Mortality and treatment response amongst HIV-infected patients 50 years and older accessing antiretroviral services in South Africa

Predictors of survival among older adults with HIV in Uganda's AIDS support organization centers of excellence (1987-2023): a retrospective longitudinal study

BACKGROUND

The growing number of older adults living with HIV, facilitated by wider access to antiretroviral therapy (ART), presents unique challenges. This study aims to identify predictors of survival among older persons living with HIV receiving ART in Uganda's AIDS Support Organization Centers of Excellence (1987-2023). Understanding these predictors can inform effective clinical interventions to improve outcomes for this population.

METHODS

This study conducted a retrospective analysis of medical records from 11 TASO centers of excellence in Uganda (1987-2023). Using Cox proportional hazards regression, we identified factors associated with survival among older adults living with HIV. TASO centers of excellence in Entebbe, Gulu, Jinja, Masaka, Masindi, Mbale, Mbarara, Mulago, Rukungiri, Soroti, and Tororo. Cox proportional hazards regression analysis identified factors influencing survival among older persons living with HIV (OPLHIV).

RESULTS

Of the 30,758 OPLHIV medical records analyzed (1987-2023), 72.5% were active on ART, 5.9% had died, 15.2% were lost to follow-up, and 5.6% transferred to other facilities. Survival was significantly associated with: gender (female, HR = 1.19, p < 0.001), marital status (married, HR = 0.99, p < 0.001; separated/divorced, HR = 0.85, p < 0.001), WHO clinical stage (II, HR = 1.66, p < 0.001), viral load (> 200 copies/ml, HR = 1.49, p < 0.001), and ART adherence (fair, HR = 0.94, p = 0.157).

CONCLUSION

Key predictors of survival among Older Adults Living with HIV (OPLHIV) include: female gender, age 50-59, weight 51-70 kg, married status, viral load > 200 copies/ml, WHO HIV clinical stage II, paid employment, and ART adherence. To improve survival outcomes, consistent clinical screenings of WHO clinical stages, viral load, and ART adherence are essential. These measures can guide healthcare providers in making informed treatment decisions to enhance survival and quality of life for OPLHIV in Uganda.

RECOMMENDATIONS

Strengthen routine monitoring of viral load, ART adherence, and WHO clinical staging. Provide targeted support to married and separated/divorced adults to improve their survival chances. Address gender disparities in care to enhance outcomes for females. Focus on maintaining ART adherence and viral suppression to reduce mortality risks.

Limited restoration of T cell subset distribution and immune function in older people living with HIV-1 receiving HAART

BACKGROUND

Older people living with HIV-1 (PLWH) experience a dual burden from the combined effects of aging and HIV-1 infection, resulting in significant immune dysfunction. Despite receiving HAART, immune reconstitution is not fully optimized. The objective of this study was to investigate the impact of aging and HAART on T cell subsets and function in PLWH across different age groups, thereby providing novel insights into the prognosis of older PLWH.

METHOD

This study was conducted at Yunnan AIDS Care Center, China, to explore the immunological responses of old PLWH to HAART and compared with the middle-age and the younger. Blood samples were collected from 146 PLWH to analyze T cell subsets and their functions, with a particular emphasis on markers related to T cell differentiation, activation, exhaustion, inflammation, and cellular function, using multicolor flow cytometry analysis.

RESULTS

Older age may have a greater effect on long-term CD4+T cell recovery. Compared with young and middle-aged PLWH, older PLWH presented distinct alterations in their immune profile, including a decline in the Naïve CD4+T and CD8+T cell subsets, an expansion of effector memory cells, and other potential immune risk phenotypes, such as activation, exhaustion, and up-regulation of aging markers. In addition, we observed a significant association between the CD4 + EM3 subset and the CD8 + EM2 subset with HIV-1 progression, independent of age, suggesting their potential as reliable markers for assessing immune reconstitution in all PLWH.

CONCLUSION

Our study extends previous findings showing that older participants exhibit a wide range of late differentiation, senescence, or exhaustion phenotypes in cells, including all the CD4+T and CD8+T subsets, consistent with an immunosenescent phenotype. This may accelerate poor immune recovery in older PLWH. Identifying new strategies to improve the immune risk phenotypes of older PLWH may help improve their immune reconstitution outcomes. The CD4 + EM3 subset and the CD8 + EM2 subset should be studied as additional markers of late presentation.

