HIV/AIDS: Never Too Old to Start ART

An increasing number of older AIDS patients are starting antiretroviral therapy (ART), according to a new study. However, the results also show that older patients (50 years or older) with advanced HIV (CD4 count of less than 50 cells per μL) are at especially high risk of death.

As people with HIV are aging, increasing numbers of older AIDS patients are starting treatment and need specialized long-term care, state the researchers, led by Morna Cornell, PhD, Centre for Infectious Disease Epidemiology and Research, University of Cape Town, in Cape Town, South Africa.

The researchers explored the effect of age on mortality of patients on ART in South Africa and whether this effect is mediated by baseline immunological status.

The retrospective cohort study analyzed HIV-positive patients aged 16–80 years who started ART for the first time in 2 primary care clinics, 3 hospitals, and a large rural cohort. The researchers estimated mortality using Cox's proportional hazards and competing risks regression, and tested the interaction between baseline CD4 cell count and age.

They followed 83,566 patients for 3 years, a total of 174,640 patient-years over a period of 10 years from 2004 to 2013. Overall median baseline CD4 count varied only slightly with age.

The proportion of patients aged 50 years or older enrolling in ART increased with successive years, from 6% in 2004 to 10% in 2012–13, comprising 9% of total enrollment. At the end of the study, 14% of the patients who were still alive and under treatment were 50 years or older.

The researchers also found that 8% of patients aged 16–29 years died compared with 19% of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2.52 for people aged 65 years or older compared with those 16–29 years of age.

In patients starting ART with a CD4 count of less than 50 cells per μL, the adjusted mortality hazard ratio was 2.52 for people aged 50 years or older compared with those 16–39 years old.

Mortality was highest in patients with CD4 counts of less than 50 cells per μL; 15% of all patients aged 50 years or older starting ART had these low counts.

The researchers concluded: “Health services need reorientation towards HIV diagnosis and starting of ART in older individuals. Policies are needed for long-term care of older people with HIV.”

In the same journal, commentators noted that the study “emphasizes 3 issues for health-care delivery: ageing of the population of people with HIV who are receiving therapy, possibly poor immunological response to ART in older people, and delayed HIV diagnosis and treatment initiation in older people.”

They were encouraged that HIV diagnosis and treatment programs are now beginning to reach older adults, but cautioned “older people continue to face barriers in accessing health-care, a possible explanation for delayed entry to HIV services until advanced disease.”

They also stated that “maximum survival benefit of ART is realized when ART is initiated at high CD4 counts, with CD4 count being a strong predictor of mortality, irrespective of age.”