Geriatric Syndromes in Older Adults Living with HIV and Cognitive Impairment

Emotional Loneliness is Related to Objective Cognitive Function in Older People With HIV in the Washington-Baltimore Area: A Cross-sectional Study

ABSTRACT

Loneliness confers a significant risk to numerous health outcomes, including cognitive impairment. This study assessed the relationship between loneliness subtypes (social and emotional) and cognition in older people with HIV (OPWH ≥ 50 years). Forty-two participants (STET = 61.5 years; 48% male; 74% Black) completed the six-item De Jong Gierveld Loneliness Scale and measures assessing objective and subjective cognition and depressive symptoms (Patient Health Questionnaire [PHQ-9]). Loneliness-cognition associations were examined using linear regression. Models were first adjusted for age, sex, race, and education, and then PHQ-9 score. Mean emotional and social loneliness scores were 1.24 (SD = 1.22) and 1.21 (SD = 1.14), respectively. After sociodemographic and PHQ-9 adjustment, emotional, but not social, loneliness was associated with poorer objective cognitive performance on processing speed (Digit Symbol) and executive function (CalCAP™). Findings have potential clinical importance for interventions that target specific loneliness subtypes to optimize cognitive performance in OPWH.

The trend analysis of HIV and other sexually transmitted infections among the elderly aged 50 to 69 years from 1990 to 2030

Background

The HIV and other sexually transmitted infections (STI) excluding HIV among the elderly population urgently require more attention and in-depth study. We aimed to present and predict the worldwide of its burden from 1990 to 2030 using data from the Global Burden of Disease (GBD) study.

Methods

Leveraging the 2019 GBD study, we investigated the average annual percentage change (AAPC) of HIV and other STI in incidence, prevalence, disability-adjusted life years (DALYs), and mortality rates for individuals aged 50-69 across different age groups, genders, sociodemographic index (SDI) regions, and nations. The incidence of STI in the population from 2020 to 2030 was explored by Bayesian age-period-cohort (BAPC) prediction model.

Results

The HIV incidence rate experienced its fastest growth 1990-1992, peaked in 1996, and gradually declined thereafter, with the 2019 rate being lower than that of 1990. The prevalence rate didn't present a sharp turning point. After 2006, its growth rate accelerated. Both DALYs and mortality rates plateaued high between 2002 and 2005, followed by a decline. The decline was steepest from 2005-2012, yet the rate of decrease slowed noticeably from 2012-2019.When segmented by age, HIV was more prevalent among those aged 55-59 and 50-54, with the 50-54 age group witnessing the fastest decline in incidence rates. However, the fastest growth in prevalence rates was seen among the 60-64 and 65-69 age groups. The other STI incidence rate declined from 1990-1996, increased up to 2006, declined until 2015, and then saw a resurgence with accelerated growth thereafter. The prevalence rate showcased varied trends, with a notable increase in the past five years. The highest growth in incidence rate was among the 65-69 age group. We predict that the incidence rate of STI will increase in the future.

Conclusions

Overall, despite the evident decline in incidence, mortality rates, and DALYs, the prevalence of HIV and other STI among the elderly is rising, and both demonstrated significant trend variations across different ages, genders, SDI regions, and nations. Comprehensive sexual health education, clinical care and adjustments in health service strategies based on the evolving trends of HIV and other STI among the elderly are paramount.

A clinical overview of people living with HIV and genitourinary cancer care

The number of people living with HIV infection has been increasing globally. Administration of antiretroviral therapy is effective in controlling the infection for most patients and, as a consequence, people living with HIV (PLWH) now often have a long life expectancy. However, their risk of developing cancer - most notably virus-related cancers - has been increasing. To date, few studies have assessed the risk of genitourinary cancers in PLWH, and robust scientific data on their treatment-related outcomes are lacking. Previous studies have noted that PLWH are at a reduced risk of prostate cancer; however, low adoption and/or availability of prostate cancer screening among these patients might be confounding the validity of this finding. In genitourinary cancers, advanced stage at diagnosis and reduced cancer-specific mortality have been reported in PLWH. These data likely reflect, at least in part, the inequity of health care access for PLWH. Notably, systemic chemotherapy and/or radiotherapy could decrease total CD4+ cell counts, which could, therefore, increase the risk of morbidity and mortality from cancer treatments in PLWH. Immune checkpoint inhibitors have become the therapeutic backbone for many advanced malignancies in the general population; however, most studies validating their efficacy have excluded PLWH owing to concerns of severe adverse effects from immune checkpoint inhibitors themselves and/or related to their immunosuppressed status. To our knowledge, no genitourinary cancer survivorship programme exists that specifically caters to the needs of PLWH. By including PLWH in ongoing cancer trials, we can gain invaluable insights that will help to improve cancer care specifically for PLWH.

