The ageing of HIV: implications for geriatric medicine

Enhancement of Human Immunodeficiency Virus-Specific CD8+ T Cell Responses with TIGIT Blockade Involves Trogocytosis

Natural killer (NK) and CD8+ T cell function is compromised in human immunodeficiency virus type 1 (HIV-1) infection by increased expression of inhibitory receptors such as TIGIT (T cell immunoreceptor with Ig and ITIM domains). Blocking inhibitory receptors or their ligands with monoclonal antibodies (mAb) has potential to improve antiviral immunity in general and facilitate HIV eradication strategies. We assessed the impact of TIGIT engagement and blockade on cytotoxicity, degranulation, and interferon-gamma (IFN-γ) production by CD8+ T cells from persons living with HIV (PLWH). The effect of TIGIT engagement on non-specific anti-CD3-redirected cytotoxicity was assessed in redirected cytotoxicity assays, and the effect of TIGIT blockade on HIV-specific CD8+ T cell responses was assessed by flow cytometry. In 14/19 cases where peripheral blood mononuclear cells (PBMC) mediated >10% redirected cytotoxicity, TIGIT engagement reduced the level of cytotoxicity to <90% of control values. We selected PLWH with >1000 HIV Gag or Nef-specific IFN-γ spot forming cells per million PBMC to quantify the effects of TIGIT blockade on HIV-specific CD8+ T cell responses by flow cytometry. Cell surface TIGIT expression decreased on CD8+ T cells from 23/40 PLWH following TIGIT blockade and this loss was associated with increased anti-TIGIT mAb fluorescence on monocytes. In total, 6 of these 23 PLWH had enhanced HIV-specific CD8+ T cell degranulation and IFN-γ production with TIGIT blockade, compared to 0/17 with no decrease in cell surface TIGIT expression. Reduced CD8+ T cell TIGIT expression with TIGIT blockade involved trogocytosis by circulating monocytes, suggesting that an effector monocyte population and intact fragment crystallizable (Fc) functions are required for mAb-based TIGIT blockade to effectively enhance HIV-specific CD8+ T cell responses.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Toward a Prognostic Model for Mortality Risk in Older People Living With HIV: A Prospective Cohort Study From Southwestern China

OBJECTIVE

The existing prognostic models for mortality risk in people living with HIV (PLWH) may not be applicable for older PLWH because the risk factors were confined to biomarkers and clinical variables. We developed and validated a nomogram for the prognosis of all-cause mortality in older PLWH based on comprehensive predictors.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

We included 824 participants aged ≥50 years (mean age, 64.0 ± 7.6 years) from 30 study sites in Sichuan, China, and followed up from Nov 2018 to Mar 2021.

METHODS

Data on demographics, biomarkers, and clinical indicators were extracted from the registry; mental and social factors were assessed by a survey. Elastic net was used to select predictors. A nomogram was developed based on Cox proportional hazards regression model to visualize the relative effect size (points) of the selected predictors. The prognostic index (PI) was calculated by summing points of all predictors to quantify mortality risk.

RESULTS

Predictive performance of PI from the nomogram was good, with area under the curve of 0.76 for the training set, and 0.77 for the validation set. Change in CD4 count, virological failure in antiretroviral therapy, and living with comorbidities were robust predictors. Depressive symptoms were an important predictor in men, those aged ≥65 years, and those with time of diagnosis <1 year; low social capital was an additional predictor in people aged <65. Mortality risk increased approximately 10-fold among participants whose PI was in the fourth quartile compared with those in the first quartile (hazard ratio, 9.5; 95% CI, 2.9-31.5).

CONCLUSION AND IMPLICATIONS

Although biological and clinical factors are crucial predictors, mental and social predictors are essential for specific groups. The developed nomogram is useful for identifying risk factors and groups at risk of mortality in older PLWH.

How do geriatricians feel about managing older people living with HIV? A scoping review

PURPOSE

The proportion of people living with HIV being older adults is increasing and due to high rates of multimorbidity and frailty within this group geriatricians are well placed to contribute to their care. However, little is known about how geriatricians feel about this new opportunity.

METHODS

A scoping review was performed following the Arksey & O'Malley's methodological framework with nine databases searched in December 2021 for studies reporting the experiences or views of geriatricians on caring for people living with HIV. Study inclusion was not limited by language or year of publication. Narrative reviews were excluded. Two reviewers independently performed the extraction using predetermined criteria. A descriptive analysis of extracted information was performed.

RESULTS

Six publications reporting four studies, all conducted in the USA, were identified. The current barriers to geriatricians being involved in the care of older people living with HIV are: their current experience in managing people living with HIV, their knowledge of HIV, specific issues related to older people living with HIV and screening for HIV in older people as well as their attitudes to people living with HIV and experience of managing older LGBTQ + people.

CONCLUSION

Prior to geriatricians being routinely involved in the care of older people living with HIV further research outside of the USA is required. Geriatricians will also require specific training which should be incorporated into geriatric medicine training curricula as well as the creation of learning tools and quality clinical practice guidelines ideally created in collaboration with HIV organisations.

General Practitioners as partners for a shared management of chronic HIV infection: An insight into the perspectives of Italian People Living with HIV

Is it possible to achieve a collaboration between Infectious Diseases (ID) Specialists and General Practitioners (GPs) in the management of chronic HIV infection? A cross sectional survey was conducted among People Living with HIV (PLWHIV) attending the outpatient services of four Italian Infectious Diseases Centers to understand to which extent patients trust their GPs and involve them in the management of their chronic condition. Information about level of communication with GPs, subjective perception of the disease, and presence of co-medications were collected and matched with socio-demographic data using χ2statistics. A p<0.05 was considered statistically significant. From December 2019 to February 2020, 672 patients completed the survey, 59% males and 56% >50 years. Overall, 508 patients (76%) had informed GPs about HIV-positivity. Communication of diagnosis was significantly associated with age >50years, lower education level, history of disease >10 years and residency in Northern Italy. The "Undetectable = Untrasmittable" (U = U) concept was investigated as an indirect measure of perceived stigma. 23% of subjects was unaware of its meaning. Despite undetectable status, 50% of PLWHIV found difficult to communicate their condition to GPs, especially married (52% vs 48% of unmarried, p = 0.003), well-educated patients (51% vs 48, p = 0.007), living in Southern vs Northern Italy (52% vs 46%, p< 0.001). More than 75% of the participants consulted the ID specialist for co-medications and DDIs management, often complaining a lack of communication of the former with GPs. Overall, a good level of communication between PLWHIV and GPs was outlined, even if a wider involvement of the latter in HIV care is desirable.

