Absence of effect of menopause status at initiation of first-line antiretroviral therapy on immunologic or virologic responses: a cohort study from Rio de Janeiro, Brazil

Brief Report: Does Menopause Transition Influence Viral Suppression and Adherence in Women Living With HIV?

BACKGROUND

Increasing numbers of women living with HIV transition through menopause. It is unclear whether this transition has an impact on treatment adherence, viral suppression, psychiatric comorbidities, or drug use. We aimed at examining adherence and viral suppression during the perimenopausal period and explored the influence of psychiatric comorbidities and active injection drug use (IDU).

SETTING

Retrospective Swiss HIV Cohort Study analysis from January 2010 to December 2018.

METHODS

We explored perimenopausal and postmenopausal trends of viral blips, low-level viremia, viral failure, adherence, psychiatric comorbidities, and IDU using interrupted time series models.

RESULTS

Rates of depression and psychiatric care increased during perimenopause before decreasing afterward. Negative treatment outcomes such as viral blips, low-level viremia, viral failure, and low adherence steadily declined while transitioning through menopause-this was also true for subgroups of women with depression, psychiatric treatment, and active IDU.

CONCLUSIONS

Increased rates of depression and psychiatric care while transitioning through menopause do not result in lower rates of adherence or viral suppression in women living with HIV in Switzerland.

Sex Differences in Human Immunodeficiency Virus Persistence and Reservoir Size During Aging

BACKGROUND

Sex differences in human immunodeficiency virus (HIV) reservoir dynamics remain underexplored.

METHODS

Longitudinal samples from virally suppressed midlife women (n = 59, median age 45 years) and age-matched men (n = 31) were analyzed retrospectively. At each time point, we measured sex hormones (by means of enzyme-linked immunosorbent assay) and cellular HIV DNA and RNA (by means of digital droplet polymerase chain reaction). Number of inducible HIV RNA+ cells, which provides an upper estimate of the replication-competent reservoir, was quantified longitudinally in a different subset of 14 women, across well-defined reproductive stages. Mixed-effects models included normalized reservoir outcomes and sex, time since antiretroviral therapy (ART) initiation, and the sex-by-time interaction as predictors.

RESULTS

At ART initiation, women and men had median (interquartile range [IQR]) CD4+ T-cell counts of 204/μL (83-306/μL) versus 238/μL (120-284/μL), respectively; median ages of 45 (42-48) versus 47 (43-51) years; and median follow-up times of 79.2/μL (60.5-121.1/μL) versus 66.2/μL (43.2-80.6/μL) months. We observed a significant decline of total HIV DNA over time in both men and women (P < .01). However, the rates of change differed significantly between the sexes (P < .01), with women having a significantly slower rate of decline than men, more pronounced with age. By contrast, the levels of inducible HIV RNA increased incrementally over time in women during reproductive aging (P < .01).

CONCLUSIONS

In contrast to men, in whom the HIV reservoir steadily declines with aging, the HIV reservoir in women is more dynamic. Total HIV DNA (including intact and defective genomes) declines more slowly in women than in men, while the inducible HIV RNA+ reservoir, which is highly enriched in replication-competent virus, increases in women after menopause.

Menopause care in women living with HIV in the UK - A review

Advances in HIV care over the last 30 years have transformed a virtually fatal condition into a chronic, manageable one. Antiretroviral therapy (ART) has dramatically changed the outlook for people living with HIV so that most individuals with well controlled disease have a normal life expectancy. As result of this increase in life expectancy, one-third of women living with HIV are of menopausal age.

Adding to the shift in age distribution, rates of new HIV diagnosis are increasing in the over 50-year age group, likely the result of a combination of low condom use and perception of transmission risk and in women, an increased risk of HIV acquisition due to the mucosal disruption that accompanies vaginal atrophy.

Many women living with HIV are unprepared for menopause, have a high prevalence of somatic, urogenital and psychological symptomatology and low rates of menopausal hormone therapy (MHT) use. Many women experience enormous frustration shuttling between their general practitioner and HIV care provider trying to have their needs met, as few HIV physicians have training in menopause medicine and primary care physicians are wary of managing women living with HIV, in part, because of fears about potential drug-drug interactions (DDIs) between MHT and ART.

Several data gaps exist with regard to the relationship between HIV and the menopause, including whether the risk of HIV transmission is increased in virally-suppressed women with vaginal atrophy, whether or not menopause amplifies the effects of HIV on cardiovascular, psychological and bone health, as well as the safety and efficacy of MHT in women living with HIV.