Human Immunodeficiency Virus in Older Adults

As people with HIV live longer, they can experience increased incidence and earlier onset of chronic conditions and geriatric syndromes. Older people are also at substantially increased risk of delayed diagnosis and treatment for HIV. Increasing provider awareness of this is pivotal in ensuring adequate consideration of HIV testing and earlier screening for chronic conditions. In addition, evaluating patients for common geriatric syndromes such as polypharmacy, frailty, falls, and cognitive impairment should be contextualized based on how they present.

Negative Lifestyle Factors Specific to Aging Persons Living with HIV and Multimorbidity

The primary goal of medical care during the pre-antiretroviral therapy (ART) era was to keep persons living with human immunodeficiency virus (HIV) alive, whereas since the advent of ART, the treatment objective has shifted to decreasing viral loads and infectiousness while increasing CD4+ T-cell counts and longevity. The health crisis, however, is in preventing and managing multimorbidity (ie, type 2 diabetes), which develops at a more accelerated or accentuated pace among aging persons living with HIV. Relative to the general population and age-matched uninfected adults, it may be more difficult for aging HIV-positive persons who also suffer from multimorbidity to improve negative lifestyle factors to the extent that their behaviors could support the prevention and management of diseases. With recommendations and a viable solution, this article explores the impact of negative lifestyle factors (ie, poor mental health, suboptimal nutrition, physical inactivity, alcohol use) on the health of aging individuals living with HIV.

An overview of neurocognitive impairment in older people living with HIV

Background

With improved survival among People Living with HIV (PLHIV), many are confronted with age associated comorbidities and geriatric syndromes. Neurocognitive impairment is one of the three most frequent conditions that affects quality of life of PLHIV despite achieving viral suppression. Healthcare providers face challenges in early identification of neurocognitive impairment, performing comprehensive assessment and managing older PLHIV.

Objectives

This paper aims to review available evidence regarding aetiology and management of older PLHIV who develop neurocognitive impairment, suggest improvements on current management and postulate future study direction.

Methods

A PubMed search for original articles and Clinical Guidelines was conducted from September 2021 to August 2022 using a combination of keywords related to neurocognitive impairment in PLHIV. The citations from all selected articles were reviewed for additional studies.

Results

Older PLHIV tend to be frailer than their uninfected counterparts, are plagued with multi-morbidity and are at increased risk of cognitive impairment. The aetiologies for neurocognitive impairment are multifactorial, multi-dimensional and complex. The management of neurocognitive impairment in older PLHIV involves identifying and optimizing predisposing factors, physical function, social and psychological health with appropriate care navigation.

Conclusion

Identification and management of neurocognitive impairment in older PLHIV through interdisciplinary collaboration among stakeholders is important. This exemplifies an integrated model of care for older PLHIV and promotes the notion of living well beyond viral suppression.

Gender and coping with HIV: a qualitative study of older childhood sexual abuse survivors living with HIV

People living with HIV often have complex identities and histories. Understanding how these experiences influence adherence to treatment and quality of life are critical to the HIV care. The experiences of older adults living with HIV are uniquely embedded within biology and aging as well as gender. This study described the gendered strategies for coping with HIV among older adults who are childhood sexual abuse survivors. Audio-recorded semi-structured interviews were performed with 24 adults who are 50 years and older from a clinic in South Carolina. Thematic analysis approach was used to discuss key concepts, reconcile codes, and name emergent themes. Overall, the participants used a spectrum of coping strategies including spirituality, seclusion, social support, substance use, engagement in HIV care, information acquisition and sharing, and cognitive reframing. Our findings suggest the potential for growth and recovery is heightened if the interplay of HIV diagnosis, aging, coping, and mental health is considered. Healthcare providers should assess the ways in which individuals interpret their HIV diagnosis and other lived experiences to better understand their patients' mental health. Knowledge of gender-based coping strategies used in HIV-relevant outcomes can be translated into more effective treatment plans to improve the overall quality of life.

