HIV infection in the elderly

Older persons' knowledge of HIV and AIDS prevention in a province of South Africa

BACKGROUND

 Population ageing and access to antiretroviral therapy have resulted in an increase in the proportion of older people living with human immunodeficiency virus (HIV). However, scant knowledge is available to inform the design of educational programmes to target these persons in low- and middle-income countries.

AIM

 This study aimed to examine how persons aged ≥ 50 years view their risk of contracting HIV, and the extent to which they are supported in preventing infection and are impacted by the HIV or acquired immune deficiency syndrome (AIDS) epidemic.

SETTING

 Rural sites in the Western Cape Province of South Africa.

METHODS

 This study followed a qualitative design. Two focus group discussions with persons aged ≥ 50 years and interviews with two key informants were conducted at seniors' centres. Discussions were digitally audio recorded and the recordings were transcribed, and data were thematically analysed.

RESULTS

 Overall, awareness of the risk of older persons contracting HIV infection in this population was poor. Stigmatisation of the disease in the community and at health care facilities affected individuals' willingness to be tested for the virus and/or to disclose their status, if positive. Participants viewed HIV and AIDS education programmes as focussed on the youth and educational sessions for large groups were not helpful in stemming the epidemic.

CONCLUSION

 Dissemination of information on older persons' vulnerability to the disease, and education on HIV and AIDS tailored for and targeted at this age group have been relatively neglected.Contribution: Educational programmes on HIV, as well as productive channels and platforms to target older populations, particularly those with a low health literacy level are required.

Human immunodeficiency virus transmission-Mechanisms underlying the cell-to-cell spread of human immunodeficiency virus

Despite the success of combined antiretroviral therapy in controlling viral load and reducing the risk of human immunodeficiency virus (HIV) transmission, an estimated 1.5 million new infections occurred worldwide in 2021. These new infections are mainly the result of sexual intercourse and thus involve cells present on the genital mucosa, such as dendritic cells (DCs), macrophages (Mø) and CD4+ T lymphocytes. Understanding the mechanisms by which HIV interacts with these cells and how HIV exploits these interactions to establish infection in a new human host is critical to the development of strategies to prevent and control HIV transmission. In this review, we explore how HIV has evolved to manipulate some of the physiological roles of these cells, thereby gaining access to strategic cellular niches that are critical for the spread and pathogenesis of HIV infection. The interaction of HIV with DCs, Mø and CD4+ T lymphocytes, and the role of the intercellular transfer of viral particles through the establishment of the infectious or virological synapses, but also through membrane protrusions such as filopodia and tunnelling nanotubes (TNTs), and cell fusion or cell engulfment processes are presented and discussed.

Sieve estimation of a class of partially linear transformation models with interval-censored competing risks data

In this paper, we consider a class of partially linear transformation models with interval-censored competing risks data. Under a semiparametric generalized odds rate specification for the cause-specific cumulative incidence function, we obtain optimal estimators of the large number of parametric and nonparametric model components via maximizing the likelihood function over a joint B-spline and Bernstein polynomial spanned sieve space. Our specification considers a relatively simpler finite-dimensional parameter space, approximating the infinite-dimensional parameter space as n → ∞, thereby allowing us to study the almost sure consistency, and rate of convergence for all parameters, and the asymptotic distributions and efficiency of the finite-dimensional components. We study the finite sample performance of our method through simulation studies under a variety of scenarios. Furthermore, we illustrate our methodology via application to a dataset on HIV-infected individuals from sub-Saharan Africa.

Using IPA tools to characterize molecular pathways underlying the involvement of IRF7 in antiviral response to HIV

Objectives

Interferon Regulatory Factors (IRFs) regulate transcription of type-I interferons (IFNs) and IFN-stimulated genes. We previously reported that IFN-regulatory factor 7 (IRF7) is significantly upregulated in the brain of HIV-1 transgenic (HIV-1Tg) rats compared to F344 control rats in a region dependent manner [Li MD, Cao J, Wang S, Wang J, Sarkar S, Vigorito M, et al. Transcriptome sequencing of gene expression in the brain of the HIV-1 transgenic rat. PLoS One 2013]. The RNA deep-sequencing data were deposited in the NCBI SRA database with Gene Expression Omnibus (GEO) number GSE47474. Our current study utilized QIAGEN CLC Genomics Workbench and Ingenuity Pathway Analysis (IPA) to identify molecular pathways underlying the involvement of IRF7 in the HIV antiviral response.

Methods

The differential RNA expression data between HIV-1Tg and F344 rats as well as HAND+ and HIV+ cognitively normal patients was collected from GSE47474 and GSE152416, respectively. The "Core Expression Data Analysis" function identified the significant canonical pathways in the datasets with or without IRF7 and its 455 associated molecules.

Results

It was found that IRF7 and its 455 associated molecules altered the expression of pathways involving neurotransmission, neuronal survival, and immune function.

Conclusions

This in-silico study reveals that IRF7 is involved in the promotion of macrophage activity, neuronal differentiation, the modulation of the Th-1/Th-2 ratio, and the suppression of HIV-1 translation. Furthermore, we demonstrate that bioinformatics tools such as IPA can be employed to simulate the complete knockout of a target molecule such as IRF7 to study its involvement in biological pathways.

DISE/6mer seed toxicity-a powerful anti-cancer mechanism with implications for other diseases

micro(mi)RNAs are short noncoding RNAs that through their seed sequence (pos. 2-7/8 of the guide strand) regulate cell function by targeting complementary sequences (seed matches) located mostly in the 3' untranslated region (3' UTR) of mRNAs. Any short RNA that enters the RNA induced silencing complex (RISC) can kill cells through miRNA-like RNA interference when its 6mer seed sequence (pos. 2-7 of the guide strand) has a G-rich nucleotide composition. G-rich seeds mediate 6mer Seed Toxicity by targeting C-rich seed matches in the 3' UTR of genes critical for cell survival. The resulting Death Induced by Survival gene Elimination (DISE) predominantly affects cancer cells but may contribute to cell death in other disease contexts. This review summarizes recent findings on the role of DISE/6mer Seed Tox in cancer; its therapeutic potential; its contribution to therapy resistance; its selectivity, and why normal cells are protected. In addition, we explore the connection between 6mer Seed Toxicity and aging in relation to cancer and certain neurodegenerative diseases.

Lifetime commercial heterosexual behavior among HIV negative elderly men from rural Chengdu, China: a modified knowledge-attitude-practice perspective

Background

China is facing big challenges to achieve the “90–90-90 targets”. The HIV prevalence of elderly (≥50 years) men have been steadily increasing in China, mainly through the sexual transmission route, but sexual behaviors of them are far from well-studied. In 2019, elderly men accounted for 59.2% of HIV/AIDS cases in Sichuan, China.

Methods

The research design is a cross-sectional study. Face-to-face interviews were conducted among 795 HIV negative elderly men from rural Chengdu, capital City of Sichuan. Bivariate and multivariate logistic regression models were applied to examine factors associated with commercial heterosexual behavior from a modified Knowledge-Attitude-Practice (KAP) perspective.

Results

129 (16.23%) respondents admitted high-risk sexual behaviors, including 11.07% commercial heterosexual behavior, 6.16% extramarital, 2.89% casual and 0.25% homosexual behavior, and no one used condom consistently. 427(68.43%) had ever gotten HIV-related Health Education (HRHE), mainly through mass media (70.49%). The HIV-related knowledge awareness rate was only 31.41%. Migration history (AOR =2.46,95% CI = 1.02–5.91), age(≥60 vs. 50–59, OR = 0.41, 95% CI = 0.19–0.91), receiving HRHE from mass media (OR = 0.37, 95%CI = 0.16–0.85), marital status (married vs. never married, OR = 0.04, 95%CI = 0–0.52), and undecided (AOR =0.02, 95%CI = 0.01–0.09) and objection (AOR =0.04, 95%CI = 0.01–0.1) attitude toward commercial sex were related to lifetime commercial heterosexual behavior.

Conclusions

High-risk sexual behaviors are common among elderly men from rural areas in Chengdu. Receiving HRHE from mass media and undecided and objection attitude toward commercial sex prevent elderly from being involving in commercial heterosexual behavior. According to the results, health facilities should continue to conduct systematic interventions, paying more attention to 50–59 years old group. Sex and condom use need to be talked in public. Working with mass media, health facilities give elderly men education not only focusing on HIV/AIDS, but also on knowledge and skills of condom use.

