icon star paper   Articles  
Back grey_arrow_rt.gif
HIV and AGE: Do Older People Fare as Well as Younger?
By Jules Levin
  Although there is little research and knowledge on the subject of how aging affects HIV and the response to HIV therapy, this article will discuss three relevant studies that have been conducted. If we are to better understand HIV and aging, more research resources will have to be devoted to studies. Because researchers have different priorities, strong advocacy is necessary in order to bring more research resources to this subject.
Karl Goodkin, M.D., a psychiatrist at the University of Miami in Florida, is now studying how HIV affects intellectual skills and motor functioning of people 50 years and older. Data from the Centers for Disease Control (CDC) show that while patients 50 and older made up 9.7 percent of AIDS cases in 1993, that percentage rose to 13.4 percent in 1999.
With a 1998 grant from the National Institutes of Health, Goodkin started recruiting 286 people, seeking both HIV infected participants and those who are not. To date, he has enrolled 196 persons, who have undergone a battery of physical and psychological tests. The researchers found that older HIV-positive participants have a level of symptoms approaching twice that of younger infected people. The gap is almost as dramatic when infected older people are compared with those who are virus free.
The results from a second study suggest that older patients respond to HAART (highly active antiretroviral therapy) equally as well as younger patients. But there are a few limitations to the study and its conclusions because (1) the study compared only people over 55 to those under 40, (2) the older group included almost twice as many whites as African-Americans, (3) the study only followed people for 12 months, and (4) this was not a randomized study. [This study is described in more detail beginning in the seventh paragraph.]
A third research paper, published in Lancet (April 2000), contained data suggesting that age at the time of HIV infection, before the era of HAART, can predict survival and how soon AIDS develops. People over 65 progressed twice as quickly as people ages 25-34 (9.8 years vs. five years). Length of survival and onset 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 eight years and developed AIDS after eight years. This study did not address what happens after a person begins ART or HAART treatment, so the question remains: can the introduction of HAART influence the differences in progression between younger and older persons?
At the Human Retrovirus Conference in February, 2001, a Canadian research group consisting of A. Chakroborty, V. Waring and I.E. Salit from Toronto General Hospital in Ontario, reported on the response to HAART by people over 55 compared to those under 40. The study, "Effectiveness of Antiretroviral Therapy in the Elderly Compared to a Younger Cohort," looks at the response to therapy after 12 months only in people over 55 years of age compared to patients younger than 40 years 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. The follow up is short, only 12 months of therapy; CD4 and viral load response over longer term may differ.
Perhaps more important, this study does not examine the effects of age on development of other complications. Do the elderly have worse experiences with side effects and toxicities from medications? What about hepatitis and other aging complications, such as heart disease? What about the capacity to tolerate treatment due to the development of side effects, toxicities and complications?
Another factor is discerning the differences between the effect of age and length of time a person has lived with HIV. Obviously, the longer a person has the HIV, the greater the chance of complications; but how much effect on complications does age have? The development of lipodystrophy (body changes) and metabolic abnormalities (sugar, cholesterol, tryglicerides) may increase the longer the person has HIV and is on HIV therapy, and may worsen with age. We know, for example, that as people age, they are more likely to develop stomach paunch. The risk for heart disease may be a concern. How about bone loss? As healthy persons age, particularly women, will HIV-induced bone loss have increased affect on older HIV-infected individuals? What will be the effect of having taken HAART for a protracted time of say 30 years as a person reaches 60+, on unknown or known complications? The development of new drugs or therapies may change all this. Perhaps, new drugs will not have affects similar as the current drugs.
This study selected 90 patients out of 1,200 who were over age 55, and 90 patients who were under 40 years of age. It is a retrospective case-control study in an HIV clinic. Each older patient (case) was matched to a younger patient under 40 years (control). This type of case-control study may not be as good as one that is randomized. Matching was done on baseline CD4, baseline viral load and year of HIV diagnosis. There were 90 case-control pairs followed for more than 12 months.
The elderly patients comprised 7.5% (90/1200) of the clinic population. The median age of cases was 59 years; of the controls, 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 affected the outcomes in the elderly group). The older and younger patients did not differ in risk category, gender, median duration of infection or antiretroviral use:
Antiretroviral naive, 10% vs. 9%; ever used a Pl, 69% vs. 79%; current Pl use, 62 % vs. 67%; currently not on antiretrovirals, 17% vs. 19%. This suggests the older and younger groups were comparable in most respects other 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.)
Results: CD4 increases were same for young and older group: the change in CD4 counts from baseline to current CD4 (+74 vs. + 69 CD 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 6 months, 39/90 (43%) vs. 47/89 (53%) (P = N.S.)) Opportunistic infections occurred at any time in 21% vs. 24%, and the morality was 0% over 12 months.
The authors concluded that, in their clinic setting, the elderly (in comparison 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. As I noted earlier, there were about twice as many whites as African-Americans in the older group. Even if response to therapy is the same between younger & older (>55 yrs. vs. <40 yrs), this study does not look separately at people who are >65 yrs. This study does not look at eventual outcome over a longer term; the study follow-up is only 12 months.
One final point: because there are no conclusive studies, it is uncertain if elderly patients are offered HAART or have equal access to treatment. Consider, for example, a general practice physician who may not believe an older person is at risk for HIV, and therefore, does not offer testing. The same can be true for women, in general.
  icon paper stack View Older Articles   Back to Top   www.natap.org