Investigating the Determinants of Mortality before CD4 Count Recovery in a Cohort of Patients Initiated on Antiretroviral Therapy in South Africa Using a Fine and Gray Competing Risks Model

CD4 count recovery is the main goal for an HIV patient who initiated ART. Early ART initiation in HIV patients can help restore immune function more effectively, even when they have reached an advanced stage. Some patients may respond positively to ART and attain CD4 count recovery. Meanwhile, other patients failing to recover their CD4 count due to non-adherence, treatment resistance and virological failure might lead to HIV-related complications and death. The purpose of this study was to find the determinants of death in patients who failed to recover their CD4 count after initiating antiretroviral therapy. The data used in this study was obtained from KwaZulu-Natal, South Africa, where 2528 HIV-infected patients with a baseline CD4 count of <200 cells/mm3 were initiated on ART. We used a Fine-Gray sub-distribution hazard and cumulative incidence function to estimate potential confounding factors of death, where CD4 count recovery was a competing event for failure due to death. Patients who had no tuberculosis were 1.33 times at risk of dying before attaining CD4 count recovery [aSHR 1.33; 95% CI (0.96-1.85)] compared to those who had tuberculosis. Rural patients had a higher risk of not recovering and leading to death [aSHR 1.97; 95% CI (1.57-2.47)] than those from urban areas. The patient's tuberculosis status, viral load, regimen, baseline CD4 count, and location were significant contributors to death before CD4 count recovery. Intervention programs targeting HIV testing in rural areas for early ART initiation and promoting treatment adherence are recommended.

Treatment outcomes amongst older people with HIV infection receiving antiretroviral therapy

OBJECTIVES

There is conflicting data regarding the response of older people with HIV (PWH) to antiretroviral therapy (ART). The objective of this study was to evaluate the long-term immunological and virological responses, changes in regimen, and adverse drug reactions (ADRs) in older participants (50+ years) compared with younger (18-34 years) and middle-aged (35-49 years) PWH.

METHODS

A retrospective review of medical records was conducted on 1622 participants who received ART in Yunnan Province, China, from 2010 to 2019. The study compared CD4+ T-cell counts, CD4+/CD8+ ratio, and relative numbers between different groups using the Kruskal-Wallis test. Cox proportional hazards regression models were used to identify variables associated with the occurrence of immune reconstitution insufficiency. The rates of immune reconstitution, incidence of ADRs, and rates of treatment change were analyzed using the chi-squared test or Fisher's exact test.

RESULTS

Over 95% achieved viral load 200 copies/ml or less, with no age-related difference. However, older participants exhibited significantly lower CD4+ T-cell counts and CD4+/CD8+ recovery post-ART (P < 0.001), with only 32.21% achieving immune reconstitution (compared with young: 52.16%, middle-aged: 39.29%, P < 0.001) at the end of follow-up. Middle-aged and elderly participants changed ART regimens more because of ADRs, especially bone marrow suppression and renal dysfunction.

CONCLUSION

Although the virological response was consistent across age groups, older individuals showed poorer immune responses and higher susceptibility to side effects. This underscores the need for tailored interventions and comprehensive management for older patients with HIV.

Virologic failure and all-cause mortality among older people living with HIV/AIDS in South China

This retrospective cohort study investigated older people living with HIV/AIDS (PLWHA) characteristics, HIV care, and treatment outcomes among all cases between 1996 and 2019 in Guangxi, China. Secondary data were extracted from two national surveillance databases. Older (≥50 years old) and younger (18-49 years old) PLWHA were compared regarding demographic and behavioral characteristics, HIV care, virologic failure, and all-cause mortality. Older PLWHA accounted for 41.6% of all HIV cases (N = 144,952) between 1996 and 2019. The proportion of older cases increased from 10.4% to 64.8% for men and from 2.4% to 66.7% for women between 2002 and 2019. Heterosexual contact accounted for 96.0% of older adults. Moreover, older PLWHA had a lower median CD4 count at the HIV diagnosis (193 vs. 212 cells/μL, p < 0.0001) and were less likely to receive antiretroviral therapy (ART) than younger adults (72.1% vs. 86.1%, p < 0.001). The all-cause mortality risk of older PLWHA was 2.87 times of younger adults [adjusted hazard ratio (AHR) 2.87; 95% confidence interval (CI) 2.76-2.98]. In addition, older PLWHA reported an 18% increase in odds for virologic failure than younger adults (AOR 1.18; 95% CI 1.08-1.30). Therefore, enhanced HIV prevention and care are urgently needed in older people.

Characteristics, clinical outcomes, and mortality of older adults living with HIV receiving antiretroviral treatment in the sub-urban and rural areas of northern Thailand

Since the introduction of antiretroviral treatment (ART), people living with HIV worldwide live into older age. This observational study described the characteristics, clinical outcomes, and mortality of older adults living with HIV (OALHIV) receiving ART from the National AIDS program in northern Thailand. Participants aged ≥ 50 years were recruited from the HIV clinics in 12 community hospitals. Data were obtained from medical records and face-to-face interviews. In 2015, 362 OALHIV were enrolled; their median (interquartile range) age and ART duration were 57 years (54-61), and 8.8 years (6.4-11.2), respectively. At study entry, 174 (48.1%) had CD4 counts ≥ 500 cells/mm3; 357 of 358 (99.6%) with available HIV RNA results were virologic-suppressed. At the year 5 follow-up, 39 died, 11 were transferred to other hospitals, 3 were lost to follow-up, and 40 did not contribute data for this analysis, but remained in care. Among the 269 who appeared, 149 (55%) had CD4 counts ≥ 500 cells/mm3, and 227/229 tested (99%) were virologic-suppressed. The probability of 5-year overall survival was 89.2% (95% confidence interval, CI 85.4-92.1%). A significantly low 5-year overall survival (66%) was observed in OALHIV with CD4 counts < 200 cells/mm3 at study entry. The most common cause of death was organ failure in 11 (28%), followed by malignancies in 8 (21%), infections in 5 (13%), mental health-related conditions in 2 (5%), and unknown in 13 (33%). In OALHIV with stable HIV treatment outcomes, mortality from non-infectious causes was observed. Monitoring of organ function, cancer surveillance, and mental health screening are warranted.