Sex Differences in HIV Testing among Older Adults in Sub-Saharan Africa: A Systematic Review

Background

Despite being sexually active and engaging in risky sexual behaviours similar to young adults, older adults (50 years or older) are less likely to receive HIV testing, and disaggregated data are still scarce about HIV prevention and treatment in this vulnerable population in sub-Saharan Africa (SSA). This systematic review is aimed at examining sex differences in HIV testing and counseling (HTC) among older adults in SSA.

Methods

A systematic search of four databases, namely, MEDLINE (Ovid), EMBASE (Ovid), Web of Science, and Global Health, was conducted from 2000 to January 2020. The primary outcome of interest for this study was gender differences in HTC among older adults in SSA. Observational studies including cross-sectional, retrospective, and prospective cohort studies were included. Eligible studies must have reported sex differences in HIV testing uptake in a standard HTC service among older adults in SSA.

Results

From the database search, 4143 articles were identified. Five studies were ultimately included in the final review. Of the 1189 participants, 606 (51.1%) and 580 (48.9%) were female and male, respectively. The review findings suggested that both men and women preferred HTC providers that are the same sex as them with women additionally preferring a provider who is also of a similar age. Men and women differed in their pathways to getting tested for HIV. The review documented mixed results with regard to the associations between sex of older adults and uptake of HTC. Older adult HTC uptake data are limited in scope and coverage in sub-Saharan Africa.

Conclusion

This review revealed shortage of evidence to evaluate optimum HTC utilization among older adults. Few studies examined sex differences in HIV testing among older adults in the region. There is a need for stakeholders working in the area of HIV prevention and treatment to focus on older adult health utilization evidence organization, disaggregated by age and sex. Hence, high-quality research designs are needed on the topic in order to generate good quality evidence for targeted interventions to improve HTC among older adults in sub-Saharan Africa.

Obesity, Vascular Disease and Frailty in Aging Women with HIV

Women with chronic HIV infection (WWH) living in the United States, experience a disproportionately high rate of obesity compared to uninfected populations. Both overweight and obesity, particularly central obesity, are major contributors to insulin resistance, hypertension, and dyslipidemia—the major components of metabolic syndromes, including type 2 diabetes, and leading to increased cardiovascular risk, including coronary heart disease, and cerebrovascular diseases. Notably, declining physical performance and frailty co-occur with vascular morbidities as well as changes in bone. These factors tend to exacerbate each other and accelerate the aging trajectory, leading to poorer quality of life, cognitive impairments, dementia, and eventually, death. In WWH, persistent HIV infection, sustained treatment for HIV infection, and concomitant obesity, may accelerate aging-related morbidities and poorer aging outcomes. Furthermore, health disparities factors common among some WWH, are independently associated with obesity and higher vascular risk. The purpose of this review is to describe the constellation of obesity, cardio- and cerebrovascular diseases, bone health and frailty among aging WWH, a 21st century emergence.

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.

Human Immunodeficiency Virus and Severe Acute Respiratory Syndrome Coronavirus 2 Coinfection: A Systematic Review of the Literature and Challenges

The concurrence of infection with human immunodeficiency virus (HIV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), presents an intriguing problem with many uncertainties underlying their pathogenesis. Despite over 96.2 million cases of COVID-19 worldwide as of January 22, 2021, reports of patients coinfected with HIV and SARS-CoV-2 are scarce. It remains unknown whether HIV patients are at a greater risk of infection from SARS-CoV-2, despite their immunocompromised status. We present a systematic review of the literature reporting cases of HIV and SARS-CoV-2 coinfection, and examine trends of clinical outcomes among coinfected patients. We systematically compiled 63 reports of HIV-1 and SARS-CoV-2 coinfection, published as of January 22, 2021. These studies were retrieved through targeted search terms applied to PubMed/Medline and manual search. Despite scattered evidence, reports indicate a favorable prognosis for HIV patients with strict adherence to combined antiretroviral therapy (cART). However, the presence of comorbidities was associated with a poorer prognosis in HIV/SARS-CoV-2 patients, despite cART and viral suppression. Studies were limited by geographic coverage, small sample size, lack of patient details, and short follow-up durations. Although some anti-HIV drugs have shown promising in vitro activity against SARS-CoV-2, there is no conclusive evidence of the clinical efficacy of any anti-HIV drug in the treatment of COVID-19. Further research is needed to explain the under-representation of severe COVID-19 cases among the HIV patient population and to explore the possible protective mechanisms of cART in this vulnerable population.

Associations of gamma-glutamyl transferase with cardio-metabolic diseases in people living with HIV infection in South Africa

Background

Gamma-glutamyl transferase (GGT) has recently been reported as a biomarker for cardiovascular (CVD) risk in general populations. We investigated the associations of GGT with cardio-metabolic diseases and CVD risk in South Africans living with HIV.

Methods

In this cross-sectional study, HIV-infected adults were randomly recruited across 17 HIV clinics in the Western Cape Province. Homeostatic model assessment for insulin resistance (HOMA-IR), hypertension, diabetes, metabolic syndrome by Joint Interim Statement criteria (JIS-MS), a ≥5% and ≥10% predicted risk for a CVD event within 10 years by the Framingham risk score (10-years-CVD risk) were computed. Associations between GGT and cardio-metabolic trait were explored using linear and binomial logistic regressions adjusted for age, gender, lifestyle behaviours and HIV-related characteristics.

Results

Among 709 participants (561 women, mean age 38.6 years), log-GGT was positively associated with waist circumference (β=2.75; p<0.001), diastolic blood pressure (β=1.65; p=0.006), total cholesterol (β=0.21; p<0.001), low-density lipoprotein-cholesterol (β=0.16; p<0.001), high-density lipoprotein-cholesterol and log-triglycerides (both β=0.12; p<0.001), fasting plasma glucose (β=0.19; p=0.031), 2-hour-post-glucose-load plasma glucose (β=0.26; p=0.007), HOMA-IR (β=0.13; p=0.001), log-high-sensitivity C-reactive-protein (β=0.3; p<0.001) in linear regression analyses; with hypertension [OR=1.41 (95%CI, 1.13-1.75); p=0.001], JIS-MS [OR=1.33 (1.05-1.68); p=0.016], ≥5% 10-year-CVD risk [OR=1.55 (1.24-1.9400); p<0.001] and ≥10% 10-year-CVD risk [OR=1.56 (1.08-2.23); p=0.016] but not with diabetes [OR=1.24 (0.88-1.71), p=0.205] in logistic regression analyses.

Conclusions

In this study, GGT levels were associated with cardio-metabolic variables independent of HIV specific attributes. If confirmed in longitudinal studies, GGT evaluation maybe included in CVD risk monitoring strategies in people living with HIV.

Beyond the Health Deficit Count: Examining Deficit Patterns in a Deficit-Accumulation Frailty Index

BACKGROUND/OBJECTIVES

Exploring deficit patterns among frail people may reveal subgroups of different prognostic importance.

DESIGN

Analysis of National Health and Aging Trends Study.

SETTING

Community.

PARTICIPANTS

Community dwelling older adults with mild to moderate frailty (deficit-accumulation frailty index (FI) of 0.25-0.40) (n = 1821).

MEASUREMENTS

Latent class analysis identified distinct clinical subgroups based on comorbidity (range: 0-10), National Health and Aging Trends Study dementia classification, and short physical performance battery (SPPB) (range: 0-12). Survival analyses compared 5-year mortality by subgroups.

RESULTS

Three latent classes existed: Class 1 (n = 831, mean FI = 0.30) had 2.7% probable dementia, high comorbidities (mean = 3.6), and low physical impairment (SPPB mean = 9.9); Class 2 (n = 734, mean FI = 0.32) had 6.9% probable dementia, low comorbidities (mean = 2.8), and moderate physical impairment (SPPB mean = 6.2); Class 3 (n = 256, mean FI = 0.34) had 20.7% probable dementia, low comorbidities (mean = 2.4), and high physical impairment (SPPB mean = 2.0). Compared to Class 1, Classes 2 and 3 experienced higher 5-year mortality (C2: 1.28 (95% confidence intervals (CI) = 1.00-1.62); C3: 1.87 (95% CI = 1.29-2.73)).

CONCLUSION

Deficit patterns among the mild-to-moderately frail provide additional prognostic information and highlight opportunities for preventive interventions.