Characterization of inpatient rehabilitation outcomes among HIV/AIDS patients: a retrospective cohort study

ABSTRACT Survival time in HIV/AIDS patients has increased as a result of improved treatments, but many acquire functional impairments that may necessitate multidisciplinary medical rehabilitation. In the United States, inpatient rehabilitation facilities (IRF) provide this care, but outcomes are not well described in this population. We used the Uniform Data System for Medical Rehabilitation (UDSMR) database to describe 11,051 HIV/AIDS IRF patients; HIV/AIDS patients were grouped according to the following admission criteria: (1) HIV/AIDS as primary reason for admission (n = 225); (2) HIV/AIDS symptomatic comorbidity (n = 6569); and (3) HIV/AIDS asymptomatic comorbidity (n = 4257). We used standard descriptive statistics to summarize demographic, medical, rehabilitation, and discharge setting characteristics by group. When compared to patients with HIV/AIDS as a comorbidity, primary HIV/AIDS patients had worse outcomes. They made less functional change (25.1 versus 29.8 and 28.9, p < .001), went home less (73.8% versus 74.5% and 77.8%, p < .001) and to an acute care hospital more frequently (18.2% versus 13.9% and 10.1%, p < .001). These findings help to characterize the HIV/AIDS patient population who receive inpatient medical rehabilitation, which helps inform clinical care, and highlight the positive impact IRF care can make to minimize functional disability among chronic HIV/AIDS patients and possibly decrease costs of home health care.

Challenges with seeking HIV care services: perspectives of older adults infected with HIV in western Kenya

BACKGROUND

While younger adults (15-49 years) form the majority of the population living with HIV, older adults (≥50 years) infected with HIV face multiple challenges related to the aging process and HIV. We explored the experiences of older persons infected with HIV at the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya to understand the challenges faced when seeking HIV care services.

METHODS

Between November 2016 and April 2017, a total of 57 adults aged 50 years and above were recruited from two AMPATH facilities - one rural and one urban facility. A total of 25 in-depth interviews and four focus group discussions were conducted, audio-recorded, transcribed and thematic analysis performed.

RESULTS

Study participants raised unique challenges with seeking HIV care that include visits to multiple healthcare providers to manage HIV and comorbidities and as a result impact on their adherence to medication and clinical visits. Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants' preference for matched gender and older age for care providers that serve older patients were identified.

CONCLUSION

Results indicate multiple challenges faced by older adults that need attention in ensuring continuous engagement in HIV care. Targeted HIV care for older adults would, therefore, significantly improve their access to and experience of HIV care. Of key importance is the integration of other chronic diseases into HIV care and employing staff that matches the needs of older adults.

Global and regional trends of people living with HIV aged 50 and over: Estimates and projections for 2000-2020

BACKGROUND

The increasing numbers of people living with HIV (PLHIV) who are receiving antiretroviral therapy (ART) have near normal life-expectancy, resulting in more people living with HIV over the age of 50 years (PLHIV50+). Estimates of the number of PLHIV50+ are needed for the development of tailored therapeutic and prevention interventions at country, regional and global level.

METHODS

The AIDS Impact Module of the Spectrum software was used to compute the numbers of PLHIV, new infections, and AIDS-related deaths for PLHIV50+ for the years 2000-2016. Projections until 2020 were calculated based on an assumed ART scale-up to 81% coverage by 2020, consistent with the UNAIDS 90-90-90 treatment targets.

RESULTS

Globally, there were 5.7 million [4.7 million- 6.6 million] PLHIV50+ in 2016. The proportion of PLHIV50+ increased substantially from 8% in 2000 to 16% in 2016 and is expected to increase to 21% by 2020. In 2016, 80% of PLHIV50+ lived in low- and middle-income countries (LMICs), with Eastern and Southern Africa containing the largest number of PLHIV50+. While the proportion of PLHIV50+ was greater in high income countries, LMICs have higher numbers of PLHIV50+ that are expected to continue to increase by 2020.

CONCLUSIONS

The number of PLHIV50+ has increased dramatically since 2000 and this is expected to continue by 2020, especially in LMICs. HIV prevention campaigns, testing and treatment programs should also focus on the specific needs of PLHIV50+. Integrated health and social services should be developed to cater for the changing physical, psychological and social needs of PLHIV50+, many of whom will need to use HIV and non-HIV services.

Leveraging Community Engagement to Develop a Mobile Health Application for Older Women With HIV Infection

OBJECTIVE

To develop a mobile health app for older women with HIV infection that will be used in a larger study.

DESIGN

A qualitative study design.

SETTING

Baltimore-Washington metropolitan area clinics and communities.

PARTICIPANTS

Ten women 50 years and older (mean age = 62.8 years, standard deviation = 3.62, range = 58-69 years) who self-identified as Black or African American and were infected with HIV.

METHODS

At the start of the study, we used relevant empirical and the self-determination theory to inform the draft Web-based app content that was shared with two focus groups. Data were analyzed with input from a community advisory board (CAB) to inform the development of the mobile health app.

RESULTS

We inductively identified eight subthemes within the coding structure of two overall themes: Navigating Content, Functions, and Features and Enhancing Provider Interaction With Patients that represented the perspectives of participants regarding the app. From the eight subthemes, we integrated the contributions from the CAB, which we then used to further optimize the app.

CONCLUSION

The app was designed to provide support, tools, and resources for older women with HIV. Engagement of community collaborators could be challenging because of multiple personal and structural barriers. Nonetheless, the potential community member benefits are invaluable. If successful, the Web-based app could be a model to address the needs of older persons with HIV infection.