Determinants of Survival of HIV Patients Receiving Dolutegravir: A Prospective Cohort Study in Conflict-Affected Bunia, Democratic Republic of Congo

This study aims to determine the factors influencing HIV-related mortality in settings experiencing continuous armed conflict atrocities. In such settings, people living with HIV (PLHIV), and the partners of those affected may encounter specific difficulties regarding adherence to antiretroviral therapy (ART), and retention in HIV prevention, treatment, and care programs. Between July 2019 and July 2021, we conducted an observational prospective cohort study of 468 PLHIV patients treated with Dolutegravir at all the ART facilities in Bunia. The probability of death being the primary outcome, as a function of time of inclusion in the cohort, was determined using Kaplan-Meier plots. We used the log-rank test to compare survival curves and Cox proportional hazard modeling to determine mortality predictors from the baseline to 31 July 2021 (endpoint). The total number of person-months (p-m) was 3435, with a death rate of 6.70 per 1000 p-m. Compared with the 35-year-old reference group, older patients had a higher mortality risk. ART-naïve participants at the time of enrollment had a higher mortality risk than those already using ART. Patients with a high baseline viral load (≥1000 copies/mL) had a higher mortality risk compared with the reference group (adjusted hazard ratio = 6.04; 95% CI: 1.78-20.43). One-fourth of deaths in the cohort were direct victims of armed conflict, with an estimated excess death of 35.6%. Improving baseline viral load monitoring, starting ART early in individuals with high baseline viral loads, the proper tailoring of ART regimens and optimizing long-term ART, and care to manage non-AIDS-related chronic complications are recommended actions to reduce mortality. Not least, fostering women's inclusion, justice, peace, and security in conflict zones is critical in preventing premature deaths in the general population as well as among PLHIV.

Risk Factors for Hospitalization or Death Among Adults With Advanced HIV at Enrollment for Care in South Africa: A Secondary Analysis of the TB Fast Track Trial

Background

Individuals with advanced HIV experience high mortality, especially before and during the first months of antiretroviral therapy (ART). We aimed to identify factors, measurable in routine, primary health clinic-based services, associated with the greatest risk of poor outcome.

Methods

We included all individuals enrolled in the standard-of-care arm of a cluster-randomized trial (TB Fast Track); adults attending participating health clinics with CD4 ≤150 cells/µL and no recent ART were eligible. Associations between baseline exposures and a composite outcome (hospitalization/death) over 6 months were estimated using multivariable Cox regression.

Results

Among 1515 individuals (12 clinics), 56% were female, the median age was 36 years, and the median CD4 count was 70 cells/μL. Within 6 months, 89% started ART. The overall rate of hospitalization/death was 32.5 per 100 person-years (218 outcomes/671 person-years). Lower baseline CD4 count (adjusted hazard ratio [aHR], 2.27 for <50 vs 100-150 cells/µL; 95% CI, 1.57-3.27), lower body mass index (aHR, 2.13 for BMI <17 vs ≥25 kg/m²; 95% CI, 1.31-3.45), presence of tuberculosis-related symptoms (aHR, 1.87 for 3-4 symptoms vs none; 95% CI, 1.20-2.93), detectable urine lipoarabinomannan (aHR, 1.97 for 1+ positivity vs negative; 95% CI, 1.37-2.83), and anemia (aHR, 4.42 for severe anemia [hemoglobin <8 g/dL] vs none; 95% CI, CI 2.38-8.21) were strong independent risk factors for hospitalization/death.

Conclusions

Simple measures that can be routinely assessed in primary health care in resource-limited settings identify individuals with advanced HIV at high risk of poor outcomes; these may guide targeted interventions to improve outcomes.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019

BACKGROUND

Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality.

METHODS

Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure.

RESULTS

During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05).

CONCLUSIONS

Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population. PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

Advanced HIV disease management practices within inpatient medicine units at a referral hospital in Zambia: a retrospective chart review

Background

Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis.

Methods

We reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 2018 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment—including tuberculosis (TB), Cryptococcus, and OI prophylaxis with co-trimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines.

Results

We reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed.

