Frailty-Related Factors among Women Living with and without HIV Aged 40 Years and Older. The Women's Interagency HIV Study

BACKGROUND

Frailty is a clinical, geriatric syndrome linked to disability and mortality; and may be associated with a variety of factors among underrepresented and underserved women living with HIV (WLWH) and without HIV (WLWOH) transitioning through the adult life course.

OBJECTIVES

Determine whether a published set of factors associated cross-sectionally with frailty in WLWH and similar WLWOH at average age 39 years in 2005/2006 were associated with frailty in 2018/2019 among women who initiated frailty assessments at age ≥40 years, or whether a new set of factors were associated with frailty.

DESIGN

Cross-sectional analyses within a longitudinal cohort study.

SETTING

The multi-center Women's Interagency HIV Study (WIHS).

PARTICIPANTS

1285 participants (951 WLWH, 334 WLWOH), median age 53 years (interquartile range 47-58 years).

MEASUREMENTS

The Fried Frailty Phenotype (FFP) in association with 23 factors representing HIV serostatus, other infections, sociodemographic factors, health behaviors, and chronic diseases.

RESULTS

Frailty prevalence was 11.1% in 2018/2019 (12.6% among WLWOH, 9.6% among WLWH, p=0.121). The published 2005/2006 final multivariable stepwise regression model contained 9 predictors of frailty. When refit to women in 2018/2019, only age ≥50 years and annual income ≤$12,000 were independently positively associated with frailty; other significant 2005/2006 factors, HIV serostatus, CD4+ count <500 cells/mL among WLWH, smoking, drinking, FIB-4 and eGFR, were not. A newly-derived stepwise model considering all 23 predictors measured in 2018/2019, showed independent positive associations between frailty and age ≥50 years, annual income ≤$12,000, obesity (body mass index (BMI) ≥30kg/m2), and history of tuberculosis and cancer.

CONCLUSION

Different chronic and infectious disease factors were associated with frailty among WLWH and WLWOH over the adult life course. Understanding factors associated with frailty by adult life stage, allows identification and implementation of novel, temporal interventions to alleviate frailty-associated outcomes and enhance quality of life among WLWH and WLWOH.

Frailty and Constellations of Factors in Aging HIV-infected and Uninfected Women--The Women's Interagency HIV Study

BACKGROUND

Biological similarities are noted between aging and HIV infection. Middle-aged adults with HIV infection may present as elderly due to accelerated aging or having more severe aging phenotypes occurring at younger ages.

OBJECTIVES

We explored age-adjusted prevalence of frailty, a geriatric condition, among HIV+ and at risk HIV- women.

DESIGN

Cross-sectional.

SETTING

The Women's Interagency HIV Study (WIHS).

PARTICIPANTS

2028 middle-aged (average age 39 years) female participants (1449 HIV+; 579 HIV-).

MEASUREMENTS

The Fried Frailty Index (FFI), HIV status variables, and constellations of variables representing Demographic/health behaviors and Aging-related chronic diseases. Associations between the FFI and other variables were estimated, followed by stepwise regression models.

RESULTS

Overall frailty prevalence was 15.2% (HIV+, 17%; HIV-, 10%). A multivariable model suggested that HIV infection with CD4 count<200; age>40 years; current or former smoking; income ≤$12,000; moderate vs low fibrinogen-4 (FIB-4) levels; and moderate vs high estimated glomerular filtration rate (eGFR) were positively associated with frailty. Low or moderate drinking was protective.

CONCLUSIONS

Frailty is a multidimensional aging phenotype observed in mid-life among women with HIV infection. Prevalence of frailty in this sample of HIV-infected women exceeds that for usual elderly populations. This highlights the need for geriatricians and gerontologists to interact with younger 'at risk' populations, and assists in the formulation of best recommendations for frailty interventions to prevent early aging, excess morbidities and early death.

Delayed tuberculosis diagnosis and tuberculosis transmission

SETTING

Tuberculosis (TB) patients and their close contacts reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001.