Characterization of data-driven geriatric syndrome clusters in older people with HIV: a Mexican multicenter cross-sectional study

Background

As living with HIV has been proposed as a condition that may accelerate aging, the main objective of this work was to estimate the prevalence of geriatric syndromes (GS) among older Mexicans with HIV dwelling in the community. Secondly, to evaluate whether the accumulation of GS could be associated with an adverse HIV-related clinical profile, independent of chronological age.

Methods

Multicenter, cross-sectional study including 501 community-dwelling people aged ≥50 years with HIV. The overall prevalence of nine selected GS and their cumulative number were estimated. An Age-Independent Cumulative Geriatric Syndromes scale (AICGSs) was constructed, and correlations between the AICGSs and HIV-related parameters assessed. Finally, k-mean clustering analyses were performed to test the secondary objective.

Findings

Median age 56 (IQR: 53-61) years, 81.6% of men. Polypharmacy (74.8%), sensorial deficit (71.2%), cognitive impairment (53.6%), physical disability (41.9%), pre-frailty (27.9%), and falls (29.7%), were the more prevalent GS. A significant negative correlation was found between the AICGSs and normalized values of CD4+ nadir cell counts (r = -0.126; 95%: CI: -0.223 to -0.026, p < 0.05). Similarly, a significant inverse adjusted association between the CD4+ nadir cells and the AICGSs was observed on linear regression analysis (β -0.058; 95%: CI: -0.109 to -0.007, p = 0.03). Cluster analysis identified three differentiated groups varying by age, metabolic comorbidities, AICGSs, and HIV-related parameters.

Interpretation

An elevated prevalence of GS was observed in the studied population. Moreover, the accumulation of GS was associated with adverse HIV-related profiles, independent of age. Thus, early detection and management of GS are crucial to promote healthier aging trajectories in people with HIV.

Funding

This work was funded in part by the National Center for the Prevention and Control of HIV/AIDS in Mexico (CENSIDA)-National Ministry of Health.

Plasma extracellular vesicles and cell-free mitochondrial DNA are associated with cognitive dysfunction in treated older adults with HIV

Extracellular vesicles (EVs) are nanoparticles with a role in intercellular communication. Cell-free mitochondrial DNA (cf-mtDNA) has been associated with cognitive dysfunction in people with HIV (PWH). We conducted a nested case-control study to test the hypothesis that plasma EVs are associated with cf-mtDNA and cognitive dysfunction in older PWH. A machine learning-based model identified total EVs, including select EV subpopulations, as well as urine cf-mtDNA and 4-meter walk time carry power to predict the neurocognitive impairment. These features resulted in an AUC-ROC of 0.845 + / - 0.109 (0.615, 1.00).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

NCT03558438.

Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough?

With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.

Frailty in older people living with HIV: current status and clinical management

This paper will update care providers on the clinical and scientific aspects of frailty which affects an increasing proportion of older people living with HIV (PLWH). The successful use of combination antiretroviral therapy has improved long-term survival in PLWH. This has increased the proportion of PLWH older than 50 to more than 50% of the HIV population. Concurrently, there has been an increase in the premature development of age-related comorbidities as well as geriatric syndromes, especially frailty, which affects an important minority of older PLWH. As the number of frail older PLWH increases, this will have an important impact on their health care delivery. Frailty negatively affects a PLWH's clinical status, and increases their risk of adverse outcomes, impacting quality of life and health-span. The biologic constructs underlying the development of frailty integrate interrelated pathways which are affected by the process of aging and those factors which accelerate aging. The negative impact of sarcopenia in maintaining musculoskeletal integrity and thereby functional status may represent a bidirectional interaction with frailty in PLWH. Furthermore, there is a growing body of literature that frailty states may be transitional. The recognition and management of related risk factors will help to mitigate the development of frailty. The application of interdisciplinary geriatric management principles to the care of older PLWH allows reliable screening and care practices for frailty. Insight into frailty, increasingly recognized as an important marker of biologic age, will help to understand the diversity of clinical status occurring in PLWH, which therefore represents a fundamentally new and important aspect to be evaluated in their health care.

