To the Editors:
The life expectancy of HIV-infected patients has increased with highly active antiretroviral therapy (HAART), and in 2005, 24% of individuals living with HIV/AIDS in the United States were aged 50 years and older.1,2 It is projected that by 2015, more than half of the HIV-infected adults in the United States will be >50 years old.1,2 With increasing life expectancy in developed nations, the United Nations currently defines elderly as older than 60 years of age.3 Only a few studies have reported on older HIV-infected adults and there are sparse data reported on HIV infection in patients 60 years of age or older.4,7
The Ruth M. Rothstein CORE Center (CORE Center) provides comprehensive outpatient care to individuals with HIV/AIDS, and of the more than 4500 HIV-infected adults who receive care at the CORE center, 27% are over the age of 50. In a small study published from our group in 2003,7 we identified 83 patients ≥60 years of whom 56 (65%) were still active in care and included in this study.
The objectives of the present study were to describe the immunologic and virologic long-term outcomes of patients aged 60 years or older and to determine if these outcomes differed by age at HIV diagnosis.
This was a retrospective chart review of 191 HIV-infected patients ≥60 years who had at least 1 clinic visit in 2008. Patients were identified from the electronic database of all patients seen at the CORE Center, Cook County Bureau of Health Services. Data on demographics, comorbidities, and laboratory values were retrieved from paper and electronic charts. Baseline CD4 count was the CD4 at the time of/closest to the time of diagnosis or at the time of presentation to care if CD4 at diagnosis was unavailable. The patients were divided into 2 groups according to age at diagnosis >50 years (group 1) or ≤50 years (group 2).
All analyses were performed using SPSS for Windows, version 15.0 (SPSS, Chicago, IL). Qualitative variables were compared using the χ2 test. The Student t test was used for numeric variables. A P value <0.05 was considered significant. The study was approved by the Cook County Bureau of Health Services Institutional Review Board.
There were 201 patients ≥60 years with ≥1 clinic visit in 2008, of which 191 were included in the study. Ten patients (5%) were excluded from final analysis due to missing information on baseline CD4 counts, first and current regimens, and comorbidities. The demographics and clinical characteristics of the 191 patients are shown in Table 1. The median age was 65 years (range 60-82 years). African Americans were more likely to have intravenous drug use risk, 30% vs. <6% (P = 0.001). The majority, 76% were diagnosed with HIV over the age of 50 years. Patients diagnosed over age 50 years were more likely to have heterosexual transmission of HIV.
Current HAART regimens were equally distributed in both groups; with most of the patients receiving nonnucleoside reverse transcriptase inhibitor or protease inhibitor-based HAART; 45% and 51%, respectively. Baseline CD4 at diagnosis was 241 cells per cubic millimeter and the most recent CD4 count for the cohort was 438 cells per cubic millimeter. There was no significant difference in mean CD4 increase between the groups 235 cells per cubic millimeter vs. 183 cells per cubic millimeter (P = 0.2). Seventy-six percent of the patients had undetectable HIV RNA. African Americans were less likely to have undetectable HIV RNA, 71% vs. 82% Hispanic, and 89% white (trend, P = 0.1).
There was a high rate of comorbidities in these older patients; hypertension 68%, hyperlipidemia 48%, Hepatitis C infection (HCV+) 29%, nephropathy (GFR < 60/mL/min) 25%, diabetes mellitus 23%, malignancy 13%, heart disease 13%. There were no differences in rates of comorbidities when stratified by age at HIV diagnosis (group 1 vs. group 2) (P = NS). Analysis by ethnicity showed that African Americans were less likely to have hyperlipidemia 39% vs. 62%-76% other groups (P < 0.00), but were more likely to have hypertension, 74% vs. 53% other groups (P = 0.02) and HCV+ 38% vs. 6% Hispanic, 15% White (P < 0.00).
