Co-morbidity and late presentation – findings from an over 50s cohort

Charlotte Walker, HIV i-Base

The number of HIV positive people accessing care in the UK who are aged over 50 years old has more than tripled between 2000-2009 from 2,432 to 12,063. Twenty percent of adults presenting for HIV care are now over 50. Previous cohort data showed an increased incidence of co-morbidities in the this group in relation to diabetes, hyperlipidaemia, cardiovascular and bone disease. [1, 2]

This study focused on the 504 participants aged over 50 out of a cohort of 2,700 participants attending Guys and St.Thomas Hospital as of 1 December 2010. [3]

Median age was 54 years (range: 50-83, IQR: 52-59), 76.4% (n=385) were male, 54.8% (n=276) were white, 38.3% (n=193) were black, 47.4% (n=239) were MSM. Median age at diagnosis was 46 years (range: 22-82, IQR: 40-52) and the median time since diagnosis was 9 years (range: <1-28, IQR: 5-14). Of the group, 35.3% (n=166) were aged 50 or over at diagnosis.

The CD4 count at diagnosis was available for 298 participants: 216 cells/mm³ (range: 3-1100, IQR: 79-401), of which 70.8% (n=211) had a CD4 count <350 cells/mm³ (50.2% of whom were <50 at diagnosis), 24.2% (n=72) had a CD4 count of 201-350 cells/mm³ at diagnosis (48.6% of whom were <50 at diagnosis) and 46.6% (n=139) had a CD4 count of <200 cells/mm³ (51.1% of whom were <50 at diagnosis).

Their current treatment included 46% on NNRTI-based regimens, 36% on PI-based regimens and 11% on other regimens, 5% were HAART naive, 1% not currently on HAART and 1% not documented. The median time on ARVs was 7 years (IQR: 3-11 years) and 55% of the group are still on their first prescribed ARV combination.

The cardiovascular health of these participants showed a median 10 year Framingham cardiovascular risk score of 12.3%. Hyperlipidaemia was present in 44% of participants (with or without a statin or other lipid lowering agent). Currently 15.7% of the group are smokers and 11.3% have diabetes. Cardiovascular events were seen in 7.3% (n=37) of participants including 7 myocardial infarctions, 6 strokes or transient ischemic attacks, 8 positive coronary angiograms. Of these 37 people, 6 (16%) were current smokers, 29 (78.4%) were on statins and 5 (13.5%) were diabetics.

Bone health is always a concern in anyone over 50. In this study 134/504 participants (26.6%) have had a DEXA scan. Of those 134 people, 70 (52.2%) had results showing reduced BMD, 22 (16.4%) had a diagnosis of osteoperosis, 48 (35.8%) had a diagnosis of osteopenia, 8 (11.4%) were current smokers, 6 (8.6%) had concurrent renal disease.

Renal disease was documented in 39 participants (7.7%) and of these, 8 (20.5%) were currently on dialysis, 6 (15.4%) had documented HIVAN and 4 (10.3%) were diabetics.

Mental health problems were documented in 154/504 participants (30.6%), 104 (67.5%) of which had depression cited in their medical notes and 41 (8.1%) had documented memory impairment.

In conclusion, 35.3% of participants at Guys and St Thomas were aged 50 or over at diagnosis and 41.9% of participants aged over 50 presented with a CD4 count of <350 cells/mm³. This group have been found to have multiple co-morbidities affecting cardiovascular, renal, bone and mental health. Future work to follow on from this study will include comparisons between HIV positive participants over 50 and HIV negative people over 50.

comment

This report provides important cross-sectional data on the changing demographics at many clinics and the high rates of comorbidities and polypharmacy associated with ageing with HIV.

It is notable that only 16% of serious cardiovascular event and only 11% of reduced bone density events occured in current smokers and that the smoking rate for this cohort was only 16%. This perhaps indicates that people have already made proactive lifestyle changes but still remain at high risk of residual complications.

References:

Onen NF et al. Aging and HIV infection: a comparison between older HIV-infected persons and the general population. HIV Clin Trials. 2010;11(2):100109. doi: 10.1310/hct1102-100.
Hasse et al. Aging and Non-HIV-associated Co-morbidity in HIV+ Persons: The SHCS. 18th Conference for Retroviruses and Opportunistic Infections. 2011. Poster abstract 792.
http://www.retroconference.org/2011/Abstracts/40790.htm
Williams H. Co-morbidity and late presentation findings from an over 50s cohort. 17th Annual BHIVA Conference, 68 April 2011, Bournemouth. Oral abstract O31.