A Lower CD4+/CD8+ Ratio Predicts Activities of Daily Living Decline Among Older Adults with HIV

Aging of people with human immunodeficiency virus (HIV) is a worldwide reality, and age-related conditions, including disability, have also increased. Efforts are being made to search for more specific markers of immune system malfunction, which serve as good predictors of adverse health-related outcomes. Therefore, this study aimed to determine the relationship between the CD4⁺/CD8⁺ ratio and functional decline in activities of daily living (ADL). Participants in this longitudinal study underwent a standardized comprehensive geriatric assessment by trained staff, using validated tools. Functional decline in ADL was established by the delta resulting from the subtraction of the score on the Barthel index at T₁ minus the score at T₀ (baseline). Multivariate linear regression analyses were used to determine the independent relationship between the CD4⁺/CD8⁺ ratio and ADL decline. Mean age was 57.9 (standard deviation 6.6; range 50-84 years), and 82.7% were men. Eleven of the 209 participants had disability for ADL at baseline. Multivariate linear regression analysis showed an inverse relationship between the log of CD4⁺/CD8⁺ ratio at baseline and the delta of Barthel index even after adjustment for multiple confounders (β = -1.68, 95% confidence interval -3.02 to -0.33; p = .01). A CD4⁺/CD8⁺ ratio of <1 predicts the development of functional decline in ADL. This ratio can be a useful marker to identify people at risk of disability and should be considered for the tailored management of older adults with HIV.

The related factors of new HIV infection among older men in Sichuan, China: A case-control study

Human immunodeficiency virus (HIV) has been widely prevalent among older men (aged ≥50 years old) in Sichuan Province. The study aimed to discover associated factors with the new HIV infection in older men, and provide a scientific basis for the prevention and control of acquired immunodeficiency syndrome (AIDS) in this group. A cross-sectional survey study of newly reported HIV/AIDS and general male residents aged 50 years and older was conducted between April and June 2019, with a resample of respondents to identify cases and controls, followed by a case–control study. Logistic regression was applied to analyse the association between the selected factors and new HIV infection among older men. At last, 242 cases and 968 controls were included. The results of multiple logistic regression suggested that many factors including living alone/concentrated (OR 1.56, 95% CI 1.20–2.04, P = 0.001), have a history of migrant worker (OR 2.10, 95% CI 1.61–2.73, P < 0.001), have commercial sexual behaviour (OR 1.71, 95% CI 1.32–2.22, P < 0.001), married (OR 0.48, 95% CI 0.37–0.64, P < 0.001), have a history of HIV antibody testing (OR 0.73, 95% CI 0.56–0.96, P = 0.026), HIV-related knowledge (OR 0.55, 95% CI 0.42–0.72, P < 0.001) were associated with new HIV infection among older men. The present study revealed some potential risky/protective factors altogether. The results highlighted the direction of HIV/AIDS prevention and control among older men, and it is a social issue that requires the joint participation of the whole society.

Plasma Cell-Free Mitochondrial DNA as a Marker of Geriatric Syndromes in Older Adults With HIV

BACKGROUND

Older people with HIV experience more comorbidities and geriatric syndromes than their HIV-negative peers, perhaps due to residual inflammation despite suppressive antiretroviral therapy. Cell-free mitochondrial DNA (cfmtDNA) released during necrosis-mediated cell death potentially acts as both mediator and marker of inflammatory dysregulation. Thus, we evaluated plasma cfmtDNA as a potential biomarker of geriatric syndromes.

METHODS

Participants underwent the Montreal Cognitive Assessment (MoCA), frailty testing, and measurement of plasma cfmtDNA by qPCR and inflammatory markers including C-reactive protein, interleukin-6 (IL-6), interferon gamma, and tumor necrosis factor alpha in this cross-sectional study.

RESULTS

Across 155 participants, the median age was 60 years (Q1, Q3: 56, 64), one-third were female, and 92% had HIV-1 viral load <200 copies/mL. The median MoCA score was 24 (21, 27). The plasma cfmtDNA level was higher in those with cognitive impairment (MoCA <23) ( P = 0.02 by the t test) and remained significantly associated with cognitive impairment in a multivariable logistic regression model controlling for age, sex, race, CD4 T-cell nadir, HIV-1 viremia, and depression. Two-thirds of participants met the criteria for a prefrail or frail state; higher plasma cfmtDNA was associated with slow walk and exhaustion but not overall frailty state. Cognitive dysfunction was not associated with C-reactive protein, IL-6, interferon gamma, or tumor necrosis factor alpha, and frailty state was only associated with IL-6.

CONCLUSIONS

Plasma cfmtDNA may have a role as a novel biomarker of cognitive dysfunction and key components of frailty. Longitudinal investigation of cfmtDNA is warranted to assess its utility as a biomarker of geriatric syndromes in older people with HIV.

