issues

While the mean age of HIV/AIDS patients at first diagnosis is progressively rising, no updated epidemiological estimates, controlled clinical data, and randomized therapeutic trials, are available regarding clinical and laboratory response to antiretroviral therapy, safety of anti-HIV compounds and their associations, potential drug-drug interactions, short- and long-term toxicity, consequences on underlying disorders, or interactions with concomitant pharmacological regimens, in the elderly. The life expectancy of HIV-infected persons treated with highly active antiretroviral therapy (HAART) now approximates that of general population matched for age, while also AIDS definition itself has lost most of its epidemiological and clinical significance, thanks to the immunoreconstitution resulting from the large-scale use of potent HAART regimens. The increased survival of HIV-infected patients, the late recognition of other subjects with missed or delayed diagnosis are responsible for a further expected rise of mean age of HIV-infected individuals, so that the patient population aged 60-70 years or more is expected to increase in coming years. Unfortunately, the majority of therapeutic trials involving antiretroviral therapy, as well as antimicrobial chemoprophylaxis for AIDS-related opportunistic complications, have advanced age and/or concurrent end-organ disorders among main exclusion criteria, or the design of these studies does not allow to extrapolate data regarding older patients, compared with younger ones. The very limited data presently available seem to demonstrate that HAART has a virological efficacy in the elderly comparable with that of younger adults, but immunological recovery is often slower and blunted, although several studies clearly demonstrated that thymic function is preserved until late adult age. When facing an HIV-infected patient with advanced age, health care givers have to pay careful attention to eventual end-organ disorders, all possible pharmacological interactions, overlapping toxicity due to concurrent drug administration. All these issues may significantly interfere with HAART activity, patient's adherence to prescribed medications, and frequency and severity of untoward effects. The guidelines of antiretroviral therapy and those of treatment and prophylaxis of AIDS-related diseases deserve appropriate updates, paralleling the increasing mean age of HIV-infected population. Moreover, epidemiological figures need an increased focus on older age, while clinical trials specifically targeting on the elderly population are mandatory to have reliable data on all aspects of HAART administration in advanced age.