Although equally considered “older people with HIV”, long-term HIV survivors and people with HIV who are aged over 65 have markedly different characteristics and related needs. This is what a Spanish study published in PLOS ONE has found, confirming that people who are ageing with HIV are a heterogeneous group.
Today, half of people with HIV are aged over 50 and this population keeps growing. This is due to the success of antiretroviral therapy and the increase of new HIV diagnoses in this age group. Older adults with HIV may have additional health conditions (co-morbidities) which, however, often present differently between individuals.
To what extent do these differences matter? Dr Fátima Brañas from the Hospital Universitario Infanta Leonor in Madrid and colleagues evaluated differences between older people with HIV, taking into account both age and how long people had been diagnosed for.
The investigators analysed data from 801 participants recruited in 2018-2019 in FUNCFRAIL, a Spanish cohort study of people with HIV aged fifty years and over.
Participants were stratified into three groups according to their chronological age (how long a person has lived) when joining the study: younger (50-54), intermediate (55-64) and older (over 65 years). They were also stratified into two groups, based on when they were diagnosed with HIV: long-term HIV survivors (before 1996) and HAART-era participants (from 1996 onwards, when highly active antiretroviral therapy became widely available in Spain).
Data were recorded on participants’ sociodemographic profiles, HIV infection, polypharmacy (five or more medicines other than antiretrovirals) and comorbidities: hypertension, diabetes, dyslipidaemia, coronary heart disease, stroke, chronic obstructive pulmonary disease (COPD), chronic kidney disease, cancer (less than five years after diagnosis), a history of cancer (over five years after diagnosis), depression, psychiatric disorders and osteoarticular disease (for example, arthritis).
Each participant went through a geriatric assessment, including an evaluation of frailty, falls, strength, gait speed and balance. (Frailty is a syndrome comprising body shrinking, weakness, poor endurance, low energy, slowness and limited physical activity that is prevalent in older adults.) Specific questionnaires tested cognitive impairment, depression, quality of life and pain.
Of the 801 participants, 195 (25%) were women. Median age was 57, with 36% aged 50-54, 49% aged 55-64 and 15% aged 65 or over. Almost half (47%) were long-term HIV survivors.
The analysis by chronological age revealed that participants 65 or over had been on average twenty years older than their younger counterparts at HIV diagnosis (53 years vs 31; p <0.001). They had lived with known HIV for the fewest years (17 vs 21 and 23 in the younger and intermediate groups, respectively; p <0.001) and significantly more of them were gay and bisexual men than in the other groups (48% vs 31% and 25% in the younger and intermediate groups, respectively; p 0.001). More participants aged 65 or over lived alone (49% vs 33% and 38%, p = 0.007).
Regarding virological and immunological response to antiretroviral therapy, there were no differences between age groups.
Compared to the youngest group, more participants 65 or over had three or four co-morbidities (34% vs 22%; p = 0.001), with the over 65s bearing the brunt of hypertension (42% vs 24% in the youngest), diabetes (25% vs 9%) and dyslipidaemia (51% vs 35%). However, depression was more prevalent in the younger and intermediate groups (15% and 18%, respectively) than in the older group (8%).
In the younger and intermediate groups, current smoking was triple the 16% rate found among the 65 or over (52% and 48%, respectively; p <0.001). Polypharmacy was significantly higher among the oldest participants (35%) than in the other age groups (around 25%). Frailty was more than twice as prevalent in the oldest age group (11% vs 4% and 5% in the 50-54 and 55-64, respectively). The proportion of participants 65 or over with functional impairment was double that of the other age groups (32% vs 12% and 15%).
Among those 65 or over, cognitive impairment was twice as prevalent (22%) as in the 50-54 (9%) and the 55-64 (11%). There were no differences between age groups regarding quality of life.
Comparing people diagnosed before and after 1996
Turning to the analysis by period of HIV diagnosis, the investigators found that women accounted for 31% of long-term HIV survivors but only 19% of the HAART-era group (p <0.001).
Of long-term HIV survivors, 56% were 55-64 years old and 9% were 65 or over when entering the study. Twenty per cent of the HAART-era participants were aged 65 or over when they joined the study – twice the proportion of long-term HIV survivors.
There were significant differences by how people acquired HIV: 61% of the long-term survivors used or had used injectable drugs, compared to 14% of the HAART-era participants. Sexual transmission was less common in the long-term survivors (34%) than among the HAART-era participants (76%). Although these differences are striking, the researchers told aidsmap.com that acquisition route was not associated with frailty, comorbidities or multimorbidity.
” Long-term HIV survivors have the highest rates of comorbidities, including those affecting quality of life.”
Significantly, more HAART-era participants than long-term HIV survivors lived alone (44% vs 31%, p <0.001).
No differences were observed regarding virological and immunological outcomes.
The mean number of comorbidities was significantly higher among long-term HIV survivors (2.6 vs 1.8 in the HAART-era group), as was the proportion of participants having five or more comorbidities (16% vs 8%). But although some comorbidities (e.g. depression, COPD) were more prevalent in long-term HIV survivors, this was not the case for some others (e.g. hypertension, diabetes, heart attack).
More long-term HIV survivors smoked than in the HAART-era group (54% vs 37%; p <0.001). Likewise, polypharmacy was more prevalent in long-term HIV survivors (31% vs 22%, p <0.001), as was the use of neuroleptics (17% vs 7%; p <0.001), benzodiazepines (27% vs 15%; p <0.001) and hypnotics (32% vs 3%; p <0.001).
No significant differences were seen between long-term HIV survivors and HAART-era individuals in terms of frailty (5% vs 6%) or falls (18% vs 14%). However, cognitive impairment was lower among long-term survivors (9% vs 14%).
Quality of life was significantly worse in long-term HIV survivors, compared to HAART-era participants (fair or poor quality of life reported by 63% vs 52%; p <0.01). Importantly, pain was more prevalent in long-term survivors (41% vs 31%).
Clearly, the study shows that long-term HIV survivors present the highest rates of comorbidities, including those known to have a stronger negative impact on quality of life, such as COPD, cancer, depression and pain. However, no differences emerged between long-term HIV survivors and HAART-era individuals in terms of frailty, demonstrating that although frailty and comorbidities are frequent in long-term HIV survivors, they are not necessarily connected.
Brañas and colleagues say their results are interesting “because HIV care providers, when referring to the older adults with HIV, commonly assume this group is mostly formed by those diagnosed before 1996.” In fact, care for older adults with HIV cannot rely on such misconceptions. Rather, it should be based on a comprehensive understanding of the many differences in this population revealed by this study.