The association between benzodiazepine use and greater risk of neurocognitive impairment is moderated by medical burden in people with HIV

Benzodiazepine use is linked to neurocognitive impairment (NCI) in the general population and people with HIV (PWH); however, this relationship may depend on age-related factors such as medical comorbidities, which occur at an elevated rate and manifest earlier in PWH. We retrospectively examined whether chronological age or medical burden, a clinical marker for aging, moderated the relationship between benzodiazepine use and NCI in PWH. Participants were 435 PWH on antiretroviral therapy who underwent neurocognitive and medical evaluations, including self-reported current benzodiazepine use. A medical burden index score (proportion of accumulated multisystem deficits) was calculated from 28 medical deficits. Demographically corrected cognitive deficit scores from 15 neuropsychological tests were used to calculate global and domain-specific NCI based on established cut-offs. Logistic regressions separately modeled global and domain-specific NCI as a function of benzodiazepine x age and benzodiazepine x medical burden interactions, adjusting for current affective symptoms and HIV disease characteristics. A statistically significant benzodiazepine x medical burden interaction (p = .006) revealed that current benzodiazepine use increased odds of global NCI only among those who had a high medical burden (index score > 0.3 as indicated by the Johnson–Neyman analysis), which was driven by the domains of processing speed, motor, and verbal fluency. No age x benzodiazepine interactive effects on NCI were present. Findings suggest that the relationship between BZD use and NCI among PWH is specific to those with greater medical burden, which may be a greater risk factor for BZD-related NCI than chronological age.

Factors associated to neurocognitive impairment in older adults living with HIV

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Sociodemographic, behavioral, and geriatric characteristics in older adults with and without HIV: A case-control study

Older adults with human immunodeficiency virus (HIV) have higher risks for early manifestations of age-related disabilities. The objective of this study was to compare HIV-positive and HIV-negative adults aged ≥50 years in relation to sociodemographic, behavioral, and geriatric characteristics. A case-control study was conducted with a >90% estimated statistical power. A total of 52 individuals living with HIV were matched by age, sex, and neighborhood of residence with 104 community controls. Age-related disabilities were assessed throughout a comprehensive geriatric assessment. Review of medical records and interviews were used to obtain behavioral and clinical covariates. No statistical differences on clinically significant age-related disabilities were found. However, multivariate regression analyses, controlling for education and income, revealed that behavioral (use of condom [odds ratio {OR}: 7.03; 95% confidence intervals {CI}: 2.80-7.65] and number of medical visits [OR: 1.25; 95%CI: 1.09-1.43]), along with faster gait speed (OR: 17.68; 95%CI: 2.55-122.85) and lower body and muscle mass indexes were independently associated with HIV (OR: .88; 95%CI: .79-.98 and OR: .72; 95%CI: .54-.97, respectively). In summary, results on age-related disabilities between groups could mean that public policies on HIV might be contributing to patients' positive outcomes regardless of the effects of aging, albeit gait speed, body and muscle mass indexes were independently associated with HIV. Screenings for age-related disabilities in specialized HIV services are recommended.

Ensemble machine learning classification of daily living abilities among older people with HIV

BACKGROUND

clinically relevant methods to identify individuals at risk for impaired daily living abilities secondary to neurocognitive impairment (ADLs) remain elusive. This is especially true for complex clinical conditions such as HIV-Associated Neurocognitive Disorders (HAND). The aim of this study was to identify novel and modifiable factors that have potential to improve diagnostic accuracy of ADL risk, with the long-term goal of guiding future interventions to minimize ADL disruption.

METHODS

study participants included 79 people with HIV (PWH; mean age = 63; range = 55-80) enrolled in neuroHIV studies at University California San Francisco (UCSF) between 2016 and 2019. All participants were virally suppressed and exhibited objective evidence of neurocognitive impairment. ADL status was defined as either normative (n = 39) or at risk (n = 40) based on a task-based protocol. Gradient boosted multivariate regression (GBM) was employed to identify the combination of variables that differentiated ADL subgroup classification. Predictor variables included demographic factors, HIV disease severity indices, brain white matter integrity quantified using diffusion tensor imaging, cognitive test performance, and health co-morbidities. Model performance was examined using average Area Under the Curve (AUC) with repeated five-fold cross validation.

