*Geriatric Division, Department of Internal Medicine, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil, †Epidemiology Division, Epidemiology Department, University of São Paulo, São Paulo, Brazil, ‡Medicine Student, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil, §Infectious Division, Department of Internal Medicine, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
To the Editor:
Considering the dynamics of the epidemic in different populational segments, HIV-positive elderly individuals form an emerging category in industrialized countries. Studies in developed countries show that HIV-positive individuals are aging in parallel with the introduction of more potent medications.1 According to the World Health Organization, approximately 2.8 million adults aged older than 50 years were living with AIDS worldwide in 2005.2 Data from the Centers for Disease Control and Prevention3 show that the number of HIV-positive elderly increased fivefold in the past decade in the United States and compose 15% of those currently infected there.4 Other authors5 obtained similar data in France in 2004. In Brazil, the percentage of patients aged older than 50 years who are diagnosed with AIDS increased from 7% in 1996 to 13% in 2004.6
The majority of the general population older than 50 years old present with chronic-degenerative diseases, depression, and cognitive decline; consequently, individuals in this age group regularly take several medications. In association with this fact are the evident side effects of highly active antiretroviral therapy (HAART), posology, and the occurrence of medication interactions.7 Patient adherence to HAART is a complex phenomenon that can be affected by a series of variables, including the complexity of the therapeutic regimens, access to medications, psychosocial support, and patient confidence in the treatment.8,9 Our study aimed to compare adherence rates to HAART between young adults and elderly individuals and elucidate the factors that most influence adherence.
A longitudinal prospective cohort study was realized from February 1 to December 31, 2007, involving patients at the Outpatient Unit of the Federal University of the Triangulo Mineiro in Uberaba, Minas Gerais, Brazil. The sample was composed of 101 individuals separated into two groups: Group 1 (n = 51), HIV-positive patients of both sexes aged 50 years or older; and Group 2 (n = 50), HIV-positive patients of both sexes aged younger than 40 years. To evaluate adherence to HAART, the following methods were adopted as a result of their easy application: self-reporting, attendance at monthly consultations, and monthly dispensation of HAART medications at the Federal University of the Triangulo Mineiro medication dispensation center. Patients defined as adherent to HAART were those who attended the monthly consultations and collected their medications for 6 months consecutively or who only failed to attend and/or collect their medications once; those defined as nonadherent to HAART were patients who failed to attend two or more consultations and who did not collect their medications more than twice during a 6-month period. Nutritional evaluations were performed on all patients to include clinical evaluation, body weight (in kilograms) measurements, and calculation of body mass index (BMI, kg/m2). Patients presenting a BMI 18.5 kg/m2 or less were classified as malnourished and those presenting a BMI greater than 25.0 kg/m2 as overweight. During the fortnightly clinical evaluations, the presence or absence of depression was assessed by the same observer; for Group 1 (older than 50 years old), the Geriatric Depression Scale was also applied. Cognitive evaluations for both groups were applied by the same examiner using the Mini Mental State Examination.10 The data obtained were used to perform descriptive analyses of the variables studied, including mean, standard deviation, standard error of mean, minimum and maximum values, and percentiles; normality and homogeneity tests for data distribution; and comparison between the groups. A value of P < 0.05 was considered significant.
The first group was composed of 51 patients, 26 (51%) women and 25 (49%) men. The mean age for this group was 56.74 years with a standard deviation (SD) of 5.85 years. In the nutritional evaluation of this group, the mean BMI was 22.2 kg/m2 with a SD of 2.59 kg/m2. A prevalence of 26 (51%) patients presenting depression was observed in this group; of these, 15 (58%) were women and 11 (42%) were men. Cognitive evaluation detected alterations in the Folstein test in nine (18%) patients, six women and three men. Regarding monthly medication collection, verification revealed that 43 (84%) collected their monthly medications and attended all their consultations, whereas eight (16%) failed to maintain continuous follow up over 6 months.
The second group was composed of 50 patients, 22 (44%) women and 28 (56%) men. The mean age for this group was 33.62 years with a SD of 4.74 years. The mean BMI in this group was 23.83 kg/m2 with a SD of 4.29 kg/m2 with significant weight variation observed in only two (4%) patients. Depression was observed in 21 (42%) patients, 14 (67%) women and seven (33%) men. Cognitive decline was detected in three (6%) patients in this group. The monthly medication dispensation showed that 32 (64%) regularly collected their medication and attended consultations and were classified as adherent, whereas 18 (36%) failed to do so regularly and were considered nonadherent.
Multivariate analysis of the variables related to adherence to HAART detected no significant difference between the groups (Table 1). However, after adjusting for age, the Spearman correlation showed that the group of young adult patients presented greater adherence to HAART than the elderly group (95% confidence interval, 1003−6.24, P = 0.04).
When comparing adherence between the two age groups by correlation, a greater rate of adherence was observed in the young adult group. As stated in our hypothesis, the elderly were more prone to poor adherence as a result of greater use of other medications, greater prevalence of side effects, medication interactions, depression, and memory alteration. Most studies concerning the influence of age on HAART adherence are inconclusive and were conducted on young individuals. Using univariate analysis, one American study demonstrated a positive association between adherence and age older than 50 years.11 Depression has been implicated as a primary cause of poor adherence to HAART.12 A considerable prevalence for depression was observed in this work according to the instrument used; however, it was not statistically significant when the data were compared with the adherence obtained. Cognitive deficit is related to disease progression and to poor adherence.13 The present study verified valid samples according to the instrument used; however, no relation to adherence was observed. The relation between adherence and malnutrition (as measured by the BMI) was investigated, and no relation between these factors was observed in this work. The deterioration in nutritional status showed strict correlation with the classes defined by the Centers for Disease Control and Prevention in 1992.
With the increased prevalence of HIV in patients older than 50 years old, it is imperative that this group is considered a risk for poor adherence to HAART. Special attention should be given to demographic, socioeconomic, neuropsychiatric, and cognitive variables during outpatient follow up of elderly individuals with AIDS receiving HAART. With the global aging process, there is also an elevated sexual life expectancy, which also makes this population susceptible to HIV. There is not enough information or concentration on prevention of HIV infection in the elderly.
Guilherme R. Pardi, MD*
Altacílio A. Nunes, MD, PhD†
Paulo Guilherme F. Canassa, MSc‡
Dalmo Correia, PhD§
*Geriatric Division, Department of Internal Medicine, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
†Epidemiology Division, Epidemiology Department, University of São Paulo, São Paulo, Brazil
‡Medicine Student, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
§Infectious Division, Department of Internal Medicine, Federal University of the Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
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