Abstract

Objective

To characterize the survival of elderly people with HIV infection who had follow-up at a reference service in Jaboatão dos Guararapes, Pernambuco, Brazil.

Methods

This is a retrospective cohort of elderly people who began follow-up between 2006 and 2021. Kaplan-Meier survival analysis was used. The Cox model was applied to calculate the hazard ratio (HR) and 95% confidence interval (95%CI) of survival based on the study variables.

Results

116 elderly people were analyzed, the majority (n=83) were 60-69 years old and were diagnosed after the age of 60 (n=45). Risk of death was higher among elderly people who were hospitalized during the study period (HR 4.83; 95%CI 1.07; 21.79). Nine people died from HIV-related causes and average survival time was 76.5±48.5 months. In the first year of the study, probability of survival was greater than 96%.

Conclusion

Survival varied from less than one month to more than 195 months. Among the sociodemographic and clinical factors studied, only hospitalization showed significant association with occurrence of deaths among the elderly. Although the study was carried out in just one service, these results can contribute to guiding care strategies for elderly people living with HIV.

Keywords
Survival Analysis; HIV infections; Elderly; Health Profile; Cohort Studies

Resumen

Objetivo

Caracterizar la supervivencia de personas mayores con infección por VIH, con seguimiento en un servicio de referencia en Jaboatão dos Guararapes, Pernambuco, Brasil.

Métodos

Se trata de una cohorte retrospectiva de personas mayores que iniciaron seguimiento entre 2006 y 2021. Se utilizó el análisis de supervivencia de Kaplan-Meier. Se aplicó el modelo de Cox para calcular el hazard ratio (HR) y el intervalo de confianza del 95% (IC95%) de supervivencia en función de las variables del estudio.

Resultados

Se analizaron 116 personas mayores, la mayoría (n=83) tenían entre 60 y 69 años y fueron diagnosticados después de los 60 años (n=45). El riesgo de muerte fue mayor entre las personas mayores hospitalizadas durante el período estudiado (HR 4,83; IC95% 1,07; 21,79). Nueve personas murieron por causas relacionadas con el VIH y el tiempo medio de supervivencia fue de 76,5±48,5 meses. En el primer año de estudio, la probabilidad de supervivencia fue superior al 96%.

Conclusión

La supervivencia varió desde menos de un mes hasta más de 195 meses. Entre los factores sociodemográficos y clínicos estudiados, sólo la ocurrencia de ingreso hospitalario mostró asociación significativa con la ocurrencia de muertes entre las personas mayores. Aunque el estudio se realizó en un solo servicio, estos resultados pueden contribuir para orientar estrategias de atención a las personas mayores con VIH.

Palabras clave
Análisis de Supervivencia; Infecciones por VIH; Anciano; Perfil de Salud; Estudios de Cohortes

Introduction

HIV infection and its progression to AIDS are a relevant public health problem. Infection affects different groups, with various forms of transmission: sexual, vertical and use of contaminated sharps (¹1 Lins MEVS, Jesus JB, Oliveira JF, Rêgo GG, Matos AVM, Wanderley NB, et al. Perfil epidemiológico de óbitos por HIV/aids na região nordeste do Brasil utilizando dados do sistema de informação de saúde do DATASUS. Braz J Health Rev. 2019;2(4):2965-73. -²2 Costa VS, Silva WRF, Fernandes EV, Berretta OCP, Takanashi SYL, Gouvêa-e-Silva LF. AIDS in the meeting of the Tapajós and Amazon rivers: deaths in the period 2010-2018 in Santarém, Pará, Brazil. ABCS Health Sci. 2021;46:e021201.).

HIV infections are increasing worldwide, whereby some important epidemics have been identified. Success or failure in combating infection depends on the path taken by current governments (³3 A urgência do agora: A AIDS frente a uma encruzilhada [Internet]. Genebra: Programa Conjunto das Nações Unidas sobre HIV/AIDS; 2024 [cited 2024 Aug 2]. Available from: https://unaids.org.br/wp-content/uploads/2024/07/RelatorioGlobalPTBR.pdf.
https://unaids.org.br/wp-content/uploads... ). In 2023, there were estimated to be 40 million people living with HIV globally (⁴4 UNAIDS. Estatísticas. Pessoas vivendo com HIV [Internet]. Brasília: UNAIDS Brasil; c2024 [cited 2024 Aug 2]. Available from: https://unaids.org.br/estatisticas/.
https://unaids.org.br/estatisticas/... ). In Brazil, almost 37,000 HIV cases were reported in 2022, an increase of 17% when compared to the number reported in 2020 (⁵5 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde e Ambiente [Internet]. Hiv e Aids 2023. Boletim Epidemiológico; 2023;No Espec [cited 2024 Aug 2]. Available from: https://www.gov.br/aids/pt-br/central-de-conteudo/boletins-epidemiologicos/2023/hiv-aids/boletim-epidemiologico-hiv-e-aids-2023.pdf/view.
https://www.gov.br/aids/pt-br/central-de... ). Among the elderly, there was a 20% increase in the number of cases between 2015 and 2022.