FINDINGS

the univariate GBM yielded an average AUC of 83% using Wide Range Achievement test 4 (WRAT-4) reading score, self-reported thought confusion and difficulty reading, radial diffusivity (RD) in the left external capsule, fractional anisotropy (FA) in the left cingulate gyrus, and Stroop performance. The model allowing for two-way interactions modestly improved classification performance (AUC of 88%) and revealed synergies between race, reading ability, cognitive performance, and neuroimaging metrics in the genu and uncinate fasciculus. Conversion of Neuropsychological Assessment Battery Daily Living Module (NAB-DLM) performance from raw scores into T scores amplified differences between White and non-White study participants.

INTERPRETATION

demographic and sociocultural factors are critical determinants of ADL risk status among older PWH who meet diagnostic criteria for neurocognitive impairment. Task-based ADL assessment that relies heavily on reading proficiency may artificially inflate the frequency/severity of ADL impairment among diverse clinical populations. Culturally relevant measures of ADL status are needed for individuals with acquired neurocognitive disorders, including HAND.

Aging-Related Concerns of People Living with HIV Referred for Geriatric Consultation

PURPOSE

People with HIV (PWH) are living longer lives and likely experiencing accentuated aging. Comprehensive geriatric assessment (CGA) has been proposed as a way to identify and help meet each individual patient's needs.

PATIENTS AND METHODS

We performed a retrospective review of the results of CGA in an HIV clinic in New York City. CGA included assessment of basic and instrumental activities of daily living, screens for depression, anxiety, frailty, cognition, and quality of life, along with general discussion of concerns and goals. We compared the group of PWH referred for CGA to those of comparable age who were not referred to determine the factors that were associated with referral. We carried out a descriptive analysis of those undergoing CGA, along with regression to determine factors associated with poorer PHQ-2 depression scores and higher VACS score.

RESULTS

A total of 105 patients underwent full CGA during the study period. Mean age of referred patients was 66.5 years, ranging from 50 to 84 years (SD 7.99). More than 92% were virally suppressed. Compared with their non-referred counterparts over 50, referred patients were older and had more functional comorbidities like cerebrovascular disease, neuropathy, and urinary incontinence. More than half complained of fatigue, and 2/3 noted poor memory. Almost 60% were frail or prefrail. Ninety patients were asked about their goals, and the most commonly cited were related to health or finances; fifteen patients were unable to articulate any goals. Having fewer goals and noting weight loss or fatigue were predictive of higher scores on the PHQ-2 depression screen.

CONCLUSION

Although most older PWH undergoing CGA can manage their ADL, many have concerns and deficits beyond their comorbidities. CGA offers an important window into the psychosocial concerns and needs of older PWH.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2020 Recommendations of the International Antiviral Society-USA Panel

Importance

Data on the use of antiretroviral drugs, including new drugs and formulations, for the treatment and prevention of HIV infection continue to guide optimal practices.

Objective

To evaluate new data and incorporate them into current recommendations for initiating HIV therapy, monitoring individuals starting on therapy, changing regimens, preventing HIV infection for those at risk, and special considerations for older people with HIV.

Evidence Review

New evidence was collected since the previous International Antiviral (formerly AIDS) Society-USA recommendations in 2018, including data published or presented at peer-reviewed scientific conferences through August 22, 2020. A volunteer panel of 15 experts in HIV research and patient care considered these data and updated previous recommendations.

Findings

From 5316 citations about antiretroviral drugs identified, 549 were included to form the evidence basis for these recommendations. Antiretroviral therapy is recommended as soon as possible for all individuals with HIV who have detectable viremia. Most patients can start with a 3-drug regimen or now a 2-drug regimen, which includes an integrase strand transfer inhibitor. Effective options are available for patients who may be pregnant, those who have specific clinical conditions, such as kidney, liver, or cardiovascular disease, those who have opportunistic diseases, or those who have health care access issues. Recommended for the first time, a long-acting antiretroviral regimen injected once every 4 weeks for treatment or every 8 weeks pending approval by regulatory bodies and availability. For individuals at risk for HIV, preexposure prophylaxis with an oral regimen is recommended or, pending approval by regulatory bodies and availability, with a long-acting injection given every 8 weeks. Monitoring before and during therapy for effectiveness and safety is recommended. Switching therapy for virological failure is relatively rare at this time, and the recommendations for switching therapies for convenience and for other reasons are included. With the survival benefits provided by therapy, recommendations are made for older individuals with HIV. The current coronavirus disease 2019 pandemic poses particular challenges for HIV research, care, and efforts to end the HIV epidemic.

