HIV and Age: do older patients fare as well as younger?
Reported by Jules Levin
It is estimated that 5-11% with HIV are older than 50 years. This is a group of patients who receive little attention in terms of research and prevention efforts.
Below are two studies related to this question of HIV and older age. The results from one study suggest that the older a person is when they get HIV the more likely they are to progress more quickly. The results from the second study suggest that older patients respond to HAART equally as well as younger patients. But this second study had some limitations, as I see it. It compared only people over 55 to those under 40. And almost twice as many whites as African-Americans were in the older group (91% vs 56%). As well, this study only followed people for 12 months. Clearly, more and better focused research appears indicated if we are to understand more about HIV in people over 50 years of age.
A popular question related to HIV and older folks: is treatment response different?
Here is a research paper published in a science journal called Lancet (April 2000) showing data suggesting that age at time of getting HIV before the era of HAART predicts survival and time to developing AIDS.
People over 65 progressed twice as quickly as people 25-34 (9.8 yrs vs 5 yrs). Time of survival and development of AIDS worsened as age at time of seroconversion increased. For example in this study, persons 25-34 years of age survived 11 years and developed AIDS after 10 years. This compared to patients 45-54 who died after 8 years and developed AIDS after 8 years. This study did not address what happens after a person starts ART or HAART treatment. (See "Age at Time of Seroconversion Reported to be Key Prognostic Factor in Era Before HAART")
At Retrovirus Conference (Feb 2001), a Canadian research group reported on the response to HAART by people over 55 compared to those under 40: "Effectiveness of Antiretroviral Therapy in the Elderly Compared to a Younger Cohort". This study looks at the response to therapy but followed patients for only about 12 months, and only in people over 55 years of age compared to patients younger than 40 yrs of age. The study finds no differences in cd4 and viral load response between the two groups. However, there were almost twice as many whites as African-Americans in the older group. So, if there were an equal amount of African-Americans and whites in both groups would the older group had done as well? We dont know. The follow-up is short--only 12 months, as cd4 & viral load response over the longer term may differ.
The study found that over the follow-up period of about 12 months the development of opportunistic infections was about the same in both groups (21% vs 24%). But, perhaps most important, this study does not look at the effects of age on developing other complications as one gets older: side effects & toxicities from medications, hepatitis and other complications that may emerge due to aging such as heart disease, and the capacity to tolerate treatment due to the development of side effects, toxicities and complications.
Another factor not addressed by these studies-- is discerning the differences of effect between age and length of time a person has had HIV. Obviously, the longer a person has HIV the greater the chance of complications, but how much of an effect on this does age have. The development of lipodystrophy (body changes) and metabolic abnormalities (sugar, cholesterol, tryglicerides) may be worse the longer a person has HIV and is on HIV therapy, and may worsen with age as the human body declines.
Here is the full abstract of this study from the Retrovirus Conference program book:
Authors: A. Chakroborty, V. Waring, and I. E. Salit; Toronto Gen. Hosp., Ontario, Canada.
511% of those with HIV are >50 years old. The elderly have more rapid progression to AIDS before the use of HAART as article above suggests. In the HAART era, it is not known if elderly patients receive therapy as frequently as younger patients and if they respond similarly.
This study selected out of 1200 clinic patients 90 patients over 55 and 90 undr 40 years of age. It is a retrospective case-control study in a tertiary-care HIV clinic. The elderly cohort consisted of all patients in this clinic with age >55 years. Each older patient (case) was matched to a younger patient age <40 years (control). Matching was done on baseline CD4, baseline viral load and year of HIV diagnosis, and comparisons were done using the paired T-test. There were 90 case-control pairs followed >12 months.
The elderly patients comprised 7.5% (90/1200) of the clinic population. The median age of the cases was 59 years, and that of the controls was 36 years. The groups also differed in race: more of the elderly patients were white (91% vs. 56%), P < 0.001 (having more whites might have effected the outcomes in the elderly group). The elderly and younger patients did not differ in risk category, gender, median duration of infection or antiretroviral use: antiretroviral naïve, 10% vs. 9%; ever used a PI, 69% vs. 79%; current PI use, 62% vs. 67%; and currently on no antiretrovirals, 17% vs. 19%. This suggests the older & younger groups were comparable in other respects than race, where they differed.
The two groups were well matched for baseline CD4 (cases vs. control, 336 vs. 347; CD4 >450, 22% vs. 25%; and CD4 <50, 10% vs. 9%) as well as baseline viral load (median viral load was 4.64 vs. 4.12) (P = N.S.).
CD4 increases were same for young & older group: the change in CD4 counts from baseline to current CD4 (+74 vs. +69 CD4 cells) (P = 0.88; not statistically significant) or from baseline to peak CD4 did not differ between the two groups.
Viral load response to therapy was the same in older and younger groups: there was also no significant difference in the response of the viral load to antiretroviral therapy in the elderly vs. the younger cohort: 73% vs. 69% had a >1 log decrease, 63% vs. 70% ever had an undetectable (<50) viral load (UDVL), and 40% vs. 36% currently have an UDVL. The durability of the UDVL was similar in the elderly and younger patients (at 3 months, 47/90 (52%) vs. 57/89 (64%), and at 6 months, 39/90 (43%) vs. 47/89 (53%) (P = N.S.)) Opportunistic infections occurred at any time in 21% vs. 24%, and the mortality was 0% over 12 months.
The study authors concluded that in our clinic setting, elderly patients compared to younger patients received similar antiretroviral therapies and had similar immunologic recovery and suppression of plasma viral load. But, I have questions about these conclusions. First, there were almost twice as many whites as African-Americans in older group. Even if response to therapy is the same between younger & older (55 vs 40, and 55 may be different than 65), this study does NOT look at eventual outcome over longer term. The study follow-up is only 12 months.