Should we start looking at the elderly for human immunodeficiency virus infections? A study of trends of human immunodeficiency virus, hepatitis B virus, and hepatitis C virus in Mumbai, Maharashtra, India

Background

There is limited information on the trends of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) co-infections in India - particularly from private health-care settings. We designed the present research to estimate the prevalence of HIV, HBV, and HCV over a period of 7 years and study the factors associated with them.

Materials and Methods

The present study is a secondary data analysis of data from the laboratory records of 24,086 individuals who were tested over a period of 7 years (2009-2015). We estimated the proportion and 95% confidence intervals (CIs) for HIV, hepatitis B surface antigen (HBsAg), and HCV antibodies.

Results

The overall seroprevalence of HIV was 0.35% (95% CI: 0.27%, 0.44%), HBsAg was 1.65% (95% CI: 1.48%, 1.82%), and HCV was 1.73% (95% CI: 1.56%, 1.90%). The prevalence of HIV among those who were more than 70 years of age was 0.14% (95% CI: 0.04%, 0.32%). The prevalence of HBsAg was highest in those aged 30-39 years (2.27%, 95% CI: 1.74%, 2.92%) (P = 0.008). The prevalence of HIV/HBsAg co-infection was 0.019% (95% CI: 0.005%, 0.050%), HIV/HCV co-infection was 0.005% (95% CI: 0.000, 0.027%), and HBsAg/HCV co-infection was 0.059% (95% CI: 0.030%, 0.102%). We did not encounter even a single case of all the three infections.

Conclusions

HIV infection is relatively high in those who were aged 50 years of more; thus, they need to be included in the National AIDS Control Programme. HIV/HBV/HCV co-infections should be regularly monitored in surveillance programs, and antiretroviral therapy officers and counselors should be trained on the management of HIV in those who are co-infected.

Polypharmacy and drug-drug interactions in older and younger people living with HIV: the POPPY study

BACKGROUND

Polypharmacy (use of ≥ five medications) increases the risk of drug-drug interactions and can lead to negative health outcomes. This study aimed to review the medications of people living with HIV (PLWH) and HIV-negative controls in the POPPY study and evaluate the frequency of polypharmacy and potential drug-drug interactions (PDDIs).

METHODS

PDDIs between non-antiretroviral (ARV) drugs were analysed using the Lexicomp^® database, and PDDIs between non-ARV and ARV drugs using the Liverpool drug interaction database. Between-group differences were assessed using χ², Mann-Whitney U and Kruskal-Wallis tests.

RESULTS

This analysis included 698 PLWH ≥50 years, 374 PLWH <50 years and 304 HIV-negative controls ≥50 years. The prevalence of polypharmacy was 65.8% in older PLWH, 48.1% in younger PLWH and 13.2% in the HIV-negative group. When ARVs were excluded, 29.8% of older PLWH and 14.2% of younger PLWH had polypharmacy. The prevalence of ≥1 PDDI involving non-ARV drugs was 36.1%, 20.3% and 16.4%, respectively, in older PLWH, younger PLWH and HIV-negative controls. In PLWH the prevalence of ≥1 PDDI involving ARV and non-ARV drugs was 57.3% in older PLWH and 32.4% in younger PLWH.

CONCLUSIONS

Polypharmacy and PDDIs involving non-ARV/ARV drugs and non-ARV/non-ARV drugs were common among older PLWH, highlighting the need for increased awareness and additional research on all types of PDDI.

Going Beyond Giving Antiretroviral Therapy: Multimorbidity in Older People Aging with HIV in Nigeria

"Graying of HIV epidemic" is observed globally, as people living with HIV (PLWH) are aging, due to effectiveness of antiretrovirals. The normal aging processes and HIV-induced immune dysfunction, are potential mechanisms, driving multimorbidity (MM) in PLWH. MM is the concurrent presence of two or more diseases in a single individual. Aging PLWH, are at increased risk of acute and chronic morbidities compared with counterpart without HIV. Despite increasing concern in Nigeria, research on correlates of MM in aging PLWH is lagging. This was a comparative study, of ≥60 years of age, age-matched (±5 years) HIV-positive and HIV-negative patients. Patients were recruited, from the Infectious Disease Institute and Geriatric clinics of the University College Hospital, Ibadan, Nigeria, between April and June 2018. MM was defined as the occurrence of more than two morbidities in an individual, and it was considered acute, when within 30 days and chronic, when above 3-months duration. Data analysis was done using SPSS 23. We studied 186 individuals (62 HIV-positive and 124 HIV-negative). The PLWH had lower mean age (63.9 vs. 68.1 years, p = .00, t = 5.68), more chronic MM (2.0 vs. 1.3, p = .004, t = 2.970), which occurred earlier (4.7 vs. 9.6 years, p = .003, t = 3.05), more overall MM (3.6 vs. 2.8, p = .015, t = 2.448), and lower quality of life (82.7 vs. 86.2, p = .002, t = 3.130). Risk estimates for "any" MM revealed the odds are in favor of the older PLWH [69.4% vs. 46.8%, p = .004, odds ratio = 0.388 (95% confidence interval = 0.204-0.740)]. Logistic regression revealed, age >64 years, higher total body fat, lower nadir CD4 counts, and longer duration of HIV infection, were significantly associated with MM in aging PLWH (p = .019). Older individuals with HIV on antiretrovirals in Ibadan, had a significantly greater burden of MM compared with those without HIV. HIV treatment programs in Nigeria will need to adapt a comprehensive health care plan for aging PLWH.

Metabolomic Profiling of Left Ventricular Diastolic Dysfunction in Women With or at Risk for HIV Infection: The Women's Interagency HIV Study

Background People living with HIV have an increased risk of left ventricular diastolic dysfunction (LVDD) and heart failure. HIV-associated LVDD may reflect both cardiomyocyte and systemic metabolic derangements, but the underlying pathways remain unclear. Methods and Results To explore such pathways, we conducted a pilot study in the Bronx and Brooklyn sites of the WIHS (Women's Interagency HIV Study) who participated in concurrent, but separate, metabolomics and echocardiographic ancillary studies. Liquid chromatography tandem mass spectrometry-based metabolomic profiling was performed on plasma samples from 125 HIV-infected (43 with LVDD) and 35 HIV-uninfected women (9 with LVDD). Partial least squares discriminant analysis identified polar metabolites and lipids in the glycerophospholipid-metabolism and fatty-acid-oxidation pathways associated with LVDD. After multivariable adjustment, LVDD was significantly associated with higher concentrations of diacylglycerol 30:0 (odds ratio [OR], 1.60, 95% CI [1.01-2.55]); triacylglycerols 46:0 (OR 1.60 [1.04-2.48]), 48:0 (OR 1.63 [1.04-2.54]), 48:1 (OR 1.62 [1.01-2.60]), and 50:0 (OR 1.61 [1.02-2.53]); acylcarnitine C7 (OR 1.88 [1.21-2.92]), C9 (OR 1.99 [1.27-3.13]), and C16 (OR 1.80 [1.13-2.87]); as well as lower concentrations of phosphocholine (OR 0.59 [0.38-0.91]). There was no evidence of effect modification of these relationships by HIV status. Conclusions In this pilot study, women with or at risk of HIV with LVDD showed alterations in plasma metabolites in the glycerophospholipid-metabolism and fatty-acid-oxidation pathways. Although these findings require replication, they suggest that improved understanding of metabolic perturbations and their potential modification could offer new approaches to prevent cardiac dysfunction in this high-risk group.

Evaluating HIV Educational Materials for Older People

OBJECTIVE

To address the gap in knowledge about HIV risk reduction materials that target older adults. This review offered a comprehensive and rigorous examination of HIV risk reduction education materials that targeted older adults in the United States, assessing the gap in their coverage and content.

METHOD

A cross-sectional review of both print and Internet sources from state departments of public health, state and area agencies on aging, and web resources that targeted older populations was performed.

RESULTS

Of 29 health departments and 13 state and area agencies on aging that responded to the request, there were 9 HIV education materials identified that targeted older people. Of those materials, only 2 addressed the majority of aging-specific recommendations made from a previous study that described important HIV risk reduction information.

DISCUSSION

Recommendations are made about dissemination ideas to increase awareness and utilization of HIV educational materials.

Hospitalization Trends and Comorbidities Among People With HIV/AIDS Compared With the Overall Hospitalized Population, Illinois, 2008-2014

OBJECTIVES

To understand trends in health care use among people living with HIV/AIDS (PLWHA), this study compared trends in hospitalization rates, comorbidities, and hospital death rates of hospitalized PLWHA with the overall hospitalized population in Illinois during 2008-2014.