Proximity of Cytomegalovirus-Specific CD8+ T Cells to Replicative Senescence in Human Immunodeficiency Virus-Infected Individuals

Antiretroviral therapy (ART) effectively extends the life expectancy of human immunodeficiency virus (HIV)-infected individuals; however, age-related morbidities have emerged as major clinical concerns. In this context, coinfection with cytomegalovirus (CMV) accelerates immune senescence and elevates risk for other age-related morbidities, possibly through increased inflammation. We investigated potential relationships between CMV memory inflation, immune senescence, and inflammation by measuring markers of inflammation and telomere lengths of different lymphocyte subsets in HIV-infected individuals seropositive for anti-CMV antibodies. Our study cohort consists mainly of middle aged men who have sex with men (MSM) and heterosexuals who are stable under long-term ART. Median levels of IL-6, TNF-α, and CRP were significantly higher in those coinfected with CMV. Lymphocyte telomere length in general correlated with age, but for 32/32 subjects tested, there was a consistent hierarchy of telomere lengths with CD8⁺ T cells’ shorter than the general lymphocyte population, CD57⁺CD8⁺ T cells’ shorter than CD8⁺ T cells’ and CMV-specific CD57⁺CD8⁺ T cells’ the shortest of all. Telomeres of HIV-specific CD8⁺ T cells were longer than those of CMV-specific CD8⁺ T cells in all cases tested and over 10 years, CMV-specific CD8⁺ T cell telomeres of two HIV-infected individuals eroded faster than those of HIV-specific CD8⁺ T cells. These data indicate that CMV-specific CD8⁺ T cells of HIV-infected individuals are the lymphocytes closest to telomere-imposed replicative senescence. Exhaustive proliferation of CMV-specific CD8⁺ T cells in HIV-infected individuals is a potential source of senescent lymphocytes affecting systemic immune function and inflammation.

Clinicoepidemiological Profile of Elderly PLHIV Attending a Tertiary Care Center in South India

BACKGROUND

Physicians are coming across a considerable number of HIV-positive patients belonging to older age-group, in practice. They pose a challenge as they might present with advanced forms and comorbid conditions. We aimed to describe the clinicoepidemiological profile of elderly people living with HIV.

METHODOLOGY

We conducted a cross-sectional study at Kasturba Medical College, Mangalore. We analyzed the record of 120 patients from 2009 to 2014. Descriptive statistics were used to describe sociodemographic and clinical profile of patients.

RESULTS

Of 786 HIV-positive patients, 120 were elderly. Mean age was 55.9 ± 6.1 years. Majority 68% were male. In all, 63.33% were male. Commonest route of transmission was heterosexual intercourse, most presented at World Health Organization (WHO) stage 1 (64.17%). In all, 77.5% had hypertension and 26.6% had tuberculosis. The median CD4 count at presentation was 245 cells/mm³ (145-426 cells/mm³). Forty-two percent were late presenters (CD4 <200 cells/mm³).

CONCLUSION

Treating physician should have a high index of suspicion in diagnosing HIV among elderly age-group.

[Sexually transmitted diseases among the elderly: a systematic review]

The prolongation of an active sexual life in addition to unsafe practices are reflected in the possibility of the occurrence of STDs among the elderly. The scope of this study is to analyze the evolving trend of STDs among the elderly in Brazil and in the world and also to identify the main issues addressed in the literature, providing data that can support public policies that address the health of the elderly. A systematic search was performed in the Lilacs, IBECS, Cochrane Library, Medline, SciELO and PubMed databases. Of a total of 979 studies found, 44 matched the inclusion criteria and comprised the sample of the review. Six main themes were identified: risk factors for infection (34 studies); the influence of Sildenafil as a possible factor (18); diagnosis of STDs in general (20); HIV treatment (24); comorbidities related to HIV (24); and the prevention of STDs (20). More than one theme can be found in each study. The conclusion drawn is that this age group remains out of the focus of public policies of health promotion in the STD context. Therefore, there is a need for awareness about the changes in behavior and the epidemiological profile of this population group.

Specialist care of older adults with HIV infection in the UK: a service evaluation

OBJECTIVES

There is a clear trajectory towards cohort ageing in the UK. HIV infection is associated with an increased prevalence of traditionally age-related comorbidities and geriatric syndromes. Some HIV services have been proactive in innovating models that cater for adapting needs. We aimed to describe how widespread this practice is and what form such services take.

METHODS

We conducted an evaluation of the perceived need for and current provision of specialist ageing services, and the need for formal guidance on monitoring or treatment of older adults with HIV infection. A web-based questionnaire was sent to the audit lead at every British HIV Association (BHIVA)-registered HIV clinic.

RESULTS

A total of 102 clinics responded, with a broad geographical spread. Five of the 102 clinics have a clinician with an interest in ageing. Two dedicated HIV ageing services exist, practising different models. A quarter (23 of 98; 23%) of clinics reported a need for an ageing service, with three in development. The majority (65 of 95; 68%) supported dedicated guidance for monitoring in older adults, but fewer (39 of 94; 41%) felt that dedicated guidance on treatment was necessary.

CONCLUSIONS

We identified two existing and three proposed HIV ageing services. Another 20 clinics (20%) reported an unmet need for a specialist ageing service, suggesting that complex older adults may pose a management challenge. This is the first survey of its kind to attempt to describe the current landscape and opinion around such services. HIV-infected cohorts will continue to age and current models of care may be insufficient, which should prompt services, their users and commissioners to consider what models may best fit current and future demand.