Menopausal women living with HIV deserve high quality individualised menopause care that is tailored to their needs. More research is needed in the field of HIV and menopause, primarily on cardiovascular disease and bone health outcomes as well as symptom control, and strategies to reduce HIV acquisition, encourage testing, and maintain older women in care in order to inform optimal clinical management.

Effectiveness and safety of antiretroviral treatment in pre- and postmenopausal women living with HIV in a multicentre cohort

BACKGROUND

To compare effectiveness and safety of initial antiretroviral therapy (ART) among premenopausal and postmenopausal women living with HIV aged 45-60 years from the cohort of the Spanish HIV/AIDS Research Network (CoRIS) who initiated ART between 2004 and 2015.

METHODS

Multivariable regression models were used to compare post- versus premenopausal women regarding viral suppression (≤50 copies/ml), change in CD4⁺ T-cell count and time to treatment change (TC) at 48 and 96 weeks after ART initiation.

RESULTS

Among 230 women, 154 (67%) were premenopausal at ART initiation. The most frequent initial regimen was tenofovir disoproxil fumarate/emtricitabine/efavirenz prescribed in 49 (32%) premenopausal and 22 (29%) postmenopausal women. The proportion of TC was 35.7% and 30.3% at 48 weeks and 51.3% and 47.4% at 96 weeks, for pre- and postmenopausal women, respectively. There were no significant differences in CD4⁺ T-cell count changes from ART initiation, viral load suppression, time to TC or reason for TC between both groups. The main reason for TC was occurrence of an adverse event, followed by simplification, in both groups.

CONCLUSIONS

ART effectiveness and safety did not differ significantly between pre- and postmenopausal women.

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.

Determinants of Restoration of CD4 and CD8 Cell Counts and Their Ratio in HIV-1-Positive Individuals With Sustained Virological Suppression on Antiretroviral Therapy

BACKGROUND

An increasing number of HIV-positive individuals now start antiretroviral therapy (ART) with high CD4 cell counts. We investigated whether this makes restoration of CD4 and CD8 cell counts and the CD4:CD8 ratio during virologically suppressive ART to median levels seen in HIV-uninfected individuals more likely and whether restoration depends on gender, age, and other individual characteristics.

METHODS

We determined median and quartile reference values for CD4 and CD8 cell counts and their ratio using cross-sectional data from 2309 HIV-negative individuals. We used longitudinal measurements of 60,997 HIV-positive individuals from the Antiretroviral Therapy Cohort Collaboration in linear mixed-effects models.

RESULTS

When baseline CD4 cell counts were higher, higher long-term CD4 cell counts and CD4:CD8 ratios were reached. Highest long-term CD4 cell counts were observed in middle-aged individuals. During the first 2 years, median CD8 cell counts converged toward median reference values. However, changes were small thereafter and long-term CD8 cell count levels were higher than median reference values. Median 8-year CD8 cell counts were higher when ART was started with <250 CD4 cells/mm. Median CD4:CD8 trajectories did not reach median reference values, even when ART was started at 500 cells/mm.

DISCUSSION

Starting ART with a CD4 cell count of ≥500 cells/mm makes reaching median reference CD4 cell counts more likely. However, median CD4:CD8 ratio trajectories remained below the median levels of HIV-negative individuals because of persisting high CD8 cell counts. To what extent these subnormal immunological responses affect specific clinical endpoints requires further investigation.

Age Differences by Sex in Antiretroviral-Naïve Participants: Pooled Analysis from Randomized Clinical Trials

Age and sex effects on antiretroviral therapy (ART) response are not well elucidated. Our pooled analysis of 40 randomized clinical trials measured the association of age and sex on CD4+ T cell count changes and virologic suppression using multivariable regression modeling. The average increase in CD4+ T cell count from baseline to week 48 was 17.3 cells/mm³ lower and clinically insignificant (95% confidence interval -30.8 to -3.8) among women ages ≥ 50 years (n = 573), compared to women ≤ 35 years (n = 3,939). Results were similar for men. Virologic suppression odds were 60% and 21% times greater among participants ≥50 years compared to ≤35 years, in women and men, respectively. In both sexes, larger increases in CD4+ T cell count changes were observed in younger, compared to older, participants; however, virologic suppression was higher in older, compared to younger, participants suggesting a non-sex-specific age effect response to ART.

