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CORRESPONDENCE

The importance of co-morbidity in older HIV-infected patients

Skiest, Daniel J

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We read with interest the recent study by Tumbarello et al. [1]. The authors compared a group of HIV-infected older patients (aged > 50 years) with a group of younger patients (aged 20–35 years). All patients received highly active antiretroviral therapy (HAART). The older cohort had a lower mean CD4 cell count than the younger cohort (108 versus 187 cells/mm3). In addition, the older cohort had a significantly higher percentage of co-morbid conditions than controls (44.8 versus 15.5%) as measured by the Charlson co-morbidity index [2]. In univariate analysis, a lower Charlson co-morbidity index (indicating fewer co-morbid illnesses) was associated with a higher chance of immunological success in response to HAART as was the baseline CD4 cell count. In multivariate analysis, after controlling for sex and co-morbid conditions, there was no difference in immunological success in response to HAART. However, as demonstrated by Tumbarello and colleagues [3,4], in clinical practice underlying non-HIV-related co-morbid conditions are present in up to a half of older patients. In the clinic, many older patients will thus have other significant illnesses that may impact their response to HIV treatment.

Several years ago we published the first report on the impact of co-morbidity on survival in older patients with HIV [4]. In a case–control study we compared an older cohort (aged > 55 years) with a matched younger cohort (aged < 45 years). Like Tumbarello et al. [1], we also found that the older cohort had significantly lower CD4 cell counts (205 versus 429 cells/mm3) and a significantly higher Charlson co-morbidity index (39.5 versus 10.5% or 0.907 versus 0.198 points per patient), indicating a high prevalence of non-HIV-related co-morbid conditions in the older cohort. A higher co-morbidity index was a predictor of mortality in our study. Older patients had more hospitalizations and shorter survival than younger patients.

It thus appears that the observations we made 7 years ago regarding lower CD4 cell counts and the importance of co-morbid conditions in older patients remain relevant in the HAART era. We agree that older patients should receive HAART and generally respond well to HAART, but would emphasize the importance of diagnosing older patients as early as possible to prevent immunological decline and to improve the chances of successful HAART. Clinicians should address and treat co-morbid conditions aggressively in order to improve outcome in this group of patients.

References

1.Tumbarello M, Rabagliati R, de Gaetano Donati K, Bertagnolio S, Tamburrini E, Tacconelli E, et al.Older HIV-positive patients in the era of highly active antiretroviral therapy: changing of a scenario.AIDS 2003, 17:128–131.
2.Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chron Dis 1987, 40:373–383.
3.Ena J, Valls V, Lopez Aldeguer J, del Pilar Garcia Gasco M, Anon S, Navarro V, et al.Clinical presentation of HIV infection in patients aged 50 years or older.J Infect 1998, 37:213–216.
4.Skiest DJ, Rubinstien E, Carley N, Gioiella L, Lyons R. The importance of comorbidity in HIV infected patients over 55: a retrospective case–control study.Am J Med 1996, 101: 605–611.
© 2003 Lippincott Williams & Wilkins, Inc.