In this study, one of the largest reports on HIV+ patients aged 60 years or older, we found excellent immunologic and virologic responses to HAART. This cohort differed from those in the literature because they were mostly ethnic minorities receiving care in an urban clinic in the United States. Despite a high rate of comorbidities and concomitant medications, these older patients were able to maintain adherence with HAART and the majority (76%) had undetectable HIV RNA. We found that African Americans were less likely to have undetectable HIV RNA, however, reasons for this were not explored as that was beyond the scope of this present study.
Previous smaller studies from Europe have also shown that the best adherence to treatment was in the eldest of the older adults, and that older adults had good virologic response to treatment and our findings support this.4,7 Results have been mixed in terms of immunologic response to HAART in the elderly compared with younger patients with most studies reporting a poor immune reconstitution with older age.4-7,8-10 Our study showed that although not statistically significant, the increase in CD4 counts in the patients diagnosed at an older age (group 1) was less robust. Patients diagnosed at a younger age (group 2) had higher current CD4 counts, which could reflect ongoing CD4 increases over at least a decade of HAART or due to the higher baseline CD4 before HAART initiation. It is important to note that the increases in CD4 counts with HAART were significant in our patients regardless of age at diagnosis, and there was no difference in the groups in terms of virologic response.
Our data also confirm previous reports from Spain and Italy4,5,9 that showed that older HIV-infected patients are more likely to report heterosexual transmission than younger patients. It is clear that older (group 1) patients presented later, with lower CD4 counts and this may be due to delayed testing in this group. With wide-spread routine HIV testing which eliminates risk-based testing, the issue of late diagnosis especially in older, heterosexual individuals should be attenuated.
Comorbidities with the use of concomitant medications were common in our patients and rates were not statistically different among the groups stratified by age at diagnosis suggesting most were aging related comorbidities. Despite these, 76% of patients had undetectable HIV RNA, which suggests a better adherence profile in older patients. The impact of polypharmacy on medication toxicities and hospitalizations were not studied but are an area of interest as the population ages with HIV infection. The clinician providing care for an older adult with HIV infection will need to aggressively manage these comorbidities, which have a significant impact on morbidity and mortality in these patients.10
Limitations of the current study include our lack of documentation of HAART duration though we know in most of our patients it is within 6 months of presentation to care. Also our first available CD4 count may not be the baseline CD4 in all cases. However, because most patients presented with CD4 counts, which put them in the treatment range, we believe that the duration of HAART, closely tracks duration of HIV diagnosis. The major strength of this study is the large number of older patients, the vast majority of whom are ethnic minorities, a population under-represented in the published literature on this subject.
In conclusion, our single center study shows that with HAART, elderly HIV patients achieved successful immunologic and virologic outcomes despite a high rate of comorbidities. The majority of patients were over age 50 years at HIV diagnosis, and age at diagnosis did not affect virologic outcomes. The less robust immunologic outcomes in older patients could be attenuated by earlier diagnosis and initiation of therapy. As this population ages, the importance of managing other medical comorbidities will become increasingly important.
Luis Manrique, MD
Mariam Aziz, MD
Oluwatoyin M. Adeyemi, MD
Department of Internal Medicine, Stroger Hospital of Cook County and Rush University Medical Center, Chicago, IL
4. Nogueras M, Navarro G, Anton E, et al. Epidemiological and clinical features, response to HAART, and survival in HIV-infected patients diagnosed at the age of 50 or more. BMC Infect Dis
5. Brañas F, Berenguer J, Sánchez-Conde M, et al. The eldest of older adults living with HIV: response and adherence to highly active antiretroviral therapy. Am J Med
6. Navarro G, Nogueras M, Segura F, et al. HIV1 infected patients older than 50 years. PISCIS cohort study. J Infect
7. Adeyemi OM, Badri SM, Max B, et al. HIV infection in older patients. Clin Infect Dis
8. Perez JL, Moore RD. Greater effect of highly active antiretroviral therapy on survival in people aged > 50 compared to younger people in an urban observational cohort. Clin Infect Dis
9. Orchi, N, Balzano R, Scognamiglio P, et al. Ageing with HIV: newly diagnosed older adults in Italy. AIDS Care
10. Simone M, Appelbaum J. Management of HIV/AIDS in older adults. Geriatrics