HIV and the menopause: A review

Effective antiretroviral therapy has resulted in a close to normal life expectancy for people living with HIV. This has led to a shift in the age distribution of women living with HIV in the UK, with one in three attending for HIV care estimated to be aged 45-56 years in 2014. The lack of experience of many HIV physicians in managing menopause, and the perceived complexity of managing menopause in women living with HIV by general practitioners means that many women are unable to access appropriate care and support. This is aggravated by the relative paucity of data on menopause in women living with HIV and conflicting results in this field, for example with regard to age of onset of menopause and symptomatology experienced. Furthermore, women living with HIV have unique considerations such as potential interactions between antiretroviral therapy and menopause hormone therapy (previously called hormone replacement therapy) and other physiological concerns such as a multifactorial propensity towards decreased bone mineral density and potentially increased cardiovascular risk. On the whole, menopause hormone therapy is probably underutilised in this group of women due to perceived concerns around drug-drug interactions, as well as fears shared with women in the general population about menopause hormone therapy. Menopausal women should be given adequate information on symptomatology, lifestyle modification and treatment options including menopause hormone therapy. Furthermore, a holistic approach which considers the increased burden of poor mental health in this population is essential.

Combined effect of sex and age in response to antiretroviral therapy in HIV-infected patients

BACKGROUND

Gender-specific data on the management of HIV infection are scarce. Further, an increase in the proportion of new HIV diagnoses in older persons has been observed. Using data from the CoRIS cohort, we compared immunovirological responses and survival in HIV-infected men and women who started their first combination antiretroviral therapy (cART) when aged < /≥50 years.

METHODS

We used multivariable logistic, linear and Cox regression, adjusting for potential confounders and including an interaction between age and sex, to assess differences in immunovirological responses and mortality, respectively.

RESULTS

At 96 weeks, among subjects <50 years, women were less likely than men to achieve virological response (VR; adjusted OR [aOR] 0.77, 95% CI 0.60, 0.99) and among women, older individuals were more likely to achieve VR than the younger ones (aOR 1.96; 95% CI 1.15, 3.34). Initiating cART at ≥50 years was associated with lower increases in CD4⁺ T-cell count both in men (-65.8; 95% CI -91.3, -40.3) and women (-37.7; 95% CI -79.7, 4.4) and women showed higher increases than men in both subjects aged <50 (21.8; 95% CI -1.9, 45.5) and ≥50 years at cART initiation (49.9; 95% CI 19.9, 79.9). A higher risk of death in men ≥50 was observed (adjusted hazard ratio [aHR] 2.69; 95% CI 1.73, 4.21), but not in women (aHR 1.49; 95% CI 0.70, 1.14). Women experienced lower mortality than men <50 (0.66; 95% CI 0.41, 1.07) and in those ≥50 (0.37; 95% CI 0.14, 0.93).

CONCLUSIONS

Sex and age at cART initiation have a noticeable association with both virological and immunological responses and mortality. Age ≥50 is associated with poorer immunological response and higher mortality but this effect is less pronounced in women than in men.

The menopause transition in women living with HIV: current evidence and future avenues of research

As the life expectancy of people living with HIV improves as a result of antiretroviral therapy, increasing numbers of women living with HIV (WLHIV) are now reaching menopausal age. The menopause transition in WLHIV remains a relatively overlooked area in clinical HIV research. Whilst there is some evidence to suggest that WLHIV experience menopause at an earlier age and that they have more menopausal symptoms, there is no clear consensus in the literature around an impact of HIV infection on either timing or symptomatology of the menopause. Data are also conflicting on whether HIV-related factors such as HIV viral load and CD4 cell count have an impact on the menopause. Furthermore, menopausal symptoms in WLHIV are known to go under-recognised by both healthcare providers and women themselves. There is likely to be a burden of unmet health needs among WLHIV transitioning through the menopause, with significant gaps in the evidence base for their care. With this in mind, we have developed the PRIME study (Positive Transitions Through the Menopause). This mixed-methods observational study will explore, for the first time in the UK, the impact of the menopause on the health and wellbeing of 1500 ethnically diverse WLHIV. In establishing a cohort of women in their midlife and following them up longitudinally, we hope to develop a nuanced understanding of the gendered aspects of ageing and HIV, informing the provision of appropriate services for WLHIV to ensure that they are supported in maintaining optimal health and wellbeing as they get older.

