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People Over 50 Face High Risk of
ART Suspension in First Months: PEPFAR
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International Workshop on HIV and Aging, October 13-14, 2022
By Mark Mascolini for NATAP and Virology Education
People over 50 starting antiretroviral therapy (ART) in 47 PEPFAR countries ran a 5 times higher risk of interrupting treatment in the first 3 months than overall, according to analysis of more than 400,000 people in all age groups [1]. Rates of interrupting ART in the first 3 months proved higher than stopping ART later in every age group assessed.
As in high-income countries, HIV-positive people over 50 make up a growing fraction of HIV populations in low- and middle-income countries. In PEPFAR, the US-funded program to broaden HIV treatment in this low- to middle-income sector, people over 50 make up 21% of the 18 million people in treatment programs and people over 40 make up 49%. The over-50 PEPFAR contingent constitutes 24% or more of the entire PEPFAR population in 10 countries: Dominican Republic, Botswana, Rwanda, Cote d'Ivoire, Burundi, Lesotho, Haiti, Cameroon, Kenya, and Tanzania.
To analyze ART interruptions by age group in PEPFAR, researchers plumbed program data in 47 PEPFAR countries with direct service delivery from January through March 2022.
Participants had to have a positive HIV test during that period and had to start their first antiretroviral regimen during that time. PEPFAR investigators defined treatment interruption as "a missed appointment more than 28 days since a client's last expected clinic appointment or medication pick-up date."
Participants over 50 accounted for 8.9% of positive HIV tests during the study period and 9.3% of first-time ART starts. The first of these findings is clear evidence that people over 50 in PEPFAR countries are still putting themselves at risk for HIV infection. Among all people in the study group who interrupted ART, 14% were over 50 years old. The over-50 group had the lowest overall proportion of ART interrupters of any age group studied, 1.7%. That compared, for example, with 2.0% in people 40 to 49, 2.5% in people 35 to 39, 3.0% in people 30 to 34, 3.4% in those 25 to 29, and 3.9% in those 20 to 24.
Among study participants who had taken ART for fewer than 3 months, 8.7% in the over-50 group suspended ART, a rate consistent with other age groups (for example, 8.7% of those 40 to 49, 8.4% of those 30 to 34, 8.5% of those 20 to 24, and 9.1% of those 15 to 19). In the over-50 cluster, the interruption rate was more than 5 times higher in the first 3 months of treatment than overall (8.7% / 1.7%).
The PEPFAR team listed two main limitations to their study—lumping everyone over 50 into a single age group, and lack of data on reasons for interruptions. They plan further study with finer age clusters among people over 50.
The investigators noted several challenges to retention in care more likely to affect people over 50: more comorbidities complicating disease management, higher risk of drug-drug interactions with side effects, and higher rates of neurocognitive problems that could affect adherence to medications. They reported that Botswana plans "an integrated package of services" to help improve retention in care and steady treatment in older people with HIV. The researchers stressed their finding confirming that people over 50 in low- and middle-income countries remain at risk for HIV infection.
Reference
1. Parrish D, Sherlock Williams M, Aberle-Grasse J, Godfrey C. Early interruptions in treatment among PLHIV over 50 years of age starting antiretroviral therapy in PEPFAR-supported low and middle-income countries. International Workshop on HIV and Aging, October 13-14, 2022. Abstract 1.
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