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Immunologic and clinical responses to highly active antiretroviral therapy over 50 years of age. Results from the French Hospital Database on HIV.
Grabar S, Kousignian I, Sobel A, Le Bras P, Gasnault J, Enel P, Jung C, Mahamat A, Lang JM, Costagliola D.
AIDS
2004 Oct 21;18(15):2029-38.
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PubMed entry
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Reviewed by
Susa Coffey, MD
Summary
Relatively little research has focused on issues concerning HIV infection and treatment in older populations, but some studies have suggested poorer CD4 count recovery in older patients treated with antiretroviral therapy (ART), and higher rates of clinical progression. This prospective cohort study evaluated the influence of older age (defined as >= 50 years) on CD4 count increase, viral suppression, and clinical progression.
The cohort comprised 3,015 previously untreated HIV-infected patients from a large French database who initiated combination ART between 1997 and 2001. Subjects were followed for a median of 31 months. The >= 50 age group included 401 subjects. Compared with the <50 age group, the older subjects were more likely to be male, and to have acquired HIV infection via heterosexual sex or by unknown means. They also had lower baseline CD4 counts (mean 193 cells/µL vs 252 cells/µL in younger subjects) and higher baseline HIV RNA (RNA >5 log
10
copies/mL in 45% of older subjects compared with 35% of younger subjects).
After initiation of ART, older subjects had lower CD4 increases than did younger subjects. The differences between groups were statistically significant (p < 0.0001) in subgroups with baseline viral loads >5 log
10
copies/mL and <5 log
10
copies/mL and with baseline CD4 counts >200 cells/µL or <200 cells/µL, and were seen both in the first 6 months of ART and in subsequent months. For example, in those with baseline viral load >5 log
10
copies/mL, the mean CD4 increase in the >50 group was 37 cells/µL per month in the first 6 months of ART compared with 43 cells/µL per month in the younger group. The differences in CD4 recovery were not explained by poorer rates of virologic suppression in older patients, as the >50 group was more likely to suppress HIV RNA to <500 copies/mL (hazard ratio [HR] = 1.23).
Of greater concern than these differences in clinical markers, the incidence of AIDS-defining events (ADEs) was significantly higher in older patients, after adjustment for baseline variables (HR = 1.5). Certain opportunistic infections and malignancies, including cytomegalovirus infections, Kaposi sarcoma, and HIV encephalopathy, occurred at significantly higher rates in the older group, and particularly in subjects with baseline CD4 counts <200 cells/µL.
Comment
In this cohort, subjects in the >50 age group experienced poorer CD4 recovery and a higher rate of clinical progression compared with younger patients, despite achieving higher rates of virologic suppression on ART. The reasons for this are not clear, and are likely multifactorial. The fact that the older patients tended to have more advanced HIV disease at the time of diagnosis certainly suggests the importance of expanded HIV education and testing efforts in older patients, and the findings of blunted CD4 increases and higher rates of ADEs may have implications for the timing of ART in older patients.
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