METHODS

This study identified principal hospitalizations (the principal discharge diagnosis coded with an HIV-related billing code) and secondary HIV hospitalizations (a non-principal discharge diagnosis coded with an HIV-related billing code) from 2008-2014 Illinois hospital discharge data. Hospitalization rates among PLWHA were calculated using prevalence data from the Illinois Electronic HIV/AIDS Registry; US Census population estimates were used to calculate overall Illinois hospitalization rates. Joinpoint regression analysis was used to assess trends overall and among demographic subgroups. Comorbidities and discharge status for all hospitalizations were identified.

RESULTS

In 2014, the hospitalization rate was 2.2 times higher among PLWHA than among the overall Illinois hospitalized population. From 2008 to 2014, principal HIV hospitalization rates per 1000 PLWHA decreased by 48% (from 71 to 37) and secondary HIV hospitalization rates declined by 26% (from 296 to 218). The decline in the principal HIV hospitalization rate was steepest from 2008 to 2011 (annual percentage change = -16.0%; P = .003). Mood disorders, substance-related diagnoses, and schizophrenia accounted for 18% to 22% of principal hospitalizations among PLWHA compared with 7% to 8% of overall Illinois hospitalizations. Hepatitis as a comorbidity was more common among hospitalized PLWHA (18%-22%) than among the overall Illinois hospitalized population (1.4%-1.5%). Hospitalized PLWHA were 3 times more likely than the overall Illinois hospitalized population to die while hospitalized.

CONCLUSIONS

HIV hospitalizations are largely preventable with appropriate treatment and adherence. Additional efforts to improve retention in HIV care that address comorbidities of PLWHA are needed.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Association Between Frailty and HIV-Associated Neurodegenerative Disorders Among Older Adults Living with HIV

The population of aging adults living with human immunodeficiency virus (HIV) is growing worldwide and evidence suggests that frailty occurs prematurely among them. In turn, frailty has been associated with cognitive decline. It is unknown, however, if people with both frailty and HIV infection have a higher risk of cognitive impairment compared with nonfrail HIV-infected persons. Therefore, the main objective of this study was to determine the association between the phenotype of frailty and HIV-associated neurocognitive disorders (HAND) among adults aged 50 years or older living with HIV/AIDS. A cross-sectional study was conducted on 206 adults living with HIV receiving care in a university-affiliated tertiary care hospital in Mexico City. Frailty was defined as per the Fried criteria. The presence of HAND was established according to the Antinori criteria: HIV-associated asymptomatic neurocognitive impairment (ANI), HIV-associated mild neurocognitive disorder (MND), or cognitively nonimpaired. Multinomial logistic regression models were used to test the independent association between frailty and HAND adjusting for potential confounders. Mean age of participants was 60.5 ± 6.3 years and 84.9% were male. Prevalence of HAND and frailty phenotype was 66.0% and 2.9%, respectively. The unadjusted analysis showed that both prefrail and frail statuses were associated with MND but not with ANI. However, after adjustment, the association with MND remained significant only among prefrail participants and no longer for frail persons (risk ratio [RR] = 5.7, 95% confidence intervals [CI] 1.09-29.82; p = .039 and RR = 18.3, 95% CI 0.93-362.6; p = .056, respectively). Prefrailty is associated with symptomatic neurocognitive disorders in older adults living with HIV. The spectrum of the frailty phenotype in this already vulnerable population should serve as an indicator of concomitant cognitive decline.

Association Between Frailty and HIV-Associated Neurodegenerative Disorders Among Older Adults Living with HIV

The population of aging adults living with human immunodeficiency virus (HIV) is growing worldwide and evidence suggests that frailty occurs prematurely among them. In turn, frailty has been associated with cognitive decline. It is unknown, however, if people with both frailty and HIV infection have a higher risk of cognitive impairment compared with nonfrail HIV-infected persons. Therefore, the main objective of this study was to determine the association between the phenotype of frailty and HIV-associated neurocognitive disorders (HAND) among adults aged 50 years or older living with HIV/AIDS. A cross-sectional study was conducted on 206 adults living with HIV receiving care in a university-affiliated tertiary care hospital in Mexico City. Frailty was defined as per the Fried criteria. The presence of HAND was established according to the Antinori criteria: HIV-associated asymptomatic neurocognitive impairment (ANI), HIV-associated mild neurocognitive disorder (MND), or cognitively nonimpaired. Multinomial logistic regression models were used to test the independent association between frailty and HAND adjusting for potential confounders. Mean age of participants was 60.5 ± 6.3 years and 84.9% were male. Prevalence of HAND and frailty phenotype was 66.0% and 2.9%, respectively. The unadjusted analysis showed that both prefrail and frail statuses were associated with MND but not with ANI. However, after adjustment, the association with MND remained significant only among prefrail participants and no longer for frail persons (risk ratio [RR] = 5.7, 95% confidence intervals [CI] 1.09-29.82; p = .039 and RR = 18.3, 95% CI 0.93-362.6; p = .056, respectively). Prefrailty is associated with symptomatic neurocognitive disorders in older adults living with HIV. The spectrum of the frailty phenotype in this already vulnerable population should serve as an indicator of concomitant cognitive decline.

Too old to test? Prevalence and correlates of HIV testing among sexually active older adults

Older adults account for 17% of new HIV diagnoses in the US and are more likely to be diagnosed with HIV later in the course of the disease compared to younger people. We calculated the prevalence and associated factors of having ever been tested for HIV among sexually active older adults. We analyzed data from the 2008-2016 General Social Survey Limited to respondents ≥65 years of age who reported more than one sex partner(s) in past 12 months (n = 757). HIV testing prevalence, prevalence ratios, and 95% confidence intervals were calculated by demographic variables and HIV-related risk behaviors. An estimated 16.3% of sexually active older adults have tested for HIV, and 15.9% were at increased risk for HIV infection (reported injection drug and/or crack-cocaine use, exchanging money for sex, more than three sex partners in the past year, or men who reported having sex with another man). In the adjusted model, adults aged 65-70, not married, self-identified as gay/bisexual, and at increased risk for HIV infection were more likely to have tested for HIV. An estimated 83.7% of sexually active older adults never tested for HIV. Strategies are needed to increase HIV awareness and testing among potentially high-risk older adults.

Redefining Aging in HIV Infection Using Phenotypes

Purpose of review

This article critically reviews the utility of “phenotypes” as behavioral descriptors in aging/HIV research that inform biological underpinnings and treatment development. We adopt a phenotypic redefinition of aging conceptualized within a broader context of HIV infection and of aging. Phenotypes are defined as dimensions of behavior, closely related to fundamental mechanisms, and, thus, may be more informative than chronological age. Primary emphasis in this review is given to comorbid aging and cognitive aging, though other phenotypes (i.e., disability, frailty, accelerated aging, successful aging) are also discussed in relation to comorbid aging and cognitive aging.

Recent findings

The main findings that emerged from this review are as follows: (1) the phenotypes, comorbid aging and cognitive aging, are distinct from each other, yet overlapping; (2) associative relationships are the rule in HIV for comorbid and cognitive aging phenotypes; and (3) HIV behavioral interventions for both comorbid aging and cognitive aging have been limited.

Summary

Three paths for research progress are identified for phenotype-defined aging/HIV research (i.e., clinical and behavioral specification, biological mechanisms, intervention targets), and some important research questions are suggested within each of these research paths.

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BACKGROUND

While in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.

METHODS

We conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.

RESULTS

Of these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.

CONCLUSION

The evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

Healthcare utilization and direct costs of non-infectious comorbidities in HIV-infected patients in the USA

OBJECTIVE

To estimate the incremental healthcare utilization and costs associated with common non-infectious comorbid conditions among commercially and Medicaid-insured HIV-infected patients in the US.

METHODS

US administrative claims were used to select adult HIV patients with chronic kidney disease (CKD), cardiovascular disease (CVD) events, or fracture/osteoporosis, three common comorbidities that have been associated with HIV and HIV treatment, between 1 January 2004 and 30 June 2013. Propensity score matched controls with no CKD, no CVD events, and no fracture/osteoporosis were identified for comparison. All-cause healthcare utilization and costs were reported as per patient per month (PPPM).

