Abstract
Background:
Physicians are coming across a considerable number of HIV-positive patients belonging to older age-group, in practice. They pose a challenge as they might present with advanced forms and comorbid conditions. We aimed to describe the clinicoepidemiological profile of elderly people living with HIV.
Methodology:
We conducted a cross-sectional study at Kasturba Medical College, Mangalore. We analyzed the record of 120 patients from 2009 to 2014. Descriptive statistics were used to describe sociodemographic and clinical profile of patients.
Results:
Of 786 HIV-positive patients, 120 were elderly. Mean age was 55.9 ± 6.1 years. Majority 68% were male. In all, 63.33% were male. Commonest route of transmission was heterosexual intercourse, most presented at World Health Organization (WHO) stage 1 (64.17%). In all, 77.5% had hypertension and 26.6% had tuberculosis. The median CD4 count at presentation was 245 cells/mm3 (145-426 cells/mm3). Forty-two percent were late presenters (CD4 <200 cells/mm3).
Conclusion:
Treating physician should have a high index of suspicion in diagnosing HIV among elderly age-group.
Introduction
Previously considered as a disease of the young, HIV is now commonly seen among older age groups as well. Prevalence of HIV among elderly is rising. 1,2 Elderly individuals are at a higher risk of acquiring HIV due to a number of reasons, that is, prevention program are not aimed at them, lack of awareness, the use of drugs that prolong their sexual life, some of the symptoms of HIV can mimic symptoms of aging, so physicians may not think of HIV in elderly. 1,3 –6 Burden of HIV in elderly individuals is ignored, and this may hamper the measures to tackle the spread of HIV. 7
Several factors have to be kept in mind while dealing with elderly people living with HIV (PLHIV). Older individuals have a higher chance of presenting with an AIDS-defining illness at initial presentation for HIV care when compared to youngsters. 8 The immunological response to combination antiretroviral therapy (cART) in elderly individuals is lower when compared to younger PLHIV. 9,10 Elderly PLHIV have other comorbid illness. 11 Comorbid illnesses may get aggravated because of the use of cART. 12 Elderly PLHIV exhibit increased susceptibility to the side effects of medications. 13 There is hardly any published literature describing the sociodemographic and clinical characteristics of elderly PLHIV in our country. Moreover, this knowledge will provide an insight for implementation of preventive and curative services through the program. Our study aimed to describe the clinicoepidemiological profile of elderly PLHIV attending a tertiary care referral institution in southern India.
Methodology
Study Design and Setting
Mangalore is one of the high prevalence cities of South India. It caters to a population of 499 487. 14 The city is experiencing rapid development with huge immigration in recent years. We conducted a hospital record–based retrospective study in one of the oldest tertiary care referral hospitals in the South India. So far, around 2000 HIV-positive patients are registered and are on treatment.
Records of elderly PLHIV patients aged ≥50 years newly diagnosed and initiated on treatment in our institution from February 2009 to July 2014 (5 years 6 months) were considered for study. 12,15 Those patients with CD4 count <200 cell/µL were classified as late presenters to care. 16 After obtaining the approval from institutional ethics committee, permission was obtained from the medical superintendent of the hospital to access the medical records from the medical records department. The data were collected using an extraction sheet consisting of 2 sections: section 1 included sociodemographic profile and section 2 included details about clinical features, presence of other comorbid illnesses, and CD4 count.
The collected data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 11.5. Descriptive statistics were calculated with the mean for variables that were normally distributed and the median and interquartile range (IQR) for variables influenced by extreme values.
Results
During the study period among 786 registered PLHIV in our institution, a total of 120 (15.27%) were elderly PLHIV. Among them 82 (68.40%) were males. Mean age of our study population was 55.9 ± 6.1 years. The mean age of males was 56.12 ± 6.88 years and females was 55.34 ± 4.23 years. In our study, 92.5% of PLHIV were married. The majority of them were employed (Table 1).
Sociodemographic Characteristics of the Study Population.a
an = 120.
bPatients did not reveal the mode of acquiring the disease.
Majority 77 (64.17%) of them were in WHO stage 1 at the time of diagnosis (Table 2). The common comorbidities seen were hypertension 93 (77.50%) and diabetes 8 (6.70%). Median CD4 count of the study population was 245 (IQR 145-426.2) cells/mm3. Median CD4 count among males and females was 223.5 (IQR 142.5-429.5) and 280.5 (IQR 150-389) cells/mm3, respectively. In our study, 32 (26.67%) had tuberculosis and 47 (41.96%) PLHIV were late presenters.