OBJECTIVES

A recent prospective study found that 49% of pulmonary TB patients had total treatment delays > or = 90 days. This cohort was analyzed to determine the association between total treatment delay and TB transmission.

DESIGN

TB patient data were collected as part of a prospective cohort study; contact data were collected from local health departments.

RESULTS

Close contacts of 54 US-born patients (n = 310) and those of 70 foreign-born cases (n = 393) received tuberculin skin tests (TSTs). Among contacts of US-born patients with a total treatment delay of > or = 90 days, 40% had positive TSTs vs. 24% contacts of patients with shorter delays (aOR 2.34; P = 0.03). Other patient factors associated with TST positivity among contacts of US-born cases were black race (aOR 3.03; P = 0.05), sputum smear positive for AFB (aOR 3.29; P = 0.01) and chest radiograph with cavitation (aOR 3.11; P = 0.01). No associations were observed between foreign-born patients and risk of TST positivity among their contacts.

CONCLUSION

Among US-born patients, delay in TB diagnosis is associated with greater transmission of infection to contacts and could be used independently of other index patient factors to identify contacts at greatest risk of TB infection.

Patient and health care system delays in pulmonary tuberculosis diagnosis in a low-incidence state

SETTING

Tuberculosis (TB) patients reported to the Maryland Department of Health and Mental Hygiene from 1 June 2000 to 30 November 2001.

OBJECTIVE

To determine the extent of delayed diagnosis of TB and to assess patient and provider factors associated with delays.

DESIGN

A prospective cohort study.

RESULTS

Median patient, health care and total delays were 32, 26 and 89 days, respectively, for 158 patients. Non-white (relative hazard [RH] 0.62; 95% CI 0.39-0.98) and less educated (RH 0.43; 95% CI 0.26-0.72) patients had longer patient delays. English-speaking patients (RH 0.40; 95% CI 0.24-0.68) had increased health care delays, as did patients who received a diagnosis of a respiratory illness and non-TB antibiotics (RH 0.69; 95% CI 0.49-0.96) prior to a TB diagnosis. Patients first presenting to a private physician (51 days) rather than a hospital emergency room (18 days; RH 1.87; 95% CI 1.05-3.33) or public health clinic (10 days; RH 1.79; 95% CI 1.21-2.63) had longer health care delays. When a TB diagnostic tool (chest radiograph or AFB culture) was utilized, a more rapid diagnosis of TB was made.

CONCLUSION

Education of the patient population about TB symptoms might reduce delays. Increased physician awareness of the current epidemiology of TB and better use of available diagnostic tools will reduce delays and may reduce TB transmission.

Impact of empiric antibiotics and chest radiograph on delays in the diagnosis of tuberculosis

SETTING

Maryland Department of Health and Mental Hygiene, Division of Tuberculosis (TB) Control.

OBJECTIVES

To assess the implications of antibiotic treatment of presumed community-acquired pneumonia (CAP) on delays in the diagnosis of TB, and to assess the frequency with which chest radiographs (CXRs) were utilized before a diagnosis of pneumonia or pulmonary TB was made.

DESIGN

A nested case-control study within a prospective study conducted to assess factors associated with delays in the diagnosis of TB.

RESULTS

Cases (n = 85; 54%) were patients who received antibiotics for non-TB diagnoses/indications prior to TB diagnosis, and controls (n = 73; 46%) were patients who had initially received TB therapy. Median health care delay for cases was 39 days vs. 15 days (P < 0.01) for controls. Median antibiotic delay was similar among all antibiotic classes. Of 54 patients who did not have a CXR at their first health care visit, 41 (79%) received empiric antibiotics, compared to 44/105 (42%) who had a CXR (P < 0.01). Only 31/54 (57%) patients initially diagnosed with CAP had a CXR at the time of diagnosis.

CONCLUSION

More widespread use of CXR when diagnosing CAP should reduce delays in diagnosing TB, and the unnecessary use of antibiotics.

