Surviving to die of something else: AIDS is a rare cause of death in old people with HIV

A French study of a group of people with HIV aged over 60 has found that over a four-year period, one in seven of the group died – but not a single death was attributable to an AIDS-defining illness.

The findings from the French COREVIH Cohort, presented at last week's European AIDS Clinical Society conference in Colgne, underline the increasingly strong realisation in HIV medicine that as patients with HIV on antiretroviral therapy age, the medical problems they face will have much more to do with diseases of ageing than AIDS-defining illnesses. The latest revision of the EACS Treatment Guidelines acknowledges this – see this report.

Other cohort studies of people ageing with HIV have tended to take 50 as their minimum age, but starting this early may dilute the prevalence of age-related conditions.

The COREVIH Cohort is as yet a relatively small group, starting in 2004 with 149 patients drawn from six HIV clinics in the Paris area. Their average age at the start was 65. Fourteen patients in the baseline group (9%) were in their 80s, the oldest being 86. The average time since HIV diagnosis was 8.5 years, but this ranged from two months to 19 years. Over a third had had an AIDS-defining illness in the past.

The group is well-balanced in terms of population groups, with just over three-quarters being male, just over half heterosexual, and two-thirds of French and other European white background. The other third were mainly composed of equal numbers of sub-Saharan Africans and of patients from the Maghreb (North Africa), reflecting the ethnic mix in France.

By the time of follow-up in 2008, the group’s average age was 71. Seventeen patients (11%) couldn’t be traced. Of the others, 21 patients (14% of the cohort) had died. Eleven – more than half - had died of various non-AIDS-defining cancers; four had died of cardiovascular disease; three had died of end-stage liver disease; and three had died of other causes including one of dementia.

In terms of morbidity rather than mortality, many cohort participants had multiple health problems. Half of the remaining patients had some manifestation of cardiovascular disease. A quarter had kidney disease, one in five had arthritis or bone problems, one in six had cognitive or neurological problems, just under one in six was dealing with cancer of one form or another, 15% had diabetes, and 9% had liver problems.

In contrast to this picture of often multiple health problems, those classically related to HIV were minimal. At the start of the cohort, 70% had a viral load under 50 copies/ml, but this had now increased to 96%, and their average CD4 count was now 494 cells/mm³, having increased from 372 at baseline.

Notably, no cohort member developed a new AIDS-defining condition over the four years of follow-up and only two saw the return of a previous condition (Kaposi’s sarcoma of the lung in one, Castleman’s disease in a patient with previous non-Hodgkin’s lymphoma in the other).

“Clinical and immunological improvement was continuous in these aged patients,” the researchers comment, “but co-morbidities are frequently observed.”