Trends in AIDS-related mortality among people aged 60 years and older in Brazil: a nationwide population-based study

The success of antiretroviral therapy has led to an increase in the number of older people living with human immunodeficiency virus worldwide. This study analyzed the epidemiological patterns and time trends of acquired immunodeficiency syndrome (AIDS) related mortality in people aged 60 and older in Brazil from 2000 to 2011. Secondary mortality data from the Brazilian Mortality Information System was used to perform a nationwide population-based study, which included all AIDS-related deaths among people aged 60 years and older in Brazil from 2000 to 2011. Crude and age-adjusted mortality rates (per 100,000 inhabitants) were calculated by sex, age group and place of residence. Trends over time were assessed using joinpoint regression analysis. In the 12-year study period, 12,491,280 deaths were recorded in Brazil, of which 144,175 were AIDS-related deaths. A total of 8194 AIDS-related deaths was identified in people aged 60 years and older (0.12% of all deaths and 5.7% of AIDS-related deaths). The overall age-adjusted mortality rate for the period was 4.30 deaths/100,000 inhabitants (95% confidence interval: 3.99-4.64). Males (6.45 deaths/100,000 inhabitants), aged 60-64 years (6.63 deaths/100,000 inhabitants) and residing in the South region (5.94 deaths/100,000 inhabitants) had the highest mortality rates. We observed a significant increase in mortality at the national level and in all the Brazilian regions, with a sharper increase in the most socioeconomically disadvantaged regions of the country, such as the North and Northeast. The findings show that AIDS in older people is an increasing public health problem in Brazil, and reinforce the need to establish public policies for the prevention, early diagnosis and appropriate clinical treatment of this age group.

Characteristics and Outcome of Patients Diagnosed With HIV at Older Age

To characterize the clinical, virological, and immunological status at presentation as well as the outcome of patients diagnosed with HIV above the age of 50. A retrospective study of 418 patients newly diagnosed with HIV in 1 Israeli center, between the years 2004 and 2013. Patients with new HIV diagnosis ≥ 50 years of age defined as "older' and < 50 defined as "younger.' Patients were evaluated every 1 to 3 months (mean follow-up 53 ± 33 months). Patients with < 2 CD4/viral-load measurements or with < 1 year of follow-up were excluded. Time of HIV infection was estimated by HIV sequence ambiguity assay. Ambiguity index ≤ 0.43 indicated recent (≤ 1 year) HIV infection. Eighty nine (21%) patients were diagnosed with HIV at an older age. Those older patients presented with significant lower CD4 cell counts and higher viral-load compared with the younger patients. At the end of the study, the older patients had higher mortality rate (21% vs 3.5%; P < 0.001) and lower CD4 cell counts (381 ± 228 vs 483 ± 26 cells/μL; P < 0.001) compared with the younger patients. This difference was also observed between older and younger patients with similar CD4 cell counts and viral load at the time of HIV diagnosis and among patients with a recent (≤ 1 year) HIV infection. One-fifth of HIV patients are diagnosed at older age (≥ 50 years). Those older patients have less favorable outcome compared with the younger patients. This point to the need of educational and screening programs within older populations and for a closer follow-up of older HIV patients.

Developing new models of shared primary and specialist HIV care in the UK: a survey of current practice

HIV care in the UK is led by hospital-based specialists with limited general practitioner (GP) involvement. As GPs have expertise in some non-microbial HIV-associated co-morbidities (e.g. cardiovascular disease), and more people are disclosing their HIV status to their GPs, there could be benefits in sharing HIV care. We describe contemporary models of shared HIV care in relevant developed world settings to inform future shared HIV care in the UK. An interview survey of key informants was used to explore experiences and models of shared care, and identify promoting and inhibiting factors. We interviewed ten key informants from six shared care models. There were three broad categories of shared care, with varying degrees of GP involvement. Strong clinical leadership in primary care, good professional relationships and communication, and tailored GP training were facilitators. Barriers included stigma, confidentiality concerns, and low prevalence of HIV outside major conurbations. Contemporary shared HIV care models have emerged organically and seem to work when grounded in good collaboration between a small number of dedicated GPs and specialist units. We propose two models for further study which may only be feasible in high HIV caseload practices. User acceptability, clinical and cost effectiveness must be considered.

Ageing with HIV: a multidisciplinary review

INTRODUCTION

After the introduction of highly active antiretroviral treatment, the course of HIV infection turned into a chronic disease and most of HIV-positive patients will soon be over 50 years old.

MATERIAL AND METHODS

This paper reviews the multiple aspects that physicians have to face while taking care of HIV-positive ageing patients including the definitions of frailty and the prevalence and risk factors of concomitant diseases. From a therapeutic point of view pharmacokinetic changes and antiretroviral-specific toxicities associated with ageing are discussed; finally therapeutic approaches to frailty are reviewed both in HIV-positive and negative patients.

CONCLUSION AND DISCUSSION

We conclude by suggesting that the combined use of drugs with the least toxicity potential and the promotion of healthy behaviours (including appropriate nutrition and exercise) might be the best practice for ageing HIV-positive subjects.

Determinants of HIV outpatient service utilization: a systematic review

Demands on HIV services are increasing as a consequence of the increased life-expectancy of HIV patients in the highly active antiretroviral therapy era. Understanding the factors that influence utilization of ambulatory HIV services is useful for planning service provision. This study reviewed factors associated with utilization of hospital based HIV out-patient services. Studies reporting person-based utilization rates of HIV-specific outpatient services broken down by patient or healthcare characteristics were eligible for inclusion. The Andersen Behavioral Model was used to organize the information extracted into pre-disposing, enabling and need components. Ten studies were included in the final review. Older age, private insurance, urban residence, lower CD4 counts, a diagnosis of AIDS, or anti-retroviral treatment were associated with higher utilization rates. The results of this review are consistent with existing knowledge regarding HIV patients' use of health services. Little information was identified on the influence of health service characteristics on utilization of out-patient services.

Gender differences in the association of hazardous alcohol use with hypertension in an urban cohort of people living with HIV in South Florida

Objective

Industrialized countries are currently experiencing an epidemic of high blood pressure (HBP) extending to people living with HIV (PLWH). Given the prevalence of hazardous alcohol use (HAU), this study examines the relationship between alcohol consumption and hypertension in PLWH. Including a gender analysis is critical, given the high rates of HAU and HIV among females.

Method

We followed PLWH including both HAU and non-HAU (200 each). Participants were assessed twice for body weight, blood pressure, alcohol consumption, and other BP-associated lifestyle factors. High blood pressure (defined as systolic/diastolic blood pressure above 140/90 mmHg and/or treatment of HBP) was the primary outcome.

