Derivation and internal validation of a mortality risk index for aged people living with HIV: The Dat'AIDS score

Epidemiological, clinical and mortality trends in people with HIV over 60 years in the PISCIS population-based cohort from Catalonia and Balearic Islands

OBJECTIVE

With HIV now a chronic condition and an aging population, understanding the evolving profiles of older people with HIV (PWH) is crucial. In this longitudinal study, we examined changes in epidemiological and mortality trends among aging PWH aged 60 and above from 1998 to 2021.

DESIGN

The study constructed four retrospective cohorts based on our calendar periods, reflecting the changing epidemiology of HIV - 1998-2003, 2004-2008, 2009-2014, and 2015-2021. Each calendar period included patients on follow-up that turned 60 during that period in PISCIS, the Populational HIV Cohort from Catalonia and Balearic Islands.

METHODS

Sociodemographic and clinical characteristics were analyzed and compared between periods, and 5-year mortality-associated factors were assessed.

RESULTS

Results indicate the proportion of those infected through intravenous drug use in older PWH has increased (4.7% in 1998-2003 vs. 24.7% in 2015-2021), as well as those born outside Spain (7.5% vs. 21.8%), alongside a lesser percentage of late HIV diagnoses (59.9% vs. 46.8%), reflecting a change in older PWH epidemiological profile. The presence of ≥3 comorbidities emerged as a significant predictor of 5-year mortality in the latest cohort, while CD4+ cell count of <200 cells/μl at the age of 60 lost significance [1998-2008: hazard ratio (HR): 3.19 (confidence interval, CI: 1.18-8.63) - 2015-2021: HR:1.38 (CI: 0.74-2.59)], underscoring the transition to the chronic disease era of the HIV pandemic.

CONCLUSION

Despite advanced treatment strategies have improved HIV health indicators, new challenges have emerged among the older PWH. Tailored interventions addressing the unique difficulties faced by this population are essential to optimize HIV care outcomes.

Validation of the Global Leadership Initiative on Malnutrition criteria for diagnosis of malnutrition and mortality prediction for people living with HIV or AIDS

OBJECTIVES

To validate the Global Leadership Initiative on Malnutrition (GLIM) criteria to diagnose malnutrition in hospitalized people living with HIV or AIDS (HA) considering different combinations, using the Subjective Global Assessment (SGA) as the semi-gold standard, and to assess the predictive effects of malnutrition according to the GLIM criteria on hospital length of stay and mortality.

METHODS

Retrospective observational study including hospitalized people living with HA aged >18 y. Forty GLIM combinations were obtained by combining the different phenotypic and etiologic criteria. The concurrent validity was assessed according to the sensitivity and specificity values, and the agreement with the SGA was tested using κ values. Multivariate logistic and Cox regression models were used to test the independent predictors for longer length of stay (LOS) and mortality, respectively.

RESULTS

The sample comprised 320 patients (mean age, 44.6 ± 12.1 y; 69.1% were men, and 68.4% were malnourished, according to the SGA). The prevalence of malnutrition, according to GLIM, varied from 10.3% to 69.1%. The combination of any phenotypic criteria with the etiologic criteria of low food intake and the combination of any phenotypic criteria with the etiologic criteria of disease severity were independent predictors for mortality (Hazard Ratio: 2.09 [95% CI, 1.15-3.77] and 2.09 [95% CI, 1.25-3.51], respectively). The combination of low body mass index and reduced absorption was independently associated with LOS higher than the median value (Oodds Ratio; 2.57; 95% CI, 1.21-5.45).

CONCLUSIONS

Nine GLIM combinations had satisfactory sensitivity and specificity values to determine concurrent validity, all of them including weight loss and low weight; two combinations were independent predictors of mortality (any phenotypic criteria and low food intake or opportunistic infections), and one combination predicted longer LOS. Combining any phenotypic criteria with low food intake resulted in adequate concurrent and predictive validity.

External validation of the Dat'AIDS score: A risk score for predicting 5-year overall mortality in people living with HIV aged 60 years or older

OBJECTIVE

To perform an external validation of the Dat'AIDS score for predicting 5-year overall mortality among people with HIV (PWH) aged 60 years or older.

METHODS

This was a multi-centre prospective cohort study at all sites participating in the Swiss HIV Cohort Study (SHCS). We calculated the Dat'AIDS score in PWH aged 60 years or older at their first visit between 1 January 2015 and 1 January 2020. People living with HIV-2 and those whose Dat'AIDS score could not be calculated were excluded. Patients were followed until 1 January 2020. The primary endpoint was all-cause mortality. Vital status was collected throughout the study period. We obtained population and score descriptive statistics and assessed the score's discrimination and calibration.

RESULTS

We included 2205 participants (82% male) of median [interquartile range (IQR)] age 62.0 (60.3-67.0) years, mostly with viraemia <50 copies/mL (92.7%). Median follow-up time was 15.9 years and median (IQR) CD4 cell count at enrolment was 586 (420-782) cells/μL. In all, 152 deaths were recorded during a total follow-up period of 7147 patient-years. The median (IQR) observed Dat'AIDS score was 3 (0-8). Discriminative capacities were good as the C-statistic was 0.73 (95% CI: 0.69-0.77) and consistent across all subgroups. Comparison of observed and expected survival probabilities showed good calibration.

