Effect of age at initiation of antiretroviral therapy on treatment outcomes; A retrospective cohort study at a large HIV clinic in southwestern Uganda

Abstract

BackgroundThe prevalence of HIV infection among older persons is increasing yet older age at initiation of antiretroviral therapy (ART) may be associated with poorer treatment outcomes including mortality. However, majority of these studies have been done in the western world and there is limited data in resource limited settings. Our study used routinely collected health facility data to assess trends in age at initiation of ART, the effect of age at ART initiation on mortality and immunological response at a large urban hospital in south western Uganda.MethodsWe conducted a retrospective records review of patients attending the HIV clinic at Mbarara Regional Referral Hospital in western Uganda. We retrieved records for 8,533 patients who started ART between January 2006 and December 2012. Their data had been collected and stored as part of the larger International Epidemiological Database for the Evaluation of AIDS (IeDEA). Age was stratified into three categories namely; 18–34 (young adults), 35–49 (mid-age) and 50 years or older (older adults). Survival analysis procedures with Kaplan-Meier’s plots were used to calculate the survival probability with mortality as the endpoint and Poisson regression analysis used to determine the adjusted relative risks (RR) of mortality.ResultsThe proportion of young adults and patients at WHO stage I initiating ART increased steadily over the 7-year period. Older age at ART initiation (> = 50 years) was associated with a higher risk of mortality with adjusted relative risk (RR) at 1.63, (95% CI 1.26–2.11) compared to younger age. Male gender, WHO stages III and IV, lower CD4 count and lower body mass index were also all independently and significantly associated with higher risk for mortality. Older adults also had a poorer immunological response RR = 1.79 (95% CI 0.89–3.58) but was not statistically significant.ConclusionsFollowing ART initiation, older adults compared to the young, have a higher risk of mortality. This age group should be targeted first for ‘screen and treat’ approach. Optimization of ART treatment regimens for this age group is also required to reduce mortality and improve immunological response.

Effects of undernutrition on mortality and morbidity among adults living with HIV in sub-Saharan Africa: a systematic review and meta-analysis

“… Liu et al, (2011) [ 20 ] Retrospective cohort 2004–2009 7 8271 11,927 (65.3) 1673 (9.2) Hgb and MUAC 17. Ssebutinde et al, (2018) [ 35 ] Retrospective cohort 2006–2012 7 8364 5308 (63.5) 180 (2.1) Age, sex, WHO staging, CD4 count, and level of education 18. Maskew et al, (2013) Retrospective cohort 2004–2010 8 7354 4621 (62.8) 333 (4.5) Sex, age, CD4 count, and Hgb 19.…”

“…Of the 23 studies included in the meta-analysis, 17 studies showed that undernutrition has a significant effect on mortality in adults living with HIV [ 18 , 21 , 24 , 25 , 27 – 31 , 34 , 101 , 105 , 106 , 110 , 111 ]. However, six studies reported that undernutrition has no significant effect on mortality in this population [ 19 , 35 , 37 – 39 , 99 ]. Finally, the pooled AHR of 23 cohort studies involving 125,790 individuals showed that undernourished adults living with HIV were two-fold (AHR: 2.1, 95% CI: 1.8, 2.4) more likely to die as compared to their well-nourished counterparts.…”

Immunologic and virologic responses to antiretroviral therapy in treatment-naïve, HIV-infected elderly patients

“…9 Ssebutinde et al observed an overall increased risk of decline in the CD4 cell count in the older age group following treatment' however, this was not identified as statistically significant. 11 . This was the first study to include patients on an INSTI-based regimen, although it was a small percentage.…”

“…observed an overall increased risk of decline in the CD4 cell count in the older age group following treatment’ however, this was not identified as statistically significant. 11 A study by Sabin et al. included pediatric and adult patients as part of an observational multicohort study.…”

“…3–8 However, other studies demonstrated no difference in immunologic response to ART based on age. 9–11 Conversely, several studies were able to identify older patients progressing more rapidly to undetectable VL as defined by the investigators. 4,5,7,10 There are limited data correlating virologic and immunologic responses with regards to a patient’s age and specific ART regimen initiated.…”