The impact of the menopause transition on the health and wellbeing of women living with HIV: A narrative review

Improvements in survival due to advances in antiretroviral therapy (ART) have led to a shift in the age distribution of those receiving HIV care, with increasing numbers of women living with HIV (WLHIV) reaching menopausal age. We present a narrative literature review of 26 studies exploring the menopause transition in WLHIV, focusing on: (1) natural history (2) symptomatology and management, and (3) immunologic and virologic effects. Data are conflicting on the association between HIV and earlier age at menopause, and the role of HIV-specific factors such as HIV viral load and CD4 count. There are some data to suggest that WLHIV experience more vasomotor and psychological symptoms during the menopause than HIV-negative women, and that uptake of hormone replacement therapy by WLHIV is comparatively low. There is no evidence that menopause affects either CD4 count or response to ART, although there may be increased immune activation in older WLHIV. We conclude that menopause in WLHIV is a neglected area of study. Specific information gaps include qualitative studies on experiences of reproductive ageing; data on the impact of the menopause on women's quality of life and ability to adhere to health-sustaining behaviors; as well as studies investigating the safety and efficacy of pharmacological and psychosocial interventions. There is likely to be a burden of unmet health need among this growing population, and better data are required to inform optimal provision of care, supporting WLHIV to maintain their health and wellbeing into their post-reproductive years.

Perspectives on menopause and women with HIV

Since the implementation of effective combination antiretroviral therapy, HIV infection has been transformed from a life-threatening condition into a chronic disease. As people with HIV are living longer, aging and its associated manifestations have become key priorities as part of HIV care. For women with HIV, menopause is an important part of aging to consider. Women currently represent more than one half of HIV-positive individuals worldwide. Given the vast proportion of women living with HIV who are, and will be, transitioning through age-related life events, the interaction between HIV infection and menopause must be addressed by clinicians and researchers. Menopause is a major clinical event that is universally experienced by women, but affects each individual woman uniquely. This transitional time in women's lives has various clinical implications including physical and psychological symptoms, and accelerated development and progression of other age-related comorbidities, particularly cardiovascular disease, neurocognitive dysfunction, and bone mineral disease; all of which are potentially heightened by HIV or its treatment. Furthermore, within the context of HIV, there are the additional considerations of HIV acquisition and transmission risk, progression of infection, changes in antiretroviral pharmacokinetics, response, and toxicities. These menopausal manifestations and complications must be managed concurrently with HIV, while keeping in mind the potential influence of menopause on the prognosis of HIV infection itself. This results in additional complexity for clinicians caring for women living with HIV, and highlights the shifting paradigm in HIV care that must accompany this aging and evolving population.

Predictors of early menopause in HIV-infected women: a prospective cohort study

OBJECTIVE

This study sought to investigate the age at natural menopause and its predictors in a cohort of human immunodeficiency virus (HIV)-infected women in Rio de Janeiro, Brazil.

STUDY DESIGN

HIV-infected women ≥30 years of age were included. Menopause was defined as having ≥1 year since the last menstrual period. Early age at natural menopause was defined as the onset of menopause at ≤45 years of age. Multivariate Cox proportional hazards analysis was applied.

RESULTS

A total of 667 women were included, and the median age at baseline was 34.9 years (interquartile range, 30.9-40.5 years). In all, 507 (76%) women were premenopausal, and 160 (24%) reached menopause during the observational period; of these, 36 of 160 (27%) had early menopause. The median age at natural menopause was 48 years (interquartile range, 45-50 years). Menarche at <11 years of age (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.23-3.37), cigarette smoking during the observational period (HR, 1.59; 95% CI, 1.08-2.33), chronic hepatitis C virus (HCV) infection (HR, 2.53; 95% CI, 1.27-5.07), and CD4 count <50 cells/mm(3) (HR, 3.07; 95% CI, 1.07-8.80) were significantly associated with an earlier age at natural menopause. The magnitudes of the effects of menarche at <11 years of age (HR, 2.7; 95% CI, 1.23-5.94), cigarette smoking during the observational period (HR, 3.00; 95% CI, 1.39-6.45), chronic HCV infection (HR, 6.26; 95% CI, 2.12-18.52), and CD4 count <50 cells/mm(3) (HR, 6.64; 95% CI, 1.91-23.20) were much higher and significantly associated with early natural menopause.

CONCLUSION

Early natural menopause was frequent among the HIV-infected women. In addition to menarche and cigarette smoking, which are menopausal factors among women in general, HIV-related immunodeficiency and chronic HCV were additional predictors for an earlier age at natural menopause. Adequate management of HIV in women is critical, as early onset of menopause has been associated with increased morbidity and mortality.