Results

Overall prevalence of hypertension was 38% and higher among HAU compared to non-HAU (42% vs. 34%, p = 0.02). Less than half with HBP (42%) were receiving treatment for hypertension. Overall, males had a 50% higher risk of HBP than women (odds ratio: 1.5, 95% CI: 1–2.6, p = 0.05). However among HAU, females were twice as likely to suffer HBP as their male counterparts (95% CI: 1–3.9, p = 0.02). Those HAU who preferred liquor, versus wine, had higher adjusted mean BP (132.6±18 vs. 122.3±14 mm Hg, p = 0.05). Additional analyses indicated that consumption of >1 standard drink of liquor or beer/day was associated with HBP. Risk of hypertension was noted in those with daily consumption of >3 glasses of wine. For those reporting <1 drink per day, the odds ratio of having HBP was 0.97 (CI: 0.6–0.99, p = 0.05). Factors associated with hypertension in the multivariate model included increased age, gender, BMI, HAU particularly of liquor, and smoking.

Conclusions

Excessive hypertension burden in this population and its association with HAU and sub-optimal care indicate the need for preventive and educational intervention in PLWH. Analyses highlight the necessity of gender and type-of-beverage specific approaches.

HIV/AIDS in the Puerto Rican elderly: immunological changes between gender and body mass index

PURPOSE

Human immunodeficiency virus (HIV) in the elderly population has serious repercussions. The elderly are underdiagnosed for HIV and the costs associated with their late-stage care represent a financial burden to the public health system. The purpose is to analyze various profiles among a cohort of elderly patients with HIV/AIDS.

METHODS

This is a baseline cohort 60 years or older seen in the Retrovirus Research Center between January 2000 to December 2011. We present the profiles of our cohort stratified by gender and body mass index viewed as a covariate of interest.

RESULTS

A total of 266 people (68% males and 32% females) seen at the Center were older than 60 years of age. Males were significantly more often overweight (p<.05). Females were significantly more underweight with chronic conditions (p<.05). Women had higher CD4 count and lower HIV viral loads (p<.05). Underweight elderly males were more heavily affected with the burden of HIV infection compared with women.

Surgery of the femur in HIV positive patients: a retrospective review from 2005 to 2011

BACKGROUND

There are an estimated 6,900 people with HIV living in Ireland. There is a significant prevalence of femoral osteonecrosis and risk factors for osteoporotic fractures. With this potential, increasing surgical workload, it is important to assess surgical demand and audit outcomes.

METHODS

The hospital's electronic records were examined. Between January 2005 and August 2011, 17 femoral surgeries were identified in seven patients. Patient records were retrospectively reviewed.

RESULTS

Elective operations undertaken were eight hip replacements and one nail dynamisation. Eight emergency operations were undertaken: two DHS, one plating, one nailing, one revision nailing, two incision and drainages and one biopsy. All procedures were carried out using appropriate safety guidelines. Indications for surgery included femoral head osteonecrosis (n = 7), osteomyelitis (n = 3), proximal femoral fracture (n = 2), femoral shaft non-union (n = 1), dynamisation of a nail (n = 1), osteoarthritis (n = 1), fractured femur (n = 1), and revision nailing (n = 1). For two procedures the patient was not on highly active anti-retroviral treatment. All elective patients had CD4 counts greater than 200 pre-operatively. Six patients had undetectable viral loads. Of the eight emergency procedures, four procedures had no preoperative immune status recorded. Complications recorded were three non-unions, one nail fracture, one lesser trochanter fracture and recurrence of osteomyelitis. No surgical site infections were recorded.

CONCLUSIONS

Complications were not related to immune status. The rate of surgical site infection in both elective and emergency procedures was low. The elective surgery patients can safely receive orthopaedic treatment in their regional orthopaedic unit. Due to the high non-infectious complication rates recorded in the emergency group, transfer to a tertiary facility with infectious disease expertise is advised.

Evidence informing the intersection of HIV, aging and health: a scoping review

The growing number of people over age 50 with HIV requires research, policy, and practice to develop a more comprehensive understanding of the health consequences of HIV in older individuals. We conducted a scoping review of peer-reviewed and grey literature published since 1996 to explore the impacts of aging on the health of older people with HIV (50 years or older). We included 209 studies (two systematic reviews, 174 quantitative studies, 28 qualitative studies, and five mixed methods studies). Health topics addressed include: HIV- and aging-related comorbidities, disease progression, neurocognitive functioning, mental health conditions, psychological well-being, social supports, stigma, antiretroviral adherence, health care utilization/access, and sexual risk behaviour. We recommend that future research takes a broader view of health, looks at aging from a strength-based perspective and examines the issue using diverse perspectives (i.e., geographic location, multiple methods, time of diagnosis, time on antiretroviral therapy (ART), demographic diversity).

Menthol cigarettes and the cardiovascular risks of people living with HIV

The possibility that menthol cigarettes add to the deleterious cardiovascular effects of smoking has been barely discussed. Although cardiovascular diseases (CVD) are at the forefront of medical concerns of people living with HIV (PLWH), an important, yet unknown, issue for clinicians and public health authorities is whether use of menthol-flavored cigarettes heightens CVD risk factors. Our study aims to assess traditional (10-year risk using the Framingham Risk Model) and nontraditional CVD risk factors and to contrast the effects of menthol-flavored versus non-menthol-flavored cigarettes on these risk factors. Compared to controls, menthol smokers were twice as likely to have hypertension. Users of menthol-flavored cigarettes had higher body mass index values, and increased risk of abdominal obesity. Multivariate analyses indicated that menthol smokers doubled the odds of having moderate to high CVD risk. This finding is highly significant given the widespread use of menthol-flavored cigarettes, particularly among women, minorities, and PLWH.

HIV and ageing: what the geriatrician needs to know

The transformation of human immunodeficiency virus (HIV) from a rapidly fatal disease to a chronic manageable illness has resulted in annual increases in the numbers of people living with HIV. The HIV cohort is therefore ageing, with numbers of older adults with HIV climbing, through both prolonged survival and late acquisition of the disease. Associated with ageing is an accumulation of HIV-associated non-AIDS related co-morbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and complex social issues. With this in mind, this review seeks to explore areas where HIV (diagnosed or undetected) may impact on the work of clinical geriatricians.

