HIV diagnosis in older adults

Abstract

It is recognised that those diagnosed with HIV infection over the age of 50 have higher rates of morbidity and mortality. Little is known about how clinical presentation at diagnosis of HIV varies within this group. We sought to compare clinical presentation and markers of outcome among those diagnosed with HIV aged 60 and over vs. those diagnosed aged 50–59, over a ten-year period. The results showed that 84/111 were diagnosed with HIV aged 50–59 and 27/111 aged ≥60. Ethnicity and HIV risk factors were similar between groups, and most infections were sexually acquired with 7.4% of those aged ≥60 suspected to have a recent infection. Median CD4 cell count at presentation was significantly lower in the ≥60 age group (111 vs. 249; p < 0.001), and the proportion with a CD4 cell count <50 was also significantly lower in this population (33% vs. 15%; p = 0.04). In keeping with this, the frequency of AIDS-defining illness at diagnosis was higher in the ≥60 group (38% vs. 4%; p < 0.001). Co-morbidities were found in both groups, and 38% of those aged ≥60 at diagnosis were known to have since died compared to 4% of those aged 50–59 at diagnosis (p ≤ 0.01). Those aged ≥60 had lower CD4 cell counts at diagnosis and more AIDS-defining illnesses, highlighting the increased risk of poor outcomes in this group. The majority of infections were sexually acquired. More work is needed to understand survival in adults diagnosed with HIV at an older age and to consider those over 60 as a specific population worthy of further research.

Keywords

HIV (human immunodeficiency virus)AIDS viral disease epidemiology older adults

Background

HIV is a global health issue with 35 million people worldwide living with HIV.¹ In the UK, this figure is almost 100,000, but it is estimated that a quarter of these individuals are undiagnosed.² To attempt to reduce the high numbers unaware of their diagnosis, many HIV testing initiatives exist, including the recent UK government supported ‘Halve It’ campaign,³ which aimed to halve the proportion of people in the UK diagnosed late with HIV by 2015. It encourages HIV testing in line with national guidelines, which suggest that in areas of high prevalence, HIV testing should be carried out in patients aged 15–59.⁴ This reflects recommendations in the US,⁵ which suggest offering ‘opt out’ HIV testing up to age 64 with no older age limit on ‘condition-based’ HIV testing.

The UK population is ageing, and people are living longer. This, alongside a change in sexual attitudes and behaviours,⁶ highlights the importance of prevention and control of HIV among older adults. The third National Survey of Sexual Attitudes and Lifestyles (Natsal) survey found that 15% of those aged 55–74 reported at least one new sexual partner in the last year and 3.5% of men aged 55–74 reported at least one male sexual partner in the last five years.⁶ Two US studies^7,8 found that older adults are taking part in high-risk sexual activity at an increasing rate without safe sex practices. Just 25% of these older adults report a history of HIV testing in this population, and they concluded that clinicians’ perceptions may preclude them from recommending an HIV test.

Most literature on this topic refer to ‘older adults’ as those aged over 50, and it is now well recognised that this age group is diagnosed at a later stage of HIV infection and is more likely to die within a year of HIV diagnosis.^2,9,10 A UK national comparison of HIV diagnoses showed those diagnosed over 50 years of age were more likely to be men, of white ethnicity and infected via homosexual sex.¹¹

Very few studies examine the differences in HIV acquisition and clinical presentation of new diagnoses of HIV in different age groups of those aged over 50. One large Italian survey found that despite similar sexual practices, those aged 60–75 were less likely to have tested for HIV or to have had a discussion around HIV with health professionals compared with those aged 50–59.¹²

In 2014, there were 77 new HIV diagnoses in those aged 65 and over in the UK¹³ representing 1.8% of all new diagnoses that year. Although these numbers are small, we should recognise the differences between this group and those aged 50–59 and ensure those diagnosed with HIV aged over 60 are investigated for significant immunosuppression and the clinical consequences of this, such as opportunistic infections.

