HIV and ageing: starting treatment promptly is important
Current UK HIV treatment guidelines recommend that people should start antiretroviral therapy when their CD4 cell count is around 350.
People over 50 are one of the groups encouraged to start treatment promptly. This is because older age is associated with declines in immune function. In addition, health problems associated with ageing are an increasingly important cause of illness and death in people living with HIV.
Researchers wanted to see the impact of late diagnosis and not starting HIV therapy on short-term outcomes, especially in older people.
The study population comprised 64,000 adults newly diagnosed with HIV in England, Wales and Northern Ireland between 2000 and 2009.
People were defined as older if they were aged 50 or over. Researchers examined mortality rates one year after diagnosis and also the factors associated with mortality.
Overall, 9% of people newly diagnosed with HIV were aged 50 or older.
Almost half of older people had a CD4 cell count below 200 when they entered care and were therefore considered to be diagnosed very late. A third of younger people were also diagnosed very late.
A CD4 cell count below 200 is associated with an increased risk of serious illness and death.
The twelve-month mortality rate among older people was 10%. This compared to a 3% mortality rate in people aged 49 or younger.
Mortality risk was especially high for older people diagnosed late who did not start HIV therapy (46 vs 15% for younger people).
Starting antiretroviral therapy was beneficial for people diagnosed late. The benefits were greatest for people aged 50 and older, with treatment associated with a 40% reduction in the absolute number of deaths, compared to a 12% absolute reduction in younger people.
The researchers conclude that their findings show the importance of prompt HIV diagnosis and early antiretroviral therapy, especially for older people.
HIV and ageing: the changing profile of the HIV-positive population
An increasing proportion of people living with HIV in richer countries are in older age groups.
It’s clear from the UK research that this is partly explained by an increase in the number of diagnoses in older people. In 2000, 8% of new HIV cases involved people aged 50 and older; this had increased to 13% in 2009.
There was even more startling evidence of ageing in a study conducted in San Francisco.
Researchers looked at the age of people diagnosed with AIDS between 1990 and 2010.
In the US, a person may be diagnosed as having AIDS if they have HIV and an opportunistic infection (sometimes called an ‘AIDS-defining illness’), or if they have HIV and a CD4 cell count below 200 cell/mm3, even if they don’t have an opportunistic infection.
There was a sharp fall in the number of new AIDS diagnoses over the 20 years of the study, further evidence of the success of antiretroviral therapy.
At the end of 2010 there were almost 10,000 people living with AIDS in San Francisco and 52% were aged 50 or older.
In 1990, the average age of people with AIDS in the city was 38 years and 48% were aged between 35 and 44. Overall, 90% of patients were aged under 50.
By 2010, however, the average age had increased to 50, only 21% were in the 35 to 44 age group and only 48% were aged under 50.
The researchers believe there are two reasons for their findings: (i) ongoing HIV transmissions and new diagnoses in older people; (ii) the success of HIV treatment in reducing HIV-related deaths.
It’s excellent news that an increasing proportion of people with HIV are living into old age. But this is going to have implications for their care.
“Older people with HIV/AIDS face both HIV/AIDS-related and age-related co-morbidities, such as hypertension [high blood pressure], chronic pain, hepatitis and arthritis, which are associated with poorer physical, mental and social well-being,” note the researchers. “A National Institutes of Health-commissioned HIV and aging working group has emphasized the need for research on the interaction of age and HIV infection and also the necessity for increased community support, caregivers, and systems infrastructure.”
HIV and hepatitis
Large numbers of people living with HIV also have HBV and/or HCV. Liver disease caused by these co-infections is an increasingly important cause of illness and death.
Monitoring liver health is an important part of routine care. The ‘gold standard’ test for assessing the extent of liver disease is a liver biopsy. This involves a minor operation and the removal of a small amount of liver tissue for examination in the lab. However, liver biopsies are uncomfortable and can involve a risk of complications.
One potential test involves monitoring blood levels of hyaluronic acid.
Clearance of hyaluronic acid is impaired in people with liver disease. Research conducted in people with hepatitis mono-infection (i.e. who don’t have HIV) showed that elevations in its levels were associated with an increased risk of serious liver-related illness and death.
Researchers wanted to see if this was also the case in people with hepatitis and HIV co-infection.
They therefore monitored 1252 people over eight years.
Overall, 7% of patients developed serious liver disease or died of liver-related causes.
People with normal hyaluronic acid levels had a 1% risk of developing a serious liver-related event over five years. This compared to a 12% risk for people with elevations in hyaluronic acid.
The higher the level of hyaluronic acid, the bigger the risk of liver disease.
Levels of the hyaluronic acid remained steady in people who did not experience a liver-related event, but increased steadily in people who did.
“Plasma hyaluronic acid may be useful, either alone or in combination with other non-invasive markers, to monitor progression of liver disease and risk of complications in patients with chronic viral hepatitis,” conclude the researchers.
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