A cross-sectional randomised study of fracture risk in people with HIV infection in the probono 1 study

Objective

To determine comparative fracture risk in HIV patients compared with uninfected controls.

Design

A randomised cross-sectional study assessing bone mineral density (BMD), fracture history and risk factors in the 2 groups.

Setting

Hospital Outpatients.

Subbbjects

222 HIV infected patients and an equal number of age-matched controls. Assessments: Fracture risk factors were assessed and biochemical, endocrine and bone markers measured. BMD was assessed at hip and spine. 10-year fracture probability (FRAX) and remaining lifetime fracture probability (RFLP) were calculated.

Main Outcome Measures

BMD, and history of fractures.

Results

Reported fractures occurred more frequently in HIV than controls, (45 vs. 16; 20.3 vs. 7%; OR=3.27; p=0.0001), and unsurprisingly in this age range, non-fragility fractures in men substantially contributed to this increase. Osteoporosis was more prevalent in patients with HIV (17.6% vs. 3.6%, p<0.0001). BMD was most reduced, and predicted fracture rates most increased, at the spine. Low BMD was associated with antiretroviral therapy (ART), low body mass index and PTH. 10-year FRAX risk was <5% for all groups. RLFP was greater in patients with HIV (OR=1.22; p=0.003) and increased with ART (2.4 vs. 1.50; OR= 1.50; p=0.03).

Conclusions

The increased fracture rate in HIV patients in our relatively youthful population is partly driven by fractures, including non-fragility fractures, in men. Nonetheless, these findings may herald a rise in osteoporotic fractures in HIV patients. An appropriate screening and management response is required to assess these risks and identify associated lifestyle factors that are also associated with other conditions such as cardiovascular disease and diabetes.

A review of cardiovascular and renal function monitoring: a consideration of older adults with HIV

The prevalence of human immunodeficiency virus (HIV) infection in older and elderly adults is significant worldwide. This population poses new challenges and opportunities in the management of HIV. In addition to the risks affecting HIV patients of all ages, including risk of opportunistic infection and medication resistance, age-related changes in physiology, higher comorbidity burdens, increased use of medications, and potential adverse drug reactions to HIV medications all factor into the care of older adults with HIV. The risk and progression of cardiovascular and renal comorbidities may be higher in the older adult HIV population and in patients taking specific HIV medications. Understanding these risks is essential when managing a new type of patient: the older adult with HIV.

Social Aspects of HIV/AIDS and Aging: A Thematic Review

Il manque de recherche spécifique qui décrit les aspects sociaux du vieillissement avec le virus de l’immunodéficience humaine/syndrome d’immunodéficience acquise (VIH/SIDA) au Canada, malgré une augmentation globale de la population viellissante et l’augmentation du nombre de ceux qui vieillissent avec le VIH/SIDA. Une revue systématique de la littérature été menée en se focalisant sélectivement sur les aspects sociaux aux personnes âgées vivant avec le VIH/SIDA. Les thèmes principaux qui se dégagent dans la littérature sont l’âgisme et la stigmatisation, le sexe, la santé mentale et les soutiens sociales. On présente des recommandations sur la recherche à l’avenir, les modèles théoriques, et le programmatisation.

Social Aspects of HIV/AIDS and Aging: A Thematic Review

Il manque de recherche spécifique qui décrit les aspects sociaux du vieillissement avec le virus de l’immunodéficience humaine/syndrome d’immunodéficience acquise (VIH/SIDA) au Canada, malgré une augmentation globale de la population viellissante et l’augmentation du nombre de ceux qui vieillissent avec le VIH/SIDA. Une revue systématique de la littérature été menée en se focalisant sélectivement sur les aspects sociaux aux personnes âgées vivant avec le VIH/SIDA. Les thèmes principaux qui se dégagent dans la littérature sont l’âgisme et la stigmatisation, le sexe, la santé mentale et les soutiens sociales. On présente des recommandations sur la recherche à l’avenir, les modèles théoriques, et le programmatisation.

Medical ICU admission diagnoses and outcomes in human immunodeficiency virus-infected and virus-uninfected veterans in the combination antiretroviral era

OBJECTIVES

Human immunodeficiency virus (HIV)-infected (HIV+) patients on combination antiretroviral therapy are living longer but have increased risk for aging-associated disease which may lead to increasing critical care requirements. We compare medical ICU admission characteristics and outcomes among HIV infected and demographically similar uninfected patients (uninfected) and considered whether an index which combines routine clinical biomarkers (the Veterans Aging Cohort Study Index) predicts 30-day medical ICU mortality.

DESIGN

Observational data analyses (Veterans Aging Cohort Study).

SETTING

Eight Veterans Affairs medical centers nationwide.

PATIENTS

HIV infected and uninfected with a medical ICU admission between 2002 and 2010.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Medical ICU admission was determined using bedsection (Veterans Affairs) and revenue center codes (Medicare). For Veterans Affairs admissions, we used clinical data to calculate Veterans Aging Cohort Study Index scores and multivariable logistic regression to determine factors associated with 30-day mortality. Overall, 539 of 3,620 (15%) HIV infected and 375 of 3,639 (10%) uninfected had a medical ICU admission; 72% and 78%, respectively, were Veterans Affairs based. HIV+ patients were younger at admission (p < 0.0001). Although most HIV+ patients were on antiretroviral therapy (71%) with undetectable HIV-1 RNA (54%), compared with uninfected they were more commonly admitted with respiratory diagnoses or infections (21% vs. 12%), were more likely to require mechanical ventilation (17% vs. 9%; p = 0.001), and had a higher mortality rate (18.6% vs. 11.2%, p = 0.003). Cardiovascular diagnoses were less common among HIV infected (18% vs. 29%; p < 0.0001). In logistic regression (c-statistic 0.87), a 5-point increment in Veterans Aging Cohort Study Index was associated with an odds ratio of death of 1.22 (95% confidence interval 1.14-1.30) among HIV infected and of 1.50 (95% confidence interval 1.29-1.76) among uninfected; infection/sepsis and respiratory diagnoses were also associated with mortality.