Dissatisfaction with medical care among women with HIV: dimensions and associated factors

Studies have shown that women with HIV/AIDS in the USA are less likely than men to have access to appropriate health care and to utilize services, including the latest antiretroviral drug therapies. One explanation for this underutilization is patient dissatisfaction with medical care. Dissatisfaction with care has been shown to be associated not only with treatment underutilization, but also with discontinuity of care and poor clinical outcomes. Using Patient Satisfaction Questionnaire data from a national cohort of women with HIV, this study examines levels of dissatisfaction across seven established dimensions of care, and uses multivariate analysis to identify patient characteristics associated with these dimensions (N = 1,303). Women were most dissatisfied with access to care and the technical quality of care, and least dissatisfied with financial aspects of care and their providers' interpersonal manner. Women who reported poor health, who had depressive symptomatology, who were not receiving antiretroviral therapy (ART), who had no consistent care providers or who were Hispanic/Latina were more likely to be dissatisfied across most dimensions of care. Implications for enhancing clinical care for women with HIV/AIDS and overcoming barriers to utilization of care and treatment are discussed.

Evidence that anoreceptive intercourse with ejaculate exposure is associated with rapid CD4 cell loss

OBJECTIVE

To determine whether ejaculate exposure through anoreceptive intercourse is associated with rapid CD4 cell loss.

DESIGN

Self-reported behavioral, demographic data and blood samples were gathered longitudinally at ten semiannual visits from individuals participating in the Multicenter AIDS Cohort Study (MACS).

PATIENTS/PARTICIPANTS

A group of 937 HIV-seropositive men who were continuously followed for four to ten semiannual visits.

OUTCOME MEASURES

A loss of 10% or more in CD4 cells between the first two of any three consecutive semiannual visits that was followed by a 10% or greater loss between the second and third visits.

RESULTS

A period of rapid CD4 cell loss over three semiannual visits occurred in 389 of the 937 (42%) HIV-seropositive men studied. Men who reported one or more anoreceptive intercourse partners with whom they were exposed to ejaculate (RAI-E) during the 12 months immediately preceding their visits were more than twice as likely to show this rapid CD4 cell loss compared with men with no such partners.

CONCLUSIONS

The association between RAI-E partnerships and rapid CD4 cell loss suggests factors associated with ejaculate exposure (e.g., sexually transmitted diseases) may hasten the clinical progression of HIV disease. It is suggested that infectious diseases, which are known to be associated with ejaculate exposure, may be the causal factor underlying the association between RAI-E partnerships and rapid CD4 cell loss in these men, although the presence of these diseases was not ascertained in these data. HIV-infected individuals should be cautioned against unprotected anoreceptive intercourse.

AIDS onset at high CD4+ cell levels is associated with high HIV load

To identify factors associated with development of AIDS at high CD4+ cell levels a nested case-control study using data from the Multicenter AIDS Cohort Study (MACS) was conducted. HIV-1-infected men who developed AIDS with > or =300/mm3 CD4+ cells (AIDS men) were compared to men who had > or =300/mm3 of CD4+ cells, but remained AIDS free for at least 2 years. The AIDS men had higher plasma HIV-1 RNA levels (mean 10(5.02) vs. 10(4.42), p<0.01) and neopterin levels (mean 18.3 vs. 11.5 units/ml, p<0.05) before the AIDS diagnosis than did the AIDS-free men. A significantly higher proportion of the AIDS men reported genital herpes within the year prior to their initial AIDS diagnosis than did the AIDS-free men (21.9 vs. 4.4%, p<0.05). The higher viral load at relatively high CD4+ cell levels in men who subsequently developed AIDS within 6 months supports the hypothesis that elevated levels of HIV precede CD4+ decline and are the major factor in determining risk of AIDS even at high levels of CD4+ cell levels.