Conclusions

At a referral hospital in Zambia, CD4 testing was inconsistent due to laboratory challenges and this reduced recognition of AHD and implementation of AHD guidelines. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including reflex VL testing, TB-LAM and serum CrAg during hospitalization.

A retrospective study of survival and risk factors for mortality among people living with HIV who received antiretroviral treatment in a resource-limited setting

BACKGROUND

The availability and accessibility of effective antiretroviral therapy (ART) for people living with HIV (PLWH) has substantially improved in the past two decades in resource-limited settings. Therefore, evaluation of survival is needed in the current setting.

METHOD

We retrospectively analyzed secondary data of the national AIDS program database from national health security region number 4 among PLWH who were ART-naive between January 2014 and December 2018. All PLWH were followed until December 2019 to evaluate their survival status and possible risk factors related to death.

RESULTS

A total of 42,229 PLWH were identified, of which 14,053 were ART-naive and thus enrolled in the study. Sixty-seven percent were male, the mean ± SD age was 35 ± 12 years, and the median (IQR) baseline CD4 count was 162 (44-353) cells/mm3. Regarding medical care benefits, 46% had a universal health coverage scheme, 34% had a national social security scheme, and 2% had a civil servants medical benefit scheme. A total of 2142 (15%) mortalities occurred during the total follow-up period of 28,254 patient-years. The mortality rate was 7.5 (95% CI 7.2-7.9) per 100 person-years. Survival rates at 1, 2, 3, 4 and 5 years after HIV registration were 88.2% (95% CI 87.6-88.7%), 85.3% (95% CI 84.6-85.9%), 82.9% (95% CI 81.9-83.4%), 81.3% (95% CI 80.5-82.0%) and 75.1% (95% CI 73.5-76.8%), respectively. The Cox proportional hazards model showed that all-cause mortality was associated with a history of ART switching (HR = 7.06, 95% CI 4.53-11.00), major opportunistic infections during ART (HR = 1.93, 95% CI 1.35-2.77), baseline CD4 count ≤ 200 vs. > 500 cells/mm3 (HR = 4.00, 95% CI 1.45-11.11), age ≥ 50 vs. < 30 years (HR = 1.77, 95% CI 1.12-2.78), and receiving nevirapine-based regimens(HR = 1.43, 95% CI 1.04-1.97).

CONCLUSIONS

This study demonstrated the substantial mortality rate over the consecutive 5 years of the follow-up period among PLWH who received ART in a resource-limited setting. Early case finding and prompt initiation of ART as well as continuous HIV care are a cornerstone to improve survival.

HIV and cardiovascular disease in sub-Saharan Africa: Demographic and Health Survey data for 4 countries

Background

Investigate the relationship between two common cardiovascular diseases and HIV in adults living in sub-Saharan Africa using population data provided through the Demographic and Health Survey.

Methods

Data for four sub-Saharan countries were used. All adults asked questions regarding diagnosis of HIV, diabetes, and hypertension were included in the sample totaling 5356 in Lesotho, 3294 in Namibia, 9917 in Senegal, and 1051 in South Africa. Logistic models were run for each country separately, with self-reported diabetes as the first outcome and self-reported hypertension as the second outcome and HIV status as the primary independent variable. Models were adjusted for age, gender, rural/urban residence and BMI. Complex survey design allowed weighting to the population.

Results

Prevalence of self-reported diabetes ranged from 3.8% in Namibia to 0.5% in Senegal. Prevalence of self-reported hypertension ranged from 22.9% in Namibia to 0.6% in Senegal. In unadjusted models, individuals with HIV in Lesotho were 2 times more likely to have self-reported diabetes (OR = 2.01, 95% CI 1.08–3.73), however the relationship lost significance after adjustment. Individuals with HIV were less likely to have self-reported diabetes after adjustment in Namibia (OR = 0.29, 95% CI 0.12–0.72) and less likely to have self-reported hypertension after adjustment in Lesotho (OR = 0.63, 95% CI 0.47–0.83). Relationships were not significant for Senegal or South Africa.

Discussion

HIV did not serve as a risk factor for self-reported cardiovascular disease in sub-Saharan Africa during the years included in this study. However, given the growing prevalence of diabetes and hypertension in the region, and the high prevalence of undiagnosed cardiovascular disease, it will be important to continue to track and monitor cardiovascular disease at the population level and in individuals with and without HIV.

Conclusions

The odds of self-reported diabetes in individuals with HIV was high in Lesotho and low in Namibia, while the odds of self-reported hypertension in individuals with HIV was low across all 4 countries included in this study. Programs are needed to target individuals that need to manage multiple diseases at once and should consider increasing access to cardiovascular disease management programs for older adults, individuals with high BMI, women, and those living in urban settings.

The Cost Effectiveness of Mental Health Treatment in the Lifetime of Older Adults with HIV in New York City: A Markov Approach

BACKGROUND

There are noticeable gaps in knowledge regarding the cost and effectiveness of integrated medical and behavioral services for older adults with HIV. Their lifespan is close to the population's level but their quality of life has sharply declined due to depression and substance use. Mental health disorders are widespread among an aging population with HIV.