CONCLUSIONS

Medical ICU admission was frequent, 30-day mortality higher, and mechanical ventilation more common in HIV infected compared with uninfected. The Veterans Aging Cohort Study Index calculated at medical ICU admission predicted 30-day mortality for HIV infected and uninfected. As more individuals age with HIV, their requirements for medical ICU care may be greater than demographically similar uninfected individuals.

Early diagnosis and treatment of HIV infection: magnitude of benefit on short-term mortality is greatest in older adults

Background: the number and proportion of adults diagnosed with HIV infection aged 50 years and older has risen. This study compares the effect of CD4 counts and anti-retroviral therapy (ART) on mortality rates among adults diagnosed aged ≥50 with those diagnosed at a younger age.

Methods: retrospective cohort analysis of national surveillance reports of HIV-diagnosed adults (15 years and older) in England, Wales and Northern Ireland. The relative impacts of age, CD4 count at diagnosis and ART on mortality were determined in Cox proportional hazards models.

Results: among 63,805 adults diagnosed with HIV between 2000 and 2009, 9% (5,683) were aged ≥50 years; older persons were more likely to be white, heterosexual and present with a CD4 count <200 cells/mm³ (48 versus 32% P < 0.01) and AIDS at diagnosis (19 versus 9%, P < 0.01). One-year mortality was higher in older adults (10 versus 3%, P < 0.01) and especially in those diagnosed with a CD4 <200 cells/mm³ left untreated (46 versus 15%, P < 0.01). While the relative mortality risk reduction from ART initiation at CD <200 cells/mm³ was similar in both age groups, the absolute risk difference was higher among older adults (40 versus 12% fewer deaths) such that the number needed to treat older adults to prevent one death was two compared with eight among younger adults.

Conclusions: the magnitude of benefit from ART is greater in older adults than younger adults. Older persons should be considered as a target for HIV testing. Coupled with prompt treatment, earlier diagnosis is likely to reduce substantially deaths in this group.

Aging with HIV: a practical review

The worldwide elderly population is expected to grow by an additional 694 million people by 2025. By that time, there will be approximately two billion elderly people in the world, most of whom (80%) will be living in developing countries. Based on recent estimates, this population will number over 40 million in 2030 in Brazil and a consequent increase in governmental spending for this population can be expected. Since highly active antiretroviral therapy became available in the mid-1990s, the life expectancy of people living with HIV has increased significantly. Approximately 12 million life years were added to the world between 1996 and 2008 as a consequence of wider access to highly active antiretroviral therapy. In Brazil, the incidence of AIDS among the population aged ≥50 years doubled between 1996 and 2006. The development of antiretroviral therapy has allowed individuals diagnosed at a younger age to live longer, which partially explains the aging tendency associated with the HIV/AIDS epidemic. It is estimated that by 2015, subjects aged ≥50 years will represent 50% of the people living with HIV undergoing clinical treatment. This scenario presents some challenges, including the fact that the diagnosis of HIV tends to be delayed in older patients compared to younger patients because the symptoms of HIV can be confused with those of other common diseases among the elderly and also because healthcare professionals do not consider this population to be at high risk for HIV infection. In regard to the individuals diagnosed with HIV, a further challenge is presented by the morbidity normally associated with aging. Finally, the elderly also exhibit higher susceptibility to the toxic effects and pharmacological interactions of medications. The present article reviews the literature regarding the profile of HIV infection among individuals aged ≥50 years focusing on practical features related to the clinical approach and long-term follow-up of this population.

At the coalface and the cutting edge: general practitioners' accounts of the rewards of engaging with HIV medicine

Background

HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine.

Methods

As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings.

Results

The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the ‘coalface’ and the ‘cutting edge’, and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change.

Conclusions

Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce.

Older HIV-positive adults in Xiangxi, China: infection modes and associated risk factors

OBJECTIVE

An unusual increase in HIV/AIDS cases among rural older adults was reported between 2005 and 2008 in Xiangxi Prefecture, Hunan Province. We explored the reasons for this increase and suggested preventive measures for the future control of HIV infection in this population.

METHODS

A cross-sectional study was conducted using an HIV/AIDS registry in Hunan Province, China, to explore the likely transmission mode and risk factors of HIV/AIDS among older adults. The data were collected by face-to-face interview.

RESULTS

A total of 80 participants including 5 couples were interviewed. Among them, 46 (57.5%) participants were male and 34 (42.5%) were female. Of 46 male HIV-positive participants, 45 (97.8%) reported to have sexual intercourse with commercial sex workers. None of the female HIV-positive participants reported to have engaged in commercial sex activities. Among 46 male participants' spouses, 71.7% of them had received HIV testing and 48.5% were HIV-positive. Among 34 female participants' spouses, 92.2% of them had received HIV testing and 87.1% were HIV-positive. Ninety-seven percent of the participants reported never using condoms during sexual intercourse with their marital partners or commercial sex workers before knowing their HIV status. Eighty-two percent of participants did not know that condoms could prevent HIV/AIDS/STIs.

CONCLUSION

Chinese older adults are an underappreciated at-risk population for HIV/AIDS. The likely transmission mode of HIV/AIDS among rural older adults was unprotected sex. The HIV/AIDS/STIs knowledge among this population is very limited.

The impact of antiretroviral treatment on the age composition of the HIV epidemic in sub-Saharan Africa

INTRODUCTION

Antiretroviral treatment (ART) coverage is rapidly expanding in sub-Saharan Africa (SSA). Based on the effect of ART on survival of HIV-infected people and HIV transmission, the age composition of the HIV epidemic in the region is expected to change in the coming decades. We quantify the change in the age composition of HIV-infected people in all countries in SSA.

METHODS

We used STDSIM, a stochastic microsimulation model, and developed an approach to represent HIV prevalence and treatment coverage in 43 countries in SSA, using publicly available data. We predict future trends in HIV prevalence and total number of HIV-infected people aged 15-49 years and 50 years or older for different ART coverage levels.