RESULTS

The commercial cohort comprised 381 CKD patients, 624 patients with CVD events, and 774 fracture/osteoporosis patients, and 1013, 1710, and 2081 matched controls, respectively; while the Medicaid HIV cohort comprised 207 CKD and 271 CVD cases, and 516 and 735 matched controls, respectively. There was insufficient Medicaid data for fracture analyses. Across both payers, HIV patients with CKD or CVD events had significantly higher healthcare utilization and costs than controls. The average incremental PPPM costs in HIV patients with CKD were $1403 in the commercial cohort and $3051 in the Medicaid cohort. In those with CVD events, the incremental costs were $2655 (commercial) and $4959 (Medicaid) for HIV patients compared to controls (p < .001).

CONCLUSIONS

The results suggested a considerable increase in healthcare utilization and costs associated with CKD, CVD and fracture/osteoporosis comorbidities among HIV patients in the past decade. Because these conditions have been associated with treatment, it is critical to consider their impact on costs and outcomes when optimizing patient care.

Socio-behavioral risk factors among older adults living with HIV in Thailand

BACKGROUND

There has been a global increase in HIV infection in persons 50 years of age and older. This group is at risk for development of chronic illness that may be exacerbated by socio-behavioral risk factors such as smoking, unhealthy alcohol use, and sedentary lifestyle. However, socio-behavioral risk factors in this older HIV infected population are not well described. The current study aims to describe and document factors related to alcohol use, tobacco smoking, and physical exercise in older adults living with HIV (OALHIV).

METHODS

This cross-sectional quantitative study was conducted between August and September 2015, and enrolled HIV-infected participants aged 50 years and older from 12 community hospitals in Chiang Mai Province, Northern Thailand.

RESULTS

Of the 364 participants recruited in the study, 57.1% were female, and 67.3% were between 50-59 years of age. Respectively, 15.1%, 59.1%, and 18.7% were current smokers, currently engaged in physical exercises, and reported ever drank alcohol in the past year. 22.1% of those who drank alcohol reported experience of heavy episodic drinking. Male gender was one of the strongest predictors of ever drank alcohol in the past year (AOR, 4.66; CI, 2.28-9.49; P<0.001) and of being a current smoker (AOR, 13.41; CI, 7.23-24.87; P<0.001). Lower household income was associated with increased odds of ever drank alcohol in the past year (household income (1 USD = 35 THB) of ≤ 5,000 Baht versus > 20,000 Baht: AOR, 5.34; CI, 1.28-22.25; P = 0.021). Lower educational level was associated with decreased odds of physical exercises (no education versus secondary and higher: AOR, 0.22; CI, 0.08-0.55; P = 0.001).

CONCLUSION

Smoking and alcohol use is common among OALHIV, with a substantial proportion not engaging in physical exercises. Interventions for OALHIV should particularly target males and those of lower socio-economic status to deter smoking and alcohol use and to promote physical exercises.

Characteristics and outcomes of older HIV-infected patients receiving antiretroviral therapy in Malawi: A retrospective observation cohort study

Objective

To estimate patients enrolling on antiretroviral therapy (ART) over time; describe trends in baseline characteristics; and compare immunological response, loss to follow-up (LTFU), and mortality by three age groups (25–39, 40–49 and ≥50 years).

Design

A retrospective observation cohort study.

Methods

This study used routine ART data from two public clinics in Lilongwe, Malawi. All HIV-infected individuals, except pregnant or breastfeeding women, aged ≥ 25 years at ART initiation between 2006 and 2015 were included. Poisson regression models estimated risk of mortality, stratified by age groups.

Results

Of 37,378 ART patients, 3,406 were ≥ 50 years old. Patients aged ≥ 50 years initiated ART with more advanced WHO clinical stage and lower CD4 cell count than their younger counterparts. Older patients had a significantly slower immunological response to ART in the first 18 months on ART compared to patients aged 25–39 years (p = 0.04). Overall mortality rates were 2.3 (95% confidence Interval (CI) 2.2–2.4), 2.9 (95% CI 2.7–3.2) and 4.6 (95% CI 4.2–5.1) per 100 person-years in patients aged 25–39 years, 40–49 years and 50 years and older, respectively. Overall LTFU rates were 6.3 (95% CI 6.1–6.5), 4.5 (95% CI 4.2–4.7), and 5.6 (95% CI 5.1–6.1) per 100 person years among increasing age cohorts. The proportion of patients aged ≥ 50 years and newly enrolling into ART care remained stable at 9% while the proportion of active ART patients aged ≥50 years increased from 10% in 2006 to 15% in 2015.

Conclusion

Older people had slower immunological response and higher mortality. Malawi appears to be undergoing a demographic shift in people living with HIV. Increased consideration of long-term ART-related problems, drug-drug interactions and age-related non-communicable diseases is warranted.

HIV-associated cellular senescence: A contributor to accelerated aging

Due to the advent of antiretroviral therapy HIV is no longer a terminal disease and the HIV infected patients are becoming increasingly older. While this is a major success, with increasing age comes an increased risk for disease. The age-related comorbidities that HIV infected patients experience suggest that they suffer from accelerated aging. One possible contributor to this accelerated aging is cellular senescence, an age-associated response that can occur prematurely in response to stress, and that is emerging as a contributor to disease and aging. HIV patients experience several stressors such as the virus itself, antiretroviral drugs and to a lesser extent, substance abuse that can induce cellular senescence. This review summarizes the current knowledge of senescence induction in response to these stressors and their relation to the comorbidities in HIV patients. Cellular senescence may be a possible therapeutic target for these comorbidities.

Predicting death over 8 years in a prospective cohort of HIV-infected women: the Women's Interagency HIV Study

OBJECTIVES

Predicting mortality in middle-aged HIV-infected (HIV+) women on antiretroviral therapies (ART) is important for understanding the impact of HIV infection. Several health indices have been used to predict mortality in women with HIV infection. We evaluated: (1) an HIV biological index, Veterans Aging Cohort Study (VACS); (2) a physical index, Fried Frailty Index (FFI); and (3) a mental health index, Center for Epidemiologic Studies-Depression (CES-D). Proportional hazards regression analyses were used to predict death and included relevant covariates.

DESIGN

Prospective, observational cohort.

SETTING

Multicentre, across six sites in the USA.

PARTICIPANTS

1385 multirace/ethnic ART-experienced HIV+ women in 2005.

PRIMARY AND SECONDARY OUTCOMES

All deaths, AIDS deaths and non-AIDS deaths up to ~8 years from baseline.

RESULTS

Included together in one model, VACS Index was the dominant, significant independent predictor of all deaths within 3 years (HR=2.20, 95% CI 1.83, 2.65, χ²=69.04, p<0.0001), and later than 3 years (HR=1.55, 95% CI 1.30, 1.84, χ²=23.88, p<0.0001); followed by FFI within 3 years (HR=2.06, 95% CI 1.19, 3.57, χ²=6.73, p=0.01) and later than 3 years (HR=2.43, 95% CI 1.58, 3.75, χ²=16.18, p=0.0001). CES-D score was not independently associated with mortality.

CONCLUSIONS AND RELEVANCE

This is the first simultaneous evaluation of three common health indices in HIV+ adults. Indices reflecting physical and biological ageing were associated with death.

Women 50 and Older and HIV: Prevention and Implications for Health Care Providers

The current article discusses the importance of implementing HIV and AIDS education, prevention, and intervention programs that are tailored to women 50 and older and to determine HIV risk factors for this population. A literature search was performed, resulting in 41 relevant articles. The literature underscored the significance of increasing awareness of HIV/AIDS, particularly among older women. HIV risk behaviors and the effect that these behaviors have on HIV transmission and prevention among women 50 and older are described. Prior research findings identified risk categories of older women that may contribute to the transmission of HIV among this particular population, including heterosexual relations, perceived HIV risk, ageism and HIV transmission, biological factors, transfusions, sexual enhancement aids, and health care providers and prevention messages. In addition, previous findings indicate that health care providers have not traditionally targeted women 50 and older for HIV prevention. Health care providers should incorporate discussion of HIV risk and transmission during clinic visits and implement prevention programs that target this population. [Journal of Gerontological Nursing, 43(12), 29-34.].

Demographic and epidemiological characteristics of HIV opportunistic infections among older adults in Nigeria

BACKGROUND

In view of the maturing HIV epidemic in sub-Saharan Africa, better understanding of its epidemiology among older adults is necessary in order to design appropriate care and treatment programmes for them.

OBJECTIVES

To describe the demographic and epidemiological characteristics of HIV opportunistic infections among newly enrolled patients aged 50 years and above in Ibadan, South-West Nigeria.