Previous work has shown multiple co-morbidities associated with HIV infection in older adults.¹⁴ As well as contributing to poorer clinical outcomes, co-morbidities could also mask the clinical presentation of HIV and decreasing suspicion of HIV as a new diagnosis in a person aged ≥60.

We conducted a retrospective case note review of all cases in our cohort to identify any difference in clinical presentation and co-morbidities between patients diagnosed aged 50–59 and those 60 and over.

Method

Study participants

The review was undertaken in an HIV service based in a teaching hospital in Glasgow, UK which had approximately 1500–1800 patients attending between 2004 and 2014. Patients were identified using our electronic database. All patients who had a new positive HIV test at age ≥50 years, and who subsequently attended the clinic for review were included. We excluded those diagnosed before 1 November 2004. Data were collected retrospectively on all patients diagnosed from 1 November 2004 to 31 October 2014.

Data collected

Data were collected from the case records by a single investigator.

Demographic information collected were: age at HIV diagnosis, date of HIV diagnosis, gender, ethnicity and HIV risk group.

Information on clinical presentation included initial CD4 cell count and HIV indicator condition and AIDS-defining illness at diagnosis, as documented by the physician reviewing the patient at the first clinic visit. Other co-morbidities documented at this first clinic visit were also recorded. HIV indicator conditions and AIDS-defining illnesses were documented as defined by BHIVA/BASHH/BIS.⁴

‘Clinical suspicion of recent seroconversion’ was recorded if the HIV physician reviewing the patient at first clinical visit felt that the patient’s HIV risk exposure history, HIV testing history and reported symptoms were consistent with seroconversion. The time frame for this was also recorded. If avidity testing was available, this result was recorded.

The current outcome was recorded and for those who had died, time from diagnosis to death and whether the documented cause of death was HIV related or not were recorded.

Ethical approval

Ethical approval was not sought as the data collected was anonymised information that had previously been collected and stored in the clinic database, as part of routine clinic care.

Statistical analysis

Data analysis was conducted using STATA version 13.1 (StataCorp., 2013, TX). Differences in continuous variables were calculated using the two-sample Wilcoxon rank-sum test. Depending on the distribution, differences in proportions were calculated using Pearson’s χ² or Fisher’s exact test. Statistically significant values were assessed at the 0.05 level. All p values are reported to two decimal places.

Results

Over a ten-year period, from 1 November 2004 to 1 November 2014, a total of 84 patients were diagnosed with HIV aged 50–59 and 27 patients diagnosed ≥60. The oldest female was aged 71 years and the oldest male 73 years.

Demographics

There was no significant difference between the two groups in terms of gender, ethnicity or risk factor (see Table 1). The majority of patients were male, of Caucasian ethnicity and acquired HIV as a result of sexual exposure.

Table 1.

Demographics by age at diagnosis.

		Age at diagnosis (years)
		50–59 N = 84		≥60 N = 27		Fisher’s exact test
		n	(n/N %)	n	(n/N %)	Fisher’s exact test
Gender	Male	67	(80)	25	(93)	p = 0.15
Ethnicity	Caucasian	64	(76)	22	(81)	p = 0.64
	Black African	18	(21)	4	(15)
	Other	2	(2)	1	(4)
HIV risk factor	Heterosexual	39	(46)	12	(44)	p = 0.17
	Homosexual	37	(44)	10	(37)
	Blood products	2	(2)	3	(11)
	IVDU	5	(6)	0	(0)
	Missing	1	(1)	2	(7)

IVDU: intravenous drug use.

There was no evidence of any difference in risk factors between the two age groups (p = 0.17). Route of acquisition was significantly associated with ethnicity, regardless of age at diagnosis. Heterosexual sex accounted for 95% (21/22) of infections among Black Africans compared to 34% (28/83) of Caucasians; homosexual risk was reported by 57% (47/83) of Caucasians and 0% (0/0) of Black Africans (p < 0.01).