RESULTS

We show that, if treatment coverage continues to increase at present rates, the total number of HIV-infected people aged 50 years or older will nearly triple over the coming years: from 3.1 million in 2011 to 9.1 million in 2040, dramatically changing the age composition of the HIV epidemic in SSA. In 2011, about one in seven HIV-infected people was aged 50 years or older; in 2040, this ratio will be larger than one in four.

CONCLUSION

The HIV epidemic in SSA is rapidly ageing, implying changing needs and demands in many social sectors, including health, social care, and old-age pension systems. Health policymakers need to anticipate the impact of the changing HIV age composition in their planning for future capacity in these systems.

Multilevel factors affecting quality: examples from the cancer care continuum

The complex environmental context must be considered as we move forward to improve cancer care and, ultimately, patient and population outcomes. The cancer care continuum represents several care types, each of which includes multiple technical and communication steps and interfaces among patients, providers, and organizations. We use two case scenarios to 1) illustrate the variability, diversity, and interaction of factors from multiple levels that affect care quality and 2) discuss research implications and provide hypothetical examples of multilevel interventions. Each scenario includes a targeted literature review to illustrate contextual influences upon care and sets the stage for theory-informed interventions. The screening case highlights access issues in older women, and the survivorship case illustrates the multiple transition challenges faced by patients, families, and organizations. Example interventions show the potential gains of implementing intervention strategies that work synergistically at multiple levels. While research examining multilevel intervention is a priority, it presents numerous study design, measurement, and analytic challenges.

Use of dual-energy x-ray absorptiometry (DXA) scans in HIV-infected patients

Multiple studies have demonstrated increased rates of osteopenia and osteoporosis in HIV-infected patients but there have been no published studies on current screening practices. We conducted a retrospective chart review of 2924 patients attending an urban HIV clinic. Thirty patients (1%) had dual-energy x-ray absorptiometry (DXA) scans. Patients undergoing DXA scans were more likely to be older, women, and have nondetectable HIV viral load and CD4 count ≥200. The most frequently cited indications for screening were perimenopausal or postmenopausal status and HIV infection. Of the patients screened, 96% had osteopenia or osteoporosis with a median T-score of -1.9 and a median of 3.8 osteoporosis risk factors in addition to HIV.  Of the 20 practitioners in the clinic, only 7 had patients with screening DXA scans. DXA scans are underutilized in the HIV population given the high rate of osteopenia and osteoporosis detected in this study.

Optimal antiretroviral therapy for aging

The introduction of highly active antiretroviral therapy (HAART) has irrevocably changed the nature of the HIV epidemic in developed countries. Although the use of HAART does not completely restore health in HIV-infected individuals, it has dramatically reduced morbidity and mortality. Increases in life expectancy resulting from effective long-term treatment mean that the proportion of older people living with HIV has increased substantially in the past 15 years. Increasing age is associated with many complications including cardiovascular disease, neurological complications, kidney and liver dysfunction, and metabolic complications such as dyslipidaemia and diabetes. HIV infection and antiretroviral drugs have also been associated with similar complications to those seen with increasing age. The increase in HIV prevalence in older age groups has not been accompanied by the development of treatment guidelines or recommendations for appropriate antiretroviral therapy or clinical management in these patients.

Out of the closet and into the trenches: gay male Baby Boomers, aging, and HIV/AIDS

Regardless of HIV status, all gay male Baby Boomers are aging in a context strongly shaped by HIV/AIDS. For this subcohort within the Baby Boom generation, the disproportionately high volume of AIDS deaths among gay men aged 25-44 years at the epidemic's peak (1987-1996) created a cohort effect, decimating their social networks and shaping their personal and social lives during the epidemic, throughout their life course, and into later years. But despite these lasting effects on an entire cohort of gay men, relevant scholarship narrowly focuses on older HIV-positive gay men using clinical, psychological, and social network approaches. It thus makes inadequate use of the life course perspective, which, by attention to timing, agency, and interdependence, can uncover the myriad interlocking and longitudinal aspects of the epidemic that affect this group. This article argues for the application of this latter approach to research into the lasting impacts of HIV/AIDS on this cohort of gay men. We examine HIV/AIDS mortality within this cohort at the epidemic's height, these deaths' concentration in urban gay communities, and the growing and increasingly diverse population of HIV-positive gay men born in the Baby Boom Years. Our conclusion suggests that a fuller examination of the role of HIV/AIDS in the lives of gay male Baby Boomers, using a life course perspective, is critical to appreciating this generation's heterogeneity and to expanding knowledge of how later life is shaped by the intersection between historical events, personal biography, and social and community ties.

Prevalence and risk factors associated with syphilis in a cohort of HIV positive individuals in Brazil

Individuals with syphilis have higher chance of having HIV, and syphilis' genital ulcers increases HIV transmission rate. Nevertheless, there are few well-documented studies about HIV and syphilis co-infection and its risk factors. The study was based on 2262 HIV infected individuals from South Brazilian HIV cohort, which began in 1991, and this analysis included individuals who were included in the cohort until November 2008. Inclusion criteria were having CD4 + T cell count and viral load at baseline, and syphilis serology tests (venereal disease research laboratory [VDRL] > 1:64 or a positive VDRL plus a positive treponemal test). A total of 1012 patients were included; 580 were men (57%); mean age at HIV diagnosis was 33 years; 591 (58%) had previous diagnosis of AIDS; most of the individuals acquired HIV from sexual contact (47.9% heterosexual and 31.7% men who had sex with men [MSM]); and 759 (75%) were on antiretroviral therapy. The prevalence of syphilis was 20.5% (208). After multivariate analysis, being male (2.01; 95% CI, 1.23-3.27; p = 0.005) and MSM (1.91; 95% CI, 1.25-2.90; p = 0.002) were significantly associated to HIV and syphilis co-infection. Males and MSM were associated with higher risk of this co-infection. Our findings may reflect that this particular population is still engaging in unprotected sexual intercourse, and efforts should be made to better target this specific group as they might perpetuate these infections.