Conclusion and Relevance

Advances in HIV prevention and management with antiretroviral drugs continue to improve clinical care and outcomes among individuals at risk for and with HIV.

Older adults at high risk of HIV infection in China: a systematic review and meta-analysis of observational studies

There is an increasing prevalence of human immunodeficiency virus (HIV) infection in older adults in China, but the findings across prevalence studies have been mixed. This is the first meta-analysis of the prevalence of HIV infection and its moderating factors in older adults in China. Two investigators systematically and independently searched both international (PubMed, PsycINFO, Web of Sciences and EMBASE) and Chinese (WanFang, CNKI, and CQVIP) databases. HIV infection rates in older adults were analyzed using the random-effects model. Altogether 46 studies were included in the analysis. The pooled prevalence of HIV infection in older adults was 2.1% (95% CI [1.9%–2.3%], I² = 99.4%). Subgroup analyses revealed that men who have sex with men (MSM), hospital population samples, publications after 2014, studies conducted in the western region of China, and higher study quality were significantly associated with higher HIV infection rate. This meta-analysis found that the HIV infection prevalence in older adults is significantly higher than the general population in China. Attention should be given to this urgent public health issue, and effective HIV/AIDS preventive, screening and treatment measures are warranted in this population. PROSPERO: CRD42019124286.

Strengths and Limitations of the Veterans Aging Cohort Study Index as a Measure of Physiologic Frailty

The Veterans Aging Cohort Study Index (VACS Index) is an index comprised of routine clinical laboratory tests that accurately and generalizably predicts all-cause mortality among those living with and without HIV infection. Increasing evidence supports its use as a measure of physiologic frailty among those aging with HIV because of its associations with frailty related outcomes including mortality, hospitalization, fragility fractures, serious falls, pneumonia, cognitive decline, delirium, and functional decline. In this review, we explore the evidence supporting the validity (construct, correlative, and predictive), responsiveness, and feasibility of the VACS Index as an early indicator of physiologic frailty. We also consider its limitations.

Testing Mindful Awareness as a Moderator in the Association Between HIV-Related Stress and Drug and Alcohol Use Problems Among People Living with HIV

Objectives

People living with HIV (PLWH) are disproportionately affected by stressful life events. HIV-related stress adds to general life stressors to increase health risks among this population. Stress has not only been associated with HIV progression but it is also linked to HIV transmission risk behavior (e.g., substance use). Older adults living with HIV (OALWH) experience additional age-related stress and are at increased risk for substance use. Mindfulness buffers against stress for PLWH; however, research has yet to examine mindfulness as a buffer between HIV-related stress and substance use for OALWH.

Methods

Participants were 130 OALWH (M _age = 54.65, SD = 4.20) and 74.6% were Black. The majority were male (69.2%), and nearly half identified as heterosexual (48.5%). A hierarchical linear regression examined the main and interactive effects of mindful awareness and two types of HIV-related stress (e.g., stigma and rumination) on alcohol and drug use problems.

Results

In step one of the model, we examined HIV stigma (β = .231, p = .015) and found no significant interaction with mindful awareness. In step two, HIV rumination (β = .288, p = .001) was added. We found a significant interaction (β = .196, p = .020), indicating those with low mindful awareness and high rumination reported the greatest substance use problems. Exploratory analyses revealed an indirect effect of HIV stigma on substance use through HIV rumination as well as a significant effect for second-stage moderated mediation.

Conclusions

These findings support mindful awareness as a buffer against HIV rumination for OALWH. Further, our results have important implications for the utility of mindfulness-based interventions (MBIs) with OALWH and comorbid substance use disorders.

"We are becoming older women and then we have two stigmas": voicing women's biopsychosocial health issues as they age with HIV

In April 2019, nine older women (age 50+) living with HIV in Palm Springs, California, participated in a 90-minute focus group to identify their major health issues, strengths, and HIV and aging-related health priorities. Using the rigorous and accelerated data reduction (RADaR) technique, we identified four major themes: (1) mental health, (2) HIV comorbidities, (3) social determinants of health, and (4) resiliencies. These results reinforce the need to conduct additional research focused on women aging with HIV, an understudied population that requires more effective, tailored interventions to promote better quality of life and healthy aging.