METHODS

Analysis of data extracted from electronic records of 17, 312 subjects enrolled for HIV/AIDS care and treatment between January 2006 and December 2014 at the ART clinic, University College Hospital, Ibadan.

RESULTS

Age of the patients ranged from 18 to 90 years with a mean of 36.4 years (SD= 10.3) with older adults constituting 12.0% (2075). Among older adults, about half (52.9%) were females. Majority (59.1%) were currently married while 25.9% were widowed. Prevalence of opportunistic infections was 46.6%. The commonest opportunistic infections (OIs) were: oral candidiasis (27.6%), chronic diarrhoea (23.5% and peripheral neuropathy (14.8%). Significant factors associated with opportunistic infections in older adults were: CD4 count less than 350 (OR=3.12, CI: 2.29-4.25) and hepatitis C virus co-infection (OR=2.17, CI: 1.14-4.13).

CONCLUSION

There is need for prompt response to the peculiar challenges associated with the emerging shift in the epidemiology of HIV and associated infections in sub-Saharan Africa.

Neither 'foolish' nor 'finished': identity control among older adults with HIV in rural Malawi

Prevalence of HIV after age 50 is considerable, especially in southern Africa. Negative social constructions of HIV in older age, and the health consequences of ageing with the virus, mean that having HIV presents a challenge for many people's roles and social memberships, threatening to disrupt their sense of self. Using constructivist grounded theory and qualitative data from rural Malawi, this paper describes how older men and women deal with these identity challenges. Drawing on a symbolic interactionist framework, it uses identity control theory to explore how the study's participants presented their post-diagnosis behaviours in ways that maintained their most significant pre-diagnosis identities as 'adults', a label they gave to the core identity of being a person who belongs in the social world. Considering the processes through which older people with HIV navigated challenges to their identities in light of the intersectional influences of HIV and age-related stigma and illness, provides insight into how older people might experience HIV, as well as informing theoretical understandings of identity formation and maintenance in light of chronic and/or stigmatising illness more broadly.

The changing epidemiology of HIV in the criminal justice system

Although the rate of HIV infection among US prison inmates is considerably higher than that of the general population, little is known about age-related changes in HIV-infected inmates over the last decade. This study of the nation's largest state prison system examined (1) whether the mean age of the HIV-infected inmate increased over the last decade, and (2) whether the prevalence of HIV and associated comorbidities varied according to age. The study population included all 230,103 inmates incarcerated in the Texas prison system for any duration during 2014. A separate analysis was conducted on all HIV-infected inmates incarcerated between 2004 and 2014. Information on medical conditions and demographic factors was obtained from an institution-wide electronic medical record system. From 2004 to 2014, the mean age of HIV-infected inmates in the prison system increased from 39.3 to 42.5 years, compared to an increase of 36.1-37.9 for all Texas prison inmates. Multivariable logistic regression was used to assess the independent contributions of multiple demographic and clinical covariates in predicting the binary outcome, HIV infection. The model showed that, in 2014, HIV infection was elevated in inmates who were aged 40-49 years (OR = 3.1; 95% CI 2.7-3.3), aged 50-59 years (OR = 2.4; 95% CI 2.1-2.7), African American (OR = 3.0; 95% CI 2.8-3.3), and in those with several chronic diseases, including chronic obstructive pulmonary disease (OR = 1.7; 95% CI 1.5-1.9), hepatitis C (OR = 2.7; 95% CI 2.5-3.1), major depressive disorder (OR = 1.7; 95% CI 1.5-2.1), bipolar disorder (OR = 2.3; 95% CI 1.8-2.8), and schizophrenia (OR = 1.5; 95% CI 1.3-1.8). Among HIV-infected inmates (n = 2960), the percentage with comorbid disease increased in a linear fashion according to age (p < .01). Correctional health systems must adapt to address the evolving epidemiology of HIV among inmate populations.

HIV Futures 8: Protocol for a Repeated Cross-sectional and Longitudinal Survey of People Living with HIV in Australia

Introduction

More than 27,000 Australians currently live with HIV. Most of these people have access to quality clinical care and antiretroviral treatment (ART) and can expect good general health. However, HIV-related stigma is a problem and many people living with HIV experience poorer than average mental health. Issues of aging are also of increasing concern. This paper describes the methods and sample for the HIV Futures 8 study, a national survey of people living with HIV in Australia that aimed to identify factors that support health and well-being among this population. HIV Futures 8 forms part of a series of cross-sectional surveys (The “HIV Futures” studies) that have been repeated periodically since 1997. In the most recent survey, participants were able to opt into a prospective longitudinal study.

Materials and equipment

HIV Futures 8 was open to people aged over 17 who were living with HIV. Data were collected in 2015/2016 using a self-complete survey that contained approximately 250 items related to physical and mental health, use of ART, HIV exposure and testing, financial security, social connectedness, relationships, life satisfaction, resilience, stigma, use of health and support services, and health literacy. To enable comparison of cross-sectional data over time, questionnaire items were consistent with those used in previous HIV Futures surveys. In HIV Futures 8, participants were invited to volunteer coded information that will allow longitudinal follow-up when participants complete subsequent HIV Futures surveys. The survey was advertised through the networks of HIV organizations, on social media and through HIV clinics and services. HIV Futures 8 was completed by 895 participants. This represents approximately 3.8% of the total number of people living with diagnosed HIV in Australia in 2014.

Expected impact of the study on public health

Findings from HIV Futures 8 will contribute important insights into the complexity of factors that support physical and mental well-being among people living with HIV. The findings will also assist HIV services to align with broader public health goals related to increasing ART use and improving quality of life among people living with HIV.

Treatment Outcomes Among Older Human Immunodeficiency Virus-Infected Adults in Nigeria

Background

Older age at initiation of combination antiretroviral therapy (cART) has been associated with poorer clinical outcomes. Our objectives were to compare outcomes between older and younger patients in our clinical cohort in Jos, Nigeria.

Methods

This retrospective cohort study evaluated patients enrolled on cART at the Jos University Teaching Hospital, Nigeria between 2004 and 2012. We compared baseline and treatment differences between older (≥50 years) and younger (15–49 years) patients. Kaplan-Meier analysis and Cox proportional hazard models estimated survival and loss to follow-up (LTFU) and determined factors associated with these outcomes at 24 months.

Results

Of 8352 patients, 643 (7.7%) were aged ≥50 years. The median change in CD4 count from baseline was 151 vs 132 (P = .0005) at 12 months and 185 vs 151 cells/mm³ (P = .03) at 24 months for younger and older patients, respectively. A total of 68.9% vs 71.6% (P = .13) and 69.6% vs 74.8% (P = .005) of younger and older patients achieved viral suppression at 12 and 24 months, with similar incidence of mortality and LTFU. In adjusted hazard models, factors associated with increased risk of mortality were male sex, World Health Organization (WHO) stage III/IV, and having a gap in care, whereas being fully suppressed was protective. The risk of being LTFU was lower for older patients, those fully suppressed virologically and with adherence rates >95%. Male sex, lack of education, WHO stage III/IV, body mass index <18.5 kg/m², and having a gap in care independently predicted LTFU.

Conclusions

Older patients achieved better viral suppression, and older age was not associated with increased mortality or LTFU in this study.

Faces of Frailty in Aging with HIV Infection

PURPOSE OF THE REVIEW

The number of adults who are aging successfully and have HIV infection is increasing. More effective antiretroviral therapy (ART) regimens are preventing individuals infected with HIV from reaching end stages of the HIV infection and developing AIDS (acquired immunodeficiency syndrome). However, even at lower viral loads, chronic HIV infection appears to have consequences on aging processes, including the development of frailty.

RECENT FINDINGS

Frailty is a term used to describe vulnerability in aging. Frailty indices such as the Fried Frailty Index (FFI), the Veterans Aging Cohort Study (VACS) Index, and the Center for Epidemiologic Studies Depression scale (CES-D), an index of emotional frailty, associate with or predict clinical outcomes and death. However, even among existing frailty definitions, components require rigorous and consistent standardization. In the Women's Interagency HIV Study (WIHS), we have shown that frailty does not exist in isolation, even in midlife, and we use frailty to predict death. Frailty indices should be systematically used by health professionals to evaluate health and future risks for adverse events. Frailty prevention efforts, especially among those with HIV infection, appear to be essential for "successful aging" or aging without disability or loss of independence and may prevent HIV transmission. Taking care of elderly people is one of the major challenges of this century, and we must expect and be prepared for an increase in the number of aging adults, some of whom are patients with many co-morbidities and HIV infection.