CD4 T cell count at diagnosis

The median (interquartile range, IQR) baseline CD4 cell count among those diagnosed aged 50–59 was 249 (105,422) cells/mm³ and 111 (48,214) cells/mm³ among those aged ≥60 (p < 0.01) (see Figure 1); 65% (55/84) aged 50–59 had a CD4 < 350 at diagnosis compared to 89% (24/27) aged ≥60 (p = 0.03) and 15% (13/84) aged 50–59 had a CD4 < 50 at diagnosis compared to 33% (9/27) aged ≥60 (p = 0.04).

Figure 1.

Box plot of CD4 cell count at diagnosis.

HIV indicator conditions at diagnosis

There was no significant difference in the proportion of patients with indicator conditions at diagnosis; 39% (33/84) of patients aged 50–59 had an HIV indicator condition compared to 22% (6/27) of those aged ≥60 (p = 0.11). These included dermatological, neurological, gastroenterology, other blood borne viruses (hepatitis B and C), haematological and respiratory conditions. There were seven other sexually transmitted infections (STIs) diagnosed concurrently in the age 50–59 group (four late latent syphilis, one acute herpes simplex virus, one new human papilloma virus and one bacterial STI). There was one case of late latent syphilis in the 60 and over group.

AIDS-defining illnesses at diagnosis

The proportion of patients in the 60 and over age group with an AIDS-defining illness at diagnosis was significantly higher; 25% (21/84) aged 50–59 had an AIDS-defining illness at diagnosis compared to 59% (16/27) aged ≥60 (p < 0.01). The most common of these were Pneumocystis jirovecii pneumonia (50–59: 7/84, ≥60: 9/27) and pulmonary Mycobacterium tuberculosis (MTB) (50–59: 3/84, ≥60: 1/27). There were also cases of oesophageal candida, extra pulmonary MTB, Kaposi sarcoma, progressive multifocal leukoencephalopathy, cerebral toxoplasmosis, cytomegalovirus retinitis and disseminated Mycobacterium avium complex disease.

Other co-morbidities at diagnosis

In our cohort, there was no evidence of higher levels of co-morbidity in the older age group; 27% (23/84) of those aged 50–59 had multiple (>1) co-morbidities at the time of diagnosis compared to 19% (5/27) of those aged ≥60 (p = 0.36) (see Table 2).

Table 2.

Co-morbidities at HIV diagnosis.

Co-morbidities	Age 50–59		Age 60 and over
Cardiovascular	19/84		6/27
Hypertension	13		3
Hypercholesterolaemia	3		2
Ischaemic heart disease	3		1
Respiratory	6/84		3/27
Pulmonary embolus	1		2
Chronic obstructive pulmonary disease	3		1
Asthma	2		0
Gastroenterology	6/84		3/27
Gastric oesophageal reflux disease	2		2
Inflammatory bowel disease	2		0
Cirrhosis	2		0
Endocrine	8/84		2/27
Diabetes mellitus	7		2
Obesity	1		0
Neurological	0/84		1/27
Seizures	0		1
Musculoskeletal	0/84		1/27
Gout	0		1
Psychiatric	13/84		0/27
Depression	4		0
Anxiety	3		0
Alcohol excess	6		0
Cancer	4/84		7/27
Skin	0		4
Urological	3		1
Head and neck	0		1
Haematological	0		1
Renal	1		0
Renal	2/84		1/27
Chronic renal failure	2		1
No of co-morbidities	1 n (%)	2 n (%)	3 n (%)	4 n (%)
Age 50–59	30 (36%)	11 (13%)	2 (2%)	0
Age 60 and over	8 (30%)	2 (7%)	0	3(11%)

Fifty percent (56/111) of the whole cohort reported at least one co-morbidity, 51% (43/84) of those aged 50–59 and 48% (13/27) of those 60 and over.

Duration of HIV infection

A total of 2/27 (7.4%) patients aged ≥ 60 were clinically suspected to have seroconverted during the preceding four months, and one had this confirmed with a positive avidity test; 4/84 (4.8%) patients aged 50–59 were clinically suspected to have seroconverted in the last six months, and one was confirmed with a positive avidity test.