OBJECTIVE

The aim of this study was to build a decision analytic model to evaluate medical interventions with and without mental health treatment using primary data of 139 older adults with HIV and health outcomes from the literature.

METHODS

We tracked the progression of depression and cumulative deaths among older adults with HIV using a Markov model with 50 annual cycles through three health states. Deterministic and probabilistic sensitivity analyses addressed uncertainty in estimating the parameters and around the model's assumptions.

RESULTS

An integrated medical and behavioral care system is cost effective at a willingness to pay of $50,000 per QALY compared with medical care only. The incremental cost was $516,452 and the incremental effectiveness was 38.8 quality-adjusted life-years (QALY), with an incremental cost-effectiveness ratio of $13,316 per QALY.

CONCLUSIONS

Appropriate and efficacious referrals to integrated medical + behavioral services, either in the same facility or connected to their primary care doctor, are instrumental to reverse loses in quality of life and avoid premature death. If mental health is left unattended, HIV would progress, causing declines in quality of life and ultimately triggering premature death. Reliable data on the cost and effectiveness of different types of HIV integrated services are needed.

Survival, CD4 T lymphocyte count recovery and immune reconstitution pattern during the first-line combination antiretroviral therapy in patients with HIV-1 infection in Mongolia

Mongolia has a low incidence of human immunodeficiency virus (HIV) infection, with 281 cases reported at the end of 2019 and an estimated incidence rate of <0.01 cases per 1000 population.

However, no study has analyzed the association between antiretroviral therapy (ART) outcomes and pretreatment characteristics of patients with HIV/acquired immunodeficiency syndrome (AIDS) in Mongolia. This retrospective study aimed to determine the survival, CD4 T cell recovery, and immune reconstitution pattern during ART in HIV patients and to determine baseline patient characteristics associated with ART outcomes. Based on three different World Health Organization (WHO) guidelines, we analyzed the 3-year observation data of 166 patients with HIV/AIDS who received treatment between 2010 and 2017. An increase of >50 cells/μL indicated CD4 T cell count recovery, and a cell count of ≥500 cells/μL in patients with a baseline cell count of <500 cells/μL indicated immune reconstitution. In this study, the 3- and 1-year mortality rates were 5.4% (survival rate: 94.6%) and 3.6%, respectively. A total of 83% of deaths that occurred in the observation time occurred within the first 3 months. The CD4 T cell count recovery rates at 3, 12, and 36 months were 62.7%, 80.7%, and 89.2%, respectively. The CD4 T cell count increased to >500 cells/μL in 95 of 145 (65.5%) patients with a baseline cell count of <500 cells/μL after 36 months of ART. The baseline CD4 T cell count was found to be a sensitive indicator for immune reconstitution. An advanced pretreatment clinical stage of HIV infection (as classified by the WHO classification), a low CD4 T cell count in the peripheral blood, and a high viral load before the initiation of the first-line ART accurately predicted survival, CD4 T cell count recovery, and immune reconstitution in Mongolian patients with HIV/AIDS.

The association between HIV tri-therapy with the development of Type-2 Diabetes Mellitus in a rural South African District: A case-control study

BACKGROUND

Combination antiretroviral drugs (cARVs) prolong patients' lives but are unfortunately thought to increase complications related to metabolic disorders including type-2 Diabetes Mellitus (DM). We sought to confirm the association of cARVs with type-2 DM and ascertain the extent of this association in a rural South African setting.

METHODS

A case-control study of 177 (33.33%) cases with HIV/AIDS and type-2 DM were selected and compared with 354 (66.67%) non-DM HIV/AIDS unmatched controls from a rural district of South Africa's third most populous province (Eastern Cape). Cases were identified from community health centres using the district health information system, and controls were identified using simple random sampling from the same health facilities. Odds Ratios (OR), together with 95% confidence intervals, were calculated for all the univariable and multivariable logistic analyses.

RESULTS

This study found that cARVs significantly increased the occurrence of type-2 DM among HIV patients. Patients on protease inhibitors (PIs) were at least 21 times significantly (p<0.0001) more likely to be diabetic than those on the fixed dose combination (FDC); those on stavudine (D4T) and zidovudine (AZT) were 2.45 times and 9.44 times respectively more likely to be diabetic than those on FDC (p<0.05). The odds of diabetes increased by more than three-folds for those who had been on antiretroviral drugs for more than 6 years (p<0.005).

CONCLUSION

This study has been able to establish the association between cARVs and type-2 DM. It therefore proposes consideration of the usage of AZT, D4T, lopivavir and ritonavir for the treatment of HIV. The study further proposes more prospective research to test these findings further.

Associations of menopausal age with virological outcomes and engagement in care among women living with HIV in the UK

Background: Women ageing with HIV undergo sex-specific changes. There is limited evidence available with regards to how the menopause impacts HIV outcomes.