Exploring gender perceptions of risk of HIV infection and related behaviour among elderly men and women of Ga-Rankuwa, Gauteng Province, South Africa

The literature shows that there are important differences between women and men in the underlying mechanisms of transmission of HIV infection and AIDS, as well as in the social and economic consequences of HIV/AIDS. These stem from sexual behaviour and socially constructed 'gender' differences between women and men in roles and responsibilities. Despite the fact that numerous gender-related sociocultural factors influence HIV/AIDS protective behaviours, little gender specificity is included in HIV prevention among the elderly. In order to close this gap, this study explored gender-related perceptions of risk of HIV infection among elderly men and women of Ga-Rankuwa in Gauteng Province, South Africa. This qualitative study used purposive sampling to conduct three focus group interviews with 22 women and 10 men who were above 60 years of age. Findings revealed that both genders blame each other for the spreading of HIV/AIDS. Male participants displayed the tendency to have multiple partners, whereas females accepted that males are promiscuous. Mixed perceptions about disclosure of HIV status were found. Condom use was a challenge, as men did not know how to introduce it with their wives, and some female participants indicated that men are resistant to using condoms. The elderly men also believed that women will have sex in exchange for money. It is concluded that there is a need for substantial behaviour change among both elderly males and females, which should address gender power relations. More in-depth and extensive research in this area is recommended.

Ageing and healthy sexuality among women living with HIV

Populations around the world are rapidly ageing and effective treatment for HIV means women living with HIV (WLHIV) can live longer, healthier lives. HIV testing and screening programmes and safer sex initiatives often exclude older sexually active WLHIV. Systematically reviewing the literature to inform World Health Organization guidelines on the sexual and reproductive health and rights (SRHR) of WLHIV, identified four studies examining healthy sexuality among older WLHIV. In Uganda, WLHIV reported lower rates of sexual activity and rated sex as less important than men. In the United States, HIV stigma, disclosure, and body image concerns, among other issues, were described as inhibiting relationship formation and safer sexual practices. Sexual activity declined similarly over time for all women, including for WLHIV who reported more protected sex, while a significant minority of WLHIV reported unprotected sex. A single intervention, the "ROADMAP" intervention, demonstrated significant increases in HIV knowledge and decreases in HIV stigma and high risk sexual behaviour. WLHIV face ageist discrimination and other barriers to remaining sexually active and maintaining healthy sexual relationships, including challenges procuring condoms and seeking advice on safe sex practices, reduced ability to negotiate safer sex, physical and social changes associated with menopause, and sexual health challenges due to disability and comorbidities. Normative guidance does not adequately address the SRHR of older WLHIV, and while this systematic review highlights the paucity of data, it also calls for additional research and attention to this important area.

HIV pharmaceutical care in primary healthcare: Improvement in CD4 count and reduction in drug-related problems

Background: Highly active antiretroviral therapy (HAART) is complex and many factors contribute to a patient's response to initial therapy including adherence, drug effectiveness, and tolerance. Close HAART follow-up is needed, particularly when there are concurrent therapies such as prophylactic antibiotics and medications for the treatment of comorbidities. Objective: To assess the effectiveness of pharmacist intervention in reducing drug related problems in HIV/AIDS outpatients (intervention group) and in improving clinical parameters in the intervention group compared to the control group. Methods: We conducted a prospective controlled intervention study with patients paired by gender and initial T CD4+ lymphocyte (CD4) count. HIV-infected patients of a public outpatient service were enrolled for the study by consecutive and convenience sampling. Patients selected for the study were divided into a control group and an intervention group. Both groups were followed for one year; however, only the intervention group received pharmaceutical care. The primary outcome was the drug related problem (DRP) analysis for the intervention group. Secondary outcomes were CD4 count and viral load evaluation for both groups. Results: There was a total of 143 patients enrolled in this study, with 53 (37.06%) patients in the control group and 90 (62.94%) patients in the intervention group. A total of 202 pharmacist interventions with 193 pharmacist-patient and 9 pharmacist-physician interventions were proposed. After one year of pharmaceutical care, a reduction of 38.43% between the initial and final DRP was found (p = 0.0001). The most common DRPs found were related to medication safety. The intervention group showed a mean increase of 84% for the CD4 count in comparison with that observed in the control group. The viral load was not significantly different between the final and initial mean values for both groups. Conclusion: Pharmacist appointments enabled identification, prevention, and solving of drug related problems, especially those related to drug safety. Also, pharmacist interventions improved adherence and increased HAART effectiveness as suggested by the higher elevation in the CD4 count seen in the intervention group in comparison with the control group.

Correlates of Combination Antiretroviral Adherence Among Recently Diagnosed Older HIV-Infected Adults Between 50 and 64 years

Optimal adherence to combination antiretroviral therapy is essential to the health of older people living with HIV (PLWH), however, the literature on adherence and aging is limited. Using Medicaid data from 29 states (N = 5177), we explored correlates of optimal adherence among older PLWH. The prevalence of optimal adherence was low (32 %) in this study. Males were more adherent than females (APR = 1.11, 95 % CI 1.02-1.21, P = 0.0127); persons with three or more co-morbidities (APR = 0.67, 95 % CI 0.60-0.74, P < 0.001), two co-morbidities (APR = 0.86, 95 % CI 0.75-0.98, P = 0.0319) and one co-morbidity (APR = 0.82, 95 % CI 0.73-0.92, P = 0.0008) were less adherent than those without any co-morbidity; and residents of rural areas (APR = 0.90, 95 % CI 0.63-0.98, P = 0.0385) and small metropolitan areas (APR = 0.82, 95 % CI 0.72-0.94, P = 0.0032) were less adherent than residents of large metropolitan areas. There were no racial differences in optimal adherence. Targeted interventions that provide adherence support, case management, and peer navigation services may be of benefit in achieving optimal adherence in this population.

Chronic health conditions in Medicare beneficiaries 65 years old, and older with HIV infection

OBJECTIVES

To examine sociodemographic factors and chronic health conditions of people living with HIV (PLWHIV/HIV+) at least 65 years old and compare their chronic disease prevalence with beneficiaries without HIV.

DESIGN

National fee-for-service Medicare claims data (parts A and B) from 2006 to 2009 were used to create a retrospective cohort of beneficiaries at least 65 years old.

METHODS

Beneficiaries with an inpatient or skilled nursing facility claim, or outpatient claims with HIV diagnosis codes were considered HIV+. HIV+ beneficiaries were compared with uninfected beneficiaries on demographic factors and on the prevalence of hypertension, hyperlipidemia, ischemic heart disease, rheumatoid arthritis/osteoarthritis, and diabetes. Odds ratios (OR), 95% confidence intervals (CIs), and P values were calculated. Adjustment variables included age, sex, race/ethnicity, end stage renal disease (ESRD), and dual Medicare-Medicaid enrollment. Chronic conditions were examined individually and as an index from zero to all five conditions.

RESULTS

Of 29 060 418 eligible beneficiaries, 24 735 (0.09%) were HIV+. HIV+ beneficiaries were more likely to be Hispanic, African-American, male, and younger (P > 0.0001) and were 1.5-2.1 times as likely to have a chronic disease [diabetes (adjusted OR) 1.51, 95% CI (1.47, 1.55): rheumatoid arthritis/osteoarthritis 2.14, 95% CI (2.08, 2.19)], and 2.4-7 times as likely to have 1-5 comorbid chronic conditions [1 condition (adjusted OR) 2.38, 95% CI (2.21, 2.57): 5 conditions 7.07, 95% CI (6.61, 7.56)].

CONCLUSION

Our results show that PLWHIV at least 65 years old are at higher risk of comorbidities than other fee-for-service Medicare beneficiaries. This finding has implications for the cost and health management of PLWHIV 65 years and older.

Design and validation of a predictive model for 1-year hospital admission in HIV patients on antiretroviral treatment

Objectives

To develop and validate a model for predicting the risk of hospital admission within 1 year in the HIV population under antiretroviral treatment.

Methods

We conducted a retrospective observational study. Patients receiving antiretroviral treatment for at least 1 year who were followed by the pharmacy service in a Spanish-speaking hospital between January 2008 and December 2012 were included. Demographics, and clinical and pharmacotherapy variables, were included in the model design. To find prognostic factors for hospital admission a multivariate logistic regression model was created after performing a univariate analysis. Model validity was determined by the shrinkage method and the model discrimination by Harrell's C-index.