Latent infection of CD4+ T cells provides a mechanism for lifelong persistence of HIV-1, even in patients on effective combination therapy

Combination therapy for HIV-1 infection can reduce plasma virus to undetectable levels, indicating that prolonged treatment might eradicate the infection. However, HIV-1 can persist in a latent form in resting CD4+ T cells. We measured the decay rate of this latent reservoir in 34 treated adults whose plasma virus levels were undetectable. The mean half-life of the latent reservoir was very long (43.9 months). If the latent reservoir consists of only 1 x 10(5) cells, eradication could take as long as 60 years. Thus, latent infection of resting CD4+ T cells provides a mechanism for lifelong persistence of HIV-1, even in patients on effective anti-retroviral therapy.

Anti-HIV type 1 memory cytotoxic T lymphocyte responses associated with changes in CD4+ T cell numbers in progression of HIV type 1 infection

We investigated memory cytotoxic T lymphocyte (CTLm) responses to HIV-1 as a determinant of HIV-1 disease progression, in relation to plasma HIV-1 load and T lymphocyte numbers in a longitudinal study of 14 homosexual men with incident HIV-1 infection. Study participants were selected who exhibited failure of T cell homeostasis, i.e., a downward inflection in CD3+ T cells that occurs in >75% of persons 1.5 to 2.5 years before development of AIDS, and compared with participants who developed low CD4+ T cell counts associated with possible T cell homeostasis failure, a subject who progressed rapidly to AIDS without well-defined T cell inflection, and subjects who had long-term preservation of T cell homeostasis (nonprogressors). High CTLm responses against Gag, but not Pol or Env, soon after seroconversion were associated with a slower loss of CD4+ T cells 1-4 years after seroconversion. Anti-Env CTLm responses decreased in most subjects around the time that T cell homeostasis failed. Plasma HIV-1 RNA increased exponentially (1.59-fold per year) over the 5 years preceding failure of T cell homeostasis, and there was a shift from a non-syncytium-inducing/CCR5 coreceptor phenotype of HIV-1 to a syncytium-inducing/CXCR4 phenotype, regardless of high or increasing levels of anti-HIV-1 CTLm during this time. These observations suggest that decreases in CTLm and increasing virus load are independent factors contributing to HIV-1 disease progression.

The proportional decrease in prostate specific antigen level best predicts the duration of survival after hormonal therapy in patients with metastatic carcinoma of the prostate

OBJECTIVE

To examine the usefulness of a test for prostate specific antigen (PSA) to predict survival in hormonally treated patients with metastatic prostate cancer.

PATIENTS AND METHODS

The study comprised 49 patients (mean age 72 years, SD 6) who underwent orchidectomy for metastatic prostate cancer. PSA was measured before orchidectomy and after 6 months, and the absolute, differential and proportional decreases calculated. A Cox proportional hazards regression model, which controlled for patient age, tumour (Gleason) grade and the number of skeletal metastases, was then used to evaluate these estimates of PSA as predictors of survival.

RESULTS

The 6-month proportional decrease in PSA from the pre-operative level was the most accurate predictor of patient survival (P = 0.006) after hormonal therapy for metastatic prostate cancer.

CONCLUSION

This information may help to direct appropriate patients to new and experimental therapies for metastatic disease.

Determinants of graft survival after renal transplantation

We studied multiple determinants of graft survival at a single center and the effects of nonimmunologic graft loss on transplant survival. This retrospective study examined the results of 589 cadaver donor transplants performed between 1986 and 1992. Graft survival rates were calculated using Kaplan-Meier estimates for both overall graft survival (all causes of graft loss) and immunologic graft survival (function lost due to acute or chronic rejection and noncompliance). Cadaver graft survival was significantly poorer with an increasing degree of DR mismatch (P=0.02). An analysis of pretransplant variables showed graft loss risk was highest with greater DR mismatches, two B-antigen mismatch, higher donor serum creatinine, and younger recipient age. After transplantation, acute rejection was the most significant factor associated with long-term graft survival. Our data demonstrate a significant advantage for zero DR and one DR mismatch cadaver donor transplants, with excellent immunologic graft survival. This study suggests that a combination of immediate graft function, prevention of acute rejection by appropriate early immunosuppressive therapy, and acceptable DR match enhances cadaveric graft survival.