Objective: To investigate whether menopausal age is associated with engagement-in-care (EIC), viral load (VL) suppression and rebound among women living with HIV.

Methods: Women were grouped by age (<40, 40–50, >50 years), corresponding to pre-, peri- and post-menopausal stages. EIC, HIV VL suppression (VL < 50 copies/mL) within 12 months of antiretroviral therapy initiation and VL rebound (two consecutive VL > 50 copies/mL) after VL suppression were compared across age groups using logistic/Cox proportional hazards regression. Associations were compared to those seen in heterosexual men.

Results: Six thousand four hundred and fifty-five (6455) eligible women (median age 36 [interquartile range: 29–42], 64.4% black African, 19.1% white) contributed 44,226 person-years (PYRS) of follow-up; 29,846, 10,980 and 3,399 PYRS in those aged <40, 40–50 and >50, respectively. Women were engaged-in-care for 79.5% of follow-up time, 3,344 (78.0%) experienced VL suppression and 739 (22.1%) VL rebound. After adjustment, women aged >50 years had lower EIC than those aged <40. Women aged 40–50 were more likely to have VL suppression and were less likely to experience VL rebound than those aged <40 years. Trends in heterosexual men were similar for EIC but with no evidence of a higher VL suppression rate in those aged 40–50 years (p_int. 0< .0001) and a stronger protective association between older age and VL rebound (p_int. 0< .0001).

Conclusion: Our findings warrant further research into the potential impact of the menopause to support women and clinicians through HIV care.

Cerebral toxoplasmosis and alcohol abuse in AIDS: dementia with multiple etiologies

Major neurocognitive disorder due to multiple etiologies, or dementia due to multiple etiologies (DME), is a term coined by the Diagnostic and Statistical Manual of Mental Disorders to refer to complex cases when multiple pathologies, such as Alzheimer's disease, Lewy Bodies, human immunodeficiency virus (HIV), vascular-related brain damage or frontotemporal lobar degeneration, are identified as contributing to neurocognitive impairment and/or behavioral alterations, based on patient's neuroimaging tests, laboratorial exams, associated symptomatology and medical history. In this study, we report the case of a 63-year-old male patient who presented with parkinsonism symptoms, aphasia and cognitive impairment on multiple domains after cerebral toxoplasmosis related to acquired immunodeficiency syndrome, vascular damage and a history of alcohol abuse. We discuss the neurocognitive and neurobehavioral variables that characterized this diagnosis, as well as the importance of the differential diagnosis of DME on the field of neuropsychology of aging and, especially, for individuals living with HIV infection.

Sex Differences in the Treatment of HIV

PURPOSE OF REVIEW

Biological and societal influences are different for men and women leading to different HIV outcomes and related infectious and non-infectious complications. This review evaluates sex differences in the epidemiology and immunological response to HIV and looks at major complications and coinfections, as well as care delivery systems focusing on low- and middle-income countries (LMICs) where most people with HIV live.

RECENT FINDINGS

More women than men access testing and treatment services in LMIC; women are more likely to be virologically suppressed in that environment. There is a growing recognition that the enhanced immunological response to several pathogens including HIV may result in improved outcomes for infectious comorbidities but may result in a greater burden of non-communicable diseases. Men and women have different requirements for HIV care. Attention to these differences may improve outcomes for all.

Immunological and Virological Responses in Older HIV-Infected Adults Receiving Antiretroviral Therapy: An Evidence-Based Meta-Analysis

BACKGROUND

Millions of people living with the HIV have received antiretroviral therapy (ART). Older adults make up a significant portion of these individuals; however, the immunological and virological responses to ART for older patients still need to be clarified.

DESIGN

Meta-analysis.

METHODS

In this article, we systematically reviewed research articles published between 2001 and 2018 that reported immunological and virological responses and AIDS-related mortality among HIV- infected adults (including individuals aged 50 years and older) receiving ART, using meta-analysis. ART efficiency was measured using 3 outcomes: (1) immunological response, (2) virological response, and (3) mortality.

RESULTS

We identified 4937 citations, and 40 studies were eventually selected to investigate ART efficiency in older HIV-infected patients, comprising more than 888,151 patients initiating ART. We report that older patients showed poor immunological responses, with CD4 counts and the restoration of CD4 counts after ART initiation being significantly lower than seen in younger patients. However, older patients exhibited better viral suppression rates (risk ratio: 1.04; 95% confidence intervals: 1.01 to 1.08) after 36 months following ART initiation. In addition, older adults had a higher risk of AIDS-related death (adjusted hazard ratio: 1.44, 95% confidence interval: 1.30 to 1.60).

CONCLUSIONS

Older age after ART initiation was associated with a poorer immunological response and a higher risk of mortality, suggesting the need to increase early diagnosis and treatment among older HIV patients.