Mortality

After excluding 11 patients who had moved away, 33% (9/27) of those aged 60 and over were known to have died vs. 4% (3/84) of those aged 50–59 (p < 0.001). Among patients known to have died, the median (IQR) time from HIV diagnosis to death was 24 (1, 84) months among those aged 50–59 compared with 0.73 (0.2, 24) months among patients aged ≥60 at diagnosis (p = 0.14).

Among those who had died, cause of death was considered to be HIV related among 2/3 (67%) of those aged 50–59 and 6/9 (67%) of those aged ≥60.

Discussion

This study demonstrates similarities in demographic features and risk factors for HIV acquisition but significant differences in the clinical presentation and markers of poor clinical outcome of new HIV diagnoses in those aged ≥60 at the time of HIV diagnosis compared to those aged 50–59.

We found that, in our cohort, those aged 60 and over at HIV diagnosis were more likely to have a lower CD4 T cell count at diagnosis and importantly, more likely to have a CD4 cell count less than 50 cells/mm³, meaning they presented at a later stage of infection and thus at higher risk of opportunistic infections and death. Given the more general age-related decline in immune function and increased cancer and cardiovascular risk in this population, a low CD4 T cell count may accelerate the time to an AIDS-defining illness among those acquiring the infection later in life.

Those aged 60 and over were more likely to have an AIDS-defining illness at the time of HIV diagnosis. In line with UK surveillance reports,² the most common AIDS-defining illnesses in both age groups were Pneumocystis jirovecii pneumonia and Mycobacterium tuberculosis.

HIV indicator conditions were present at diagnosis in approximately one-third of the cohort, with no significant difference between age groups and the frequency of co-morbidities at diagnosis was similar in both groups but lower than cohorts reported elsewhere.¹⁴ Co-morbidities are a recognised problem with an ageing HIV-positive population with regards to HIV affecting other diseases, long-term effect of antiretroviral medications and drug–drug interactions. Further, given the frequency of co-morbidities it is likely that the patients were in contact with healthcare professionals prior to HIV diagnosis, and therefore, perhaps there were missed opportunities for earlier HIV testing and diagnosis.

Recent HIV infection was suspected or confirmed among 5% of this cohort, reminding us that this age group remains sexually active. Some recent infections were confirmed by avidity testing in both groups, but this was limited as avidity testing was not routinely available at diagnosis for the majority of the cohort. In analysing more recent cohorts, it will be possible to use avidity to better understand recency of transmission and how this related to CD4 cell counts at presentation, and outcome, in the older population.

At the time of data collection, 4% of those diagnosed with HIV aged 50–59 had died compared with 38% of those diagnosed aged ≥60. Overall life expectancy in our health board area is the lowest in Scotland. Life expectancy at birth is 73.4 and 78.7 for males and females, respectively.¹⁵ In both groups, cause of death was determined to be HIV related in two-thirds of cases. Further work is needed to understand whether deaths in this age group are related to HIV infection or the older age.

Conclusion

As life expectancy increases and treatment of HIV improves, we need to consider HIV in the older demographic, including new presentations over the age of 60. In our cohort, those aged 60 and over had similar demographic and HIV acquisition risks but lower CD4 cell count at diagnosis and more AIDS-defining illnesses. This highlights the increased risk of poor outcomes in this group. The majority of infections were sexually acquired, and recent infections were found in both groups.

We feel this study adds to current knowledge by highlighting that HIV can remain undiagnosed and present late in an older population. Delayed diagnosis and co-morbidities may contribute to a higher mortality rate, and further study in larger cohorts may help to define this further. Often services do not recognise this age group as being at risk of HIV infection, and we think that disseminating this information to our colleagues in other medical specialties, including elderly care physicians will highlight instances where an HIV test should be considered.

Footnotes

Acknowledgements

The authors thank Revathy Raajaravi, IM&T analyst, NHS Greater Glasgow & Clyde.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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