CONCLUSIONS

External validation of the Dat'AIDS score in patients aged 60 years or older showed that it could be a useful tool not only for research purposes, but also to identify older patients at a higher mortality risk and to tailor the most appropriate interventions.

Prevalence of anemia among people living with HIV: A systematic review and meta-analysis

BACKGROUND

Anemia is the most frequent hematologic abnormality among people living with human immunodeficiency virus (HIV) (PLWHIV) and is associated with HIV disease progression and higher risk of mortality of the patients. However, there is a wide variation of the prevalence of anemia among PLWHIV in different clinical settings. We aimed to obtain more precise estimates of prevalence of anemia and severity of anemia among PLWHIV, which may be important for patients, caregivers, researchers and health policy-makers.

METHODS

We systematically searched PubMed, EMBASE, Web of Science, and Cochrane Library for original articles reporting the prevalence of anemia defined using age and sex-specific hemoglobin levels according to World Health Organization criteria among PLWHIV from inception to August 31, 2021. We used DerSimonian-Laird random-effects meta-analyses to obtain pooled prevalence and 95% confidence intervals (CIs) of anemia and severity of anemia among PLWHIV. A univariable meta-regression has been conducted to assess the association between anemia prevalence and study characteristics, including study design, median year of sampling, geographical region, World Bank Income level, and proportion of antiretroviral therapy (ART).

FINDINGS

We included 63 observational studies covering 110,113 PLWHIV. The pooled prevalence of anemia was 39.7% (95% CI: 31.4%-48.0%) for children living with HIV aged <15 years, 46.6% (95% CI: 41.9%-51.4%) for adults (men and non-pregnant women) living with HIV aged ≥15 years, and 48.6% (95% CI: 41.6%-55.6%) for pregnant women living with HIV. Among adults living with HIV, the pooled prevalence of severity of anemia was 21.6% (95% CI: 19.9%-23.3%), 22.6% (95% CI: 14.8%-30.4%), and 6.2% (95% CI: 4.4%-8.1%) for mild, moderate and severe anemia, respectively. Compared with East Africa, anemia prevalence among adults living with HIV was higher in Southern Africa (p = 0.033).

INTERPRETATION

Anemia is prevalent among PLWHIV. Thus, policies, strategies, and programs should be considered to identify the predictors of anemia among PLWHIV to reduce the burden of anemia among patients in the ART era.

Review on the Alteration of Gut Microbiota: The Role of HIV Infection and Old Age

Human immunodeficiency virus (HIV) infection results in gut microbiota alteration and this is associated with immune activation and chronic inflammation. The gastrointestinal tract is a primary site of viral replication and thus HIV-induced loss of T-helper (Th) cells in the gut causes impairments in intestinal barriers, resulting in disruptions in intestinal immunity and precipitating into gut dysbiosis. Here, we show that late HIV diagnosis can negatively affect the immunological, virological, and clinical prognosis of the patients with its higher implication at an older age. Further, the review indicates that antiretroviral therapy affects the gut microbiota. We discussed the use of probiotics and prebiotics that have been indicated to play a promising role in reversing gut microbiota alteration in HIV patients. Though there are several studies reported with regard to such alterations in gut microbiota regarding HIV infection, there is a need to provide comprehensive updates. It is, therefore, the objective of this review to present most recently available evidence on the alteration of gut microbiota among HIV patients.

HIV-related excess mortality and age-related comorbidities in patients with HIV aged ≥60: a relative survival analysis in the French Dat'AIDS cohort

OBJECTIVE

The objective was to evaluate the association between age-related comorbidities (ARCs) and 5-year HIV-related excess mortality in people living with HIV aged ≥60 years.

DESIGN

Cohort study using relative survival analysis (Estève's model).

SETTING

The French multicentre prospective Dat'AIDS cohort that involves 12 French hospitals.

PARTICIPANTS

Inclusion of 1415 HIV-1 infected patients actively followed aged ≥60 years on January 2008, with a 5-year follow-up period in the late combination antiretroviral therapy era.

RESULTS

Among 1415 patients included, 154 died. By multivariable analysis, factors predictive of 5-year HIV-related excess mortality were non-AIDS-related cancer (adjusted excess HR (aEHR)=2.94; 95% CI 1.32 to 6.57), cardiovascular disease (aEHR=6.00; 95% CI 2.45 to 14.65), chronic renal disease (aEHR=4.86; 95% CI 2.24 to 10.53), cirrhosis (aEHR=3.58; 95% CI 1.25 to 10.28), hepatitis C co-infection (aEHR=3.63; 95% CI 1.44 to 9.12), body mass index<18.5 kg/m² (aEHR=4.10; 95% CI 1.61 to 10.48) and having a CD4 cell count ≤200/mm³ (aEHR=5.79; 95% CI 2.28 to 14.69).

CONCLUSIONS

ARCs, particularly cardiovascular disease and chronic renal disease, are predictive of HIV-related excess mortality, with an increase in hazard similar to that of CD4 cell count.

TRIAL REGISTRATION NUMBER

NCT02898987.