Characteristics and outcomes of older people on antiretroviral therapy in Tlokwe Clinics, South Africa

Background

South Africa (SA) has a large human immunodeficiency virus (HIV) epidemic but little is known of its effect on those ≥ 60 years of age viz. ‘older-persons’ living with HIV (OPLWH). Numbers in this age group are increasing and are expected to place a greater strain on existing resources.

Objectives

To describe the demographic features and the co-morbidities of OPLWH in Tlokwe. This included an assessment of viral load (VL) suppression and the identification of associations between patient characteristics and clinical outcomes.

Methods

A retrospective file review was undertaken to cover the period 01 May 2017 to 30 April 2018. Descriptive statistics were applied to demographic and clinical data and to treatment outcomes. Statistically significant associations were subjected to logistic regression analysis.

Results

Of the 191 participants, 111/191 (58.1%) were female and 167/191 (87.4%) were 60 –70 years of age. Of the participants, 154/191 (81.9%) were virally suppressed (< 400 copies/mL). Hypertension (n = 106/191, 55.5%) was the most frequently identified co-morbidity. A CD4 cell count of ≥ 350 cells/mm³ at last assessment correlated positively with VL suppression (odds ratio 2.3, confidence interval 1.05–5.02, p = 0.037).

Conclusion

Although the level of VL suppression in this cohort was high, greater effort is required to bring this in line with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommendations viz. 90% viral suppression in PLWH by 2030. Further research is needed to define the evolving long-term needs of OPLWH and to facilitate entry into care of those currently not in care.

Mortality estimates by age and sex among persons living with HIV after ART initiation in Zambia using electronic medical records supplemented with tracing a sample of lost patients: A cohort study

BACKGROUND

Men in sub-Saharan Africa have lower engagement and retention in HIV services compared to women, which may result in differential survival. However, the true magnitude of difference in HIV-related mortality between men and women receiving antiretroviral therapy (ART) is incompletely characterized.

METHODS AND FINDINGS

We evaluated HIV-positive adults ≥18 years old newly initiating ART in 4 Zambian provinces (Eastern, Lusaka, Southern, and Western). In addition to mortality data obtained from routine electronic medical records, we intensively traced a random sample of patients lost to follow-up (LTFU) and incorporated tracing outcomes through inverse probability weights. Sex-specific mortality rates and rate differences were determined using Poisson regression. Parametric g-computation was used to estimate adjusted mortality rates by sex and age. The study included 49,129 adults newly initiated on ART between August 2013 and July 2015; overall, the median age among patients was 35 years, the median baseline CD4 count was 262 cells/μl, and 37.2% were men. Men comprised a smaller proportion of individuals starting ART (37.2% versus 62.8%), tended to be older (median age 37 versus 33 years), and tended to have lower CD4 counts (median 220 versus 289 cells/μl) at the time of ART initiation compared to women. The overall rate of mortality among men was 10.3 (95% CI 8.2-12.4) deaths/100 person-years (PYs), compared to 5.5 (95% CI 4.3-6.8) deaths/100 PYs among women (difference +4.7 [95% CI 2.3-7.2] deaths/100 PYs; p < 0.001). Compared to women in the same age groups, men's mortality rates were particularly elevated among those <30 years old (+6.7 deaths/100 PYs difference), those attending rural health centers (+9.4 deaths/100 PYs difference), those who had an initial CD4 count < 100 cells/μl (+9.2 deaths/100 PYs difference), and those who were unmarried (+8.0 deaths/100 PYs difference). After adjustment for potential confounders and mediators including CD4 count, a substantially higher mortality rate was predicted among men <30 years old compared to women of the same age, while women ≥50 years old had a mortality rate similar to that of age-matched men, but considerably higher than that predicted among young women (<30 years old). No clinically significant differences were evident with respect to rates of facility transfer or care disengagement between men and women. The main study limitations were the inability to successfully ascertain outcomes in all patients selected for tracing and missing clinical and laboratory data due to the use of medical records.

CONCLUSIONS

In this study, we found that among HIV-positive adults newly initiating ART, mortality among men exceeded mortality among women; disparities were most pronounced among young patients. Older women, however, also experienced high mortality. Specific interventions for men and older women at highest mortality risk are needed to improve HIV treatment outcomes.

Joint modelling of longitudinal and time-to-event data: an illustration using CD4 count and mortality in a cohort of patients initiated on antiretroviral therapy

Background

Modelling of longitudinal biomarkers and time-to-event data are important to monitor disease progression. However, these two variables are traditionally analyzed separately or time-varying Cox models are used. The former strategy fails to recognize the shared random-effects from the two processes while the latter assumes that longitudinal biomarkers are exogenous covariates, resulting in inefficient or biased estimates for the time-to-event model. Therefore, we used joint modelling for longitudinal and time-to-event data to assess the effect of longitudinal CD4 count on mortality.