Results

442 patients were included in the study. The variables 'CD4 count <200 (cells/µL)', 'drug/alcohol use', 'detectable viral load (>50 copies/mL)', 'number of previous admissions', and 'number of drugs different from antiretroviral treatment' were the independent predictors of risk of hospital admission. Probabilities predicted by the model showed an R²=0.98 for the development sample and an R²=0.86 for the validation sample. The Harrell's C index for the development and validation data were 0.82 (95% CI 0.77 to 0.87) and 0.80 (95% CI 0.73 to 0.88), respectively.

Conclusions

The model developed in this study may be useful in daily practice for identifying HIV patients at high risk of 1-year hospital admission.

Clinical characteristics and outcomes of HIV-seropositive men treated with surgery for prostate cancer

PURPOSE

The natural history and optimal management strategy for men with human immunodeficiency virus (HIV) and prostate cancer remain to be definitively characterized. This study was conducted to evaluate the clinical characteristics and outcomes of HIV-seropositive men treated with robotic-assisted radical laparoscopic prostatectomy for localized prostate cancer.

METHODS

After Institutional Review Board approval, a prospective database of 2175 operative cases of clinically localized prostate adenocarcinoma was reviewed. Thirteen patients were identified as HIV-positive. Tumor characteristics, operative outcomes, postoperative outcomes, histology (Gleason score), local invasion, biochemical recurrence, and surgical complications were compared with HIV-negative patients.

RESULTS

There were no preoperative demographic differences between the HIV-positive and HIV-negative patients. HIV-positive patients had higher prostate specific antigen (PSA) levels at time of diagnosis which was not statistically significant. However, HIV-positive patients had higher D'Amico risk assessment (p < 0.05). There was no postoperative complication. HIV-positive patients treated with robotic prostatectomy had similarly favorable perioperative and short-term biochemical recurrence-free survival outcomes.

CONCLUSION

Our findings show that minimally invasive prostatectomy can be safely considered as a therapeutic option in otherwise eligible HIV-positive patients with clinically significant prostate cancer. Further research is necessary to outline a diagnostic and treatment guideline for HIV-positive men in detection and treatment of prostate cancer.

Frailty and Constellations of Factors in Aging HIV-infected and Uninfected Women--The Women's Interagency HIV Study

BACKGROUND

Biological similarities are noted between aging and HIV infection. Middle-aged adults with HIV infection may present as elderly due to accelerated aging or having more severe aging phenotypes occurring at younger ages.

OBJECTIVES

We explored age-adjusted prevalence of frailty, a geriatric condition, among HIV+ and at risk HIV- women.

DESIGN

Cross-sectional.

SETTING

The Women's Interagency HIV Study (WIHS).

PARTICIPANTS

2028 middle-aged (average age 39 years) female participants (1449 HIV+; 579 HIV-).

MEASUREMENTS

The Fried Frailty Index (FFI), HIV status variables, and constellations of variables representing Demographic/health behaviors and Aging-related chronic diseases. Associations between the FFI and other variables were estimated, followed by stepwise regression models.

RESULTS

Overall frailty prevalence was 15.2% (HIV+, 17%; HIV-, 10%). A multivariable model suggested that HIV infection with CD4 count<200; age>40 years; current or former smoking; income ≤$12,000; moderate vs low fibrinogen-4 (FIB-4) levels; and moderate vs high estimated glomerular filtration rate (eGFR) were positively associated with frailty. Low or moderate drinking was protective.

CONCLUSIONS

Frailty is a multidimensional aging phenotype observed in mid-life among women with HIV infection. Prevalence of frailty in this sample of HIV-infected women exceeds that for usual elderly populations. This highlights the need for geriatricians and gerontologists to interact with younger 'at risk' populations, and assists in the formulation of best recommendations for frailty interventions to prevent early aging, excess morbidities and early death.

Spatial dynamics of AIDS incidence in the elderly in Rio de Janeiro, Brazil, 1997-2011

The dynamics of the spread of the AIDS epidemic ranges according to the characteristics of each geographical region in different population groups. The aim of this study was to evaluate spatial and temporal trends of the AIDS epidemic among the elderly in the State of Rio de Janeiro, Brazil. A retrospective study using spatial analysis techniques was conducted among AIDS cases (≥ 60 years) diagnosed from 1997-2011. The Poisson regression model was used to assess the relationship between year of diagnosis and incidence of AIDS, adjusted by sex. The AIDS epidemic began in the south coast of the state and gradually reached neighboring cities. The highest rates were found in regions around Rio de Janeiro and Niterói cities. The highest smoothed rates of the period were observed in Niterói in 2002-2006: 11.87/100,000 (men) and 8,5/100,000 (women). AIDS incidence rates among the elderly have stabilized in recent decades. To prevent HIV from spreading further among the general population, greater attention should be given to the older population.

Chronic pruritus in the elderly: pathophysiology, diagnosis and management

Chronic itch in the elderly is a common problem, with a significant impact on quality of life and sleep in elderly patients. Chronic itch may be attributable to several causes, including dry skin, immunosenescence and neural degeneration. Itch may also be caused by skin diseases, such as seborrhoeic dermatitis and stasis dermatitis; systemic conditions, such as end-stage renal disease and diabetes; and psychogenic conditions, such as depression and anxiety. The use of polypharmacy may also cause itch, with or without a rash. Specifically, thiazides and calcium channel blockers have been known to cause itch in elderly patients. Management should be tailored according to the underlying dermatological or systemic aetiology of itch. Topical treatment is the mainstay of therapy, providing special emphasis on skin hydration and barrier repair. In addition, topical and oral medications that target the nervous system and reduce neuronal hypersensitization, such as gabapentin and selective antidepressants, have a role in treating patients with severe chronic itch. Furthermore, management must account for changes in metabolism and pharmacokinetics of drugs in the aging population in order to prevent the occurrence of adverse effects.

Lessons to Exchange: A Comparison of Long-Term Care Between Two Cultures: Uganda and Singapore

Today, both the developed and developing world are facing fast-aging populations. Projections show that by 2050, 80% of the world's older persons will live in low and middle-income countries. As developed countries look to institutionalization as one of the means to cope with the challenges of long-term care of seniors, the developing world, with a different cultural, socioeconomic, and environmental context, may yet offer insights that instruct and inspire. By analyzing and comparing the approaches, context, and progress of Singapore and Uganda in coping with frail and dependent seniors, this article provides lessons about what the developing and developed world can offer each other, and in turn, teach us about long-term care of seniors.

Increased susceptibility of CD4+ T cells from elderly individuals to HIV-1 infection and apoptosis is associated with reduced CD4 and enhanced CXCR4 and FAS surface expression levels

Background

Elderly HIV-1 infected individuals progress to AIDS more frequently and rapidly than people becoming infected at a young age. To identify possible reasons for these differences in clinical progression, we performed comprehensive phenotypic analyses of CD4+ T cells from uninfected young and elderly individuals, and examined their susceptibility to HIV-1 infection and programmed death.

Results

Peripheral blood mononuclear cells (PBMCs) from older people contain an increased percentage of central memory and Th17 CD4+ T cells that are main target cells of HIV-1 and strongly reduced proportions of naïve T cells that are poorly susceptible to HIV-1. Unstimulated T cells from elderly individuals expressed higher levels of activation markers, death receptors, and the viral CXCR4 co-receptor than those from young individuals but responded poorly to stimulation. CD4+ T cells from older individuals were highly susceptible to CXCR4- and CCR5-tropic HIV-1 infection but produced significantly lower quantities of infectious virus than cells from young individuals because they were highly prone to apoptosis and thus presumably had a very short life span. The increased susceptibility of T cells from the elderly to HIV-1 infection correlated directly with CXCR4 and inversely with CD4 expression. The levels of apoptosis correlated with the cell surface expression of FAS but not with the expression of programmed death receptor 1 (PD1) or tumor necrosis factor-related apoptosis-inducing ligand (TRAIL).

Conclusions

Increased levels of activated and highly susceptible HIV-1 target cells, reduced CD4 and enhanced CXCR4 cell surface expression, together with the high susceptibility to FAS-induced programmed cell death may contribute to the rapid CD4+ T cell depletion and accelerated clinical course of infection in elderly HIV-1-infected individuals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12977-015-0213-1) contains supplementary material, which is available to authorized users.