Clinical Characteristics of the Study Population.a
Abbreviation: WHO, World Health Organization.
an = 120.
bAt the time of diagnosis of HIV.
cStroke = 2; ischemic heart disease = 2; malignancy = 2; chronic liver disease = 1; chronic kidney disease = 1.
Discussion
Elderly population is unique in a sense that, they already have various comorbidities, some of them may itself cause immunosuppression. Reduced immunity due to age, malnutrition, and thinning of vagina in elderly females, makes them prone not only for infection but also for rapid progression of disease and higher rates of opportunistic infection. This is further complicated in presence of multiple comorbidities. 1 –3,6
In our study, 15% of HIV-positive patients attending a tertiary care institution were elderly. Majority of them (94%) had comorbidities. Hypertension was the most common comorbid illness seen in our study group. In the Greek study, among 103 elderly PLHIV, hyperlipidemia (36.9%), hypertension (33.0%), cardiovascular disease (20.4%), and diabetes (13.6%) were the common comorbidities. 17 In our country, tenofovir (TDF)-based cART is the preferred first line regimen as a part of our national programme. Elderly patients have diabetes, hypertension, and increased creatinine clearance and so they may be predisposed to TDF nephrotoxicity.
In our study, 41.96% of elderly PLHIV were late presenters. One of the reasons could be the reluctance to visit a health care facility in India, another could be stigma attached to the disease. 18 A study conducted by Raffetti et al showed that 75% of elderly population were late presenter. 19
Much attention was not given towards elderly PLHIV in the past because their number was less. 20 According to US Centers for Disease Control and Prevention (CDC) in 2014, PLHIV aged ≥50 accounted for 17% (7391) of an estimated 44 073 HIV diagnoses in the United States. 21 In 2007, 12.9% of newly confirmed HIV cases in Western Europe were over 50 years of age. 22 In a study in northern Greece, out of 558 newly diagnosed HIV-positive patients, 103 (18.5%) were elderly PLHIV. 17 In a study 9 done in 4 sub-Saharan African countries, the percentage of elderly PLHIV newly enrolled in HIV care was 10. In a study done in South Africa during 2007 to 2008, the prevalence of HIV among elderly individuals was 6.4%. 23 In a study conducted in Kolkata by Talukdar et al, 567 (9.9%) of 5720 PLHIV were ≥50 years at the time of diagnosis. 12 A study conducted by Majumdar et al showed that there are various needs of an elderly individuals which should be addressed in order to give them a better quality of life. 24
Mean age of our study population was 55.9 ± 6.1 years. Mean age of elderly PLHIV in the Greek study was 57.74 ± 6.72 years. Majority of our study population were male. Our findings are similar to the Kolkata and the Greek study. 12,17 In a study done in China, majority of elderly PLHIV were females. 25 Majority of elderly PLHIV in our study belonged to stage 1. In the Kolkata study, majority of PLHIV belonged to stage 4. 12
In our study, the mean CD4 count was 308 ± 224.8 cells/mm3. The mean CD4 count in the Greek study 9 was 303.86 ± 236.22 cells/mm3. In the Kolkata study, the mean CD4 count among males and females was 112 and 137, respectively. Management of elderly HIV individuals with multiple comorbidities can be challenging for physicians. 26 As age increases, production of naive T cell reduces with declined functionality. These factors make them prone for opportunistic infections OIs and complications. 27
Our study has some limitations. Our institution caters predominantly to an urban population and it was a single-center study, so generalization of results may be difficult. CD4 count was available in 93% of patients which is another limitation of our study. Retrospective studies have their own limitations. Despite these limitations, this is probably the first study from South India, describing the baseline characteristics of elderly PLHIV at entry into the HIV clinic of a tertiary care institute.
Conclusion
Traditionally HIV was considered a disease of the young but now geriatric HIV is a force to reckon with. Management of this disease in the elderly individuals can be challenging due to comorbidities. Policy makers and physicians must pay special attention toward geriatric HIV otherwise our aim of “getting to zero” cannot be achieved.
Footnotes
Acknowledgments
We are grateful to the study participants who participated voluntarily. We acknowledge Dr TMA Pai Endowment Chair in the field of HIV and Opportunistic Infection, Manipal University. We express our heartfelt thanks to the Departments of Medicine and Community Medicine, Kasturba Medical College, Mangalore, India, for the support and Manipal University for encouraging research and its publication in national and international journals of repute.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.