Methods

We studied 4014 patients from the Centre for the AIDS Programme of Research in South Africa (CAPRISA) who initiated ART between June 2004 and August 2013. We used proportional hazards regression model to assess the effect of baseline characteristics (excluding CD4 count) on mortality, and linear mixed effect models to evaluate the effect of baseline characteristics on the CD4 count evolution over time. Thereafter, the two analytical approaches were amalgamated to form an advanced joint model for studying the effect of longitudinal CD4 count on mortality. To illustrate the virtues of the joint model, the results from the joint model were compared to those from the time-varying Cox model.

Results

Using joint modelling, we found that lower CD4 count over time was associated with a 1.3-fold increase in the risk of death, (HR: 1.34, 95% CI: 1.27-1.42). Whereas, results from the time-varying Cox model showed lower CD4 count over time was associated with a 1.2-fold increase in the risk of death, (HR: 1.17, 95% CI: 1.12-1.23).

Conclusions

Joint modelling enabled the assessment of the effect of longitudinal CD4 count on mortality while correcting for shared random effects between longitudinal and time-to-event models. In the era of universal test and treat, the evaluation of CD4 count is still crucial for guiding the initiation and discontinuation of opportunistic infections prophylaxis and assessment of late presenting patients. CD4 count can also be used when immunological failure is suspected as we have shown that it is associated with mortality.

A critical review of intervention and policy effects on the health of older people in sub-Saharan Africa

This paper provides a critical review of publications containing information about specific health effects on older adults of interventions and policies in sub-Saharan Africa. Interventions and policies fell into the following categories: testing or treating HIV, the provision of pensions, screening for non-communicable diseases (NCDs), health service financing and interventions related to visual conditions. The review finds that the relevant literature is very limited relative to the size of older populations in the region. Conditions of particular relevance to older adults, such as NCDs, are under-represented and most studies treat older people as a single category, typically including all adults aged 50 and over. The paper concludes that evidence about the health effects of interventions and policies on the region's rapidly growing older populations remains minimal, and that this both reflects and reinforces a bias against older people in health policy.

Mortality Among People With HIV Treated for Tuberculosis Based on Positive, Negative, or No Bacteriologic Test Results for Tuberculosis: The IeDEA Consortium

Background

In resource-constrained settings, many people with HIV (PWH) are treated for tuberculosis (TB) without bacteriologic testing. Their mortality compared with those with bacteriologic testing is uncertain.

Methods

We conducted an observational cohort study among PWH ≥15 years of age initiating TB treatment at sites affiliated with 4 International epidemiology Databases to Evaluate AIDS consortium regions from 2012 to 2014: Caribbean, Central and South America, and Central, East, and West Africa. The exposure of interest was the TB bacteriologic test status at TB treatment initiation: positive, negative, or no test result. The hazard of death in the 12 months after TB treatment initiation was estimated using a Cox proportional hazard model. Missing covariate values were multiply imputed.

Results

In 2091 PWH, median age 36 years, 53% had CD4 counts ≤200 cells/mm³, and 52% were on antiretroviral therapy (ART) at TB treatment initiation. The adjusted hazard of death was higher in patients with no test compared with those with positive test results (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.08–2.26). The hazard of death was also higher among those with negative compared with positive tests but was not statistically significant (HR, 1.28; 95% CI, 0.91–1.81). Being on ART, having a higher CD4 count, and tertiary facility level were associated with a lower hazard for death.

Conclusions

There was some evidence that PWH treated for TB with no bacteriologic test results were at higher risk of death than those with positive tests. Research is needed to understand the causes of death in PWH treated for TB without bacteriologic testing.

Prevalence of HIV-1 Infection in an elderly rural population and associations with neurocognitive impairment

OBJECTIVE

We explored the prevalence of HIV infection in older rural South Africans and its associations, as well as the point prevalence of dementia and its associations with HIV and aging.

DESIGN

We utilized a cross-sectional analytic design.

METHODS

Using the brief Community Screening Instrument for Dementia together with a rapid HIV test, we conducted a home-based screening survey among 1150 older South Africans. We explored the prevalence of HIV and dementia, and their associations using descriptive statistics and logistic regression analysis.

RESULTS

The HIV prevalence was 4.78%. Overall, participants were on average 71.3 years old, with nearly 70% having no primary school education. HIV+ participants were significantly younger, more likely to be single and had lower BMI. The overall dementia prevalence was 11.04%. HIV+ participants had higher rates of dementia compared with HIV- participants (18.18 vs. 10.68%) but the difference was NS. In adjusted analysis, screened dementia was associated with older age, the presence of self-reported depression and HIV+ status. Participants were also more likely to self-report cognitive impairment if they were older, depressed and had objective evidence of dementia.

CONCLUSION

Infection with HIV in rural older South Africans is a prevalent problem, and together with older age, is a significant contributor to cognitive impairment. It is possible that HIV infection contributes to dementia on the basis of an acceleration of degeneration - because our HIV-infected participants were younger - AND an accentuation of aging - because of the higher rates of impairment for similar age groups.