The increase in the number of cases of HIV infection in the elderly population may be associated with the lack of prevention campaigns aimed at safe sex practices among the elderly involving condom use, in addition to the existence of taboos about sexuality as age advances. Elderly people having insufficient knowledge about HIV infection may also be a factor (⁶6 Vieira CPB, Costa ACSS, Dias MCL, Araújo TME, Galiza FT. Tendência de infecções por HIV/Aids: aspectos da ocorrência em idosos entre 2008 e 2018. Esc Anna Nery 2021;25(2):e20200051.).

Survival analyses of people living with HIV/AIDS in the context of the Brazilian regions and regarding the elderly are still incipient (⁷7 Lemes CD, Favoretto CK, Gomes CE. Fatores associados à mortalidade por HIV/Aids em idosos: análise espacial para as microrregiões do sul e do sudeste do Brasil. Rev. Econ. NE. 2021; 52(2):81-101. ). This study aims to characterize, according to demographic and clinical aspects, the survival of elderly patients living with HIV in follow-up at a reference service in Jaboatão dos Guararapes, Pernambuco, Brazil.

Methods

Design

This is a retrospective cohort study of HIV-infected elderly people in follow-up at a reference service in Jaboatão dos Guararapes, Pernambuco, Brazil.

Background

Jaboatão dos Guararapes is the second most populous municipality in the state of Pernambuco, with 644,037 inhabitants in 2022 (⁸8 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Brasileiro de 2021. Pernambuco: IBGE, 2023.), approximately 15% of whom were elderly.

The study location, the Specialized Care Service, is a municipal outpatient care unit, a reference service for attending to and monitoring people living with HIV in the municipality. The service is comprised of a multidisciplinary team of professionals who provide care, guidance and advice to service users on prevention and treatment of sexually transmitted infections (⁹9 Jaboatão dos Guararapes (PE). Serviço de Atenção Especializada em HIV/Aids (SAE) [Internet]. Pernambuco: SEGD; 2022 [cited 2022 Feb 25]. Available from: https://jaboatao.pe.gov.br/servicos-de-atencao-especializada-em-hiv-aids-sae/.
https://jaboatao.pe.gov.br/servicos-de-a... ).

Participants

The study included elderly people (≥60 years old) who began follow-up at the Specialized Service between January 2006 and December 2021 and who had follow-up at the service until December 2022. The study examined active cases and those closed due to transfer, treatment dropout or death during the period analyzed.

We excluded duplicate records or those with illegible information, cases whose medical records were missing and elderly patients undergoing follow-up care in private services.

Data source and variables

Data were collected from the consultation follow-up and monitoring records held at the service, between October and December 2022. The primary outcome was death from causes related to HIV infection.

The following variables comprised the study: age (in years: 60-69, 70-79, >80), sex (female, male), age at diagnosis (in years: <60, >60), education (illiterate, elementary education, high school education and above), municipality of residence (Jaboatão dos Guararapes, other municipalities), living with a partner (yes, no), hospitalization (yes, no), contracted opportunistic infections (yes, no), HIV viral load (in copies/mL: <5,000, >5,000), treatment failure at last appointment (yes, no) and change of antiretroviral regimen (yes, no).

Statistical methods

The service entry date for survival calculation was defined as the date monitoring started at the service. The final date was the date of death for patients who died and the date of the last consultation for patients whose final situation was active, transferred or treatment dropout. Survival time was defined as the duration of follow-up in months.

The survival estimate for elderly people living with HIV/AIDS was calculated from a certain time T until the outcome, in this case, death from causes related to HIV infection. Censorsing was characterized by the final situation: transfer between services, deaths from other causes, treatment dropout and elderly people with active monitoring.

The hazard ratio (HR) and 95% confidence interval (95%CI) of death were calculated based on the study variables using Cox regression. Survival was calculated using the Kaplan-Meier estimator and expressed as a survival curve, estimated according to the study variables. All variables with a p-value<0.2 were included in the multivariate analysis. The threshold for statistical significance was set at p-value<0.05. The analyses were performed using Stata 12.0.

Results

A total of 126 eligible records were identified, ten of which were excluded (9 records not located and 1 follow-up at a private service), so that 116 elderly people were included in the study.

The majority (n=83) were 60 to 69 years old and male (n=60). Diagnosis occurred after the age of 60 (n=45), 73 had low education levels, 102 lived in Jaboatão dos Guararapes and 62/115 lived alone (Table 1).

The majority had not been hospitalized (n=96)and did not present opportunistic infections (n=80). Four elderly people had a viral load above 5,000 copies/mL at the last consultation, 83 had no treatment failure and 63 had changed their antiretroviral regimen during the follow-up period. In the univariate analysis, no factors associated with death due to HIV were identified (Table 1).

Hospitalization among the elderly increased the risk of death (HR 4.83; 95%CI 1.07; 21.79) (Table 2). Of the total number of elderly people in the study group, nine died from HIV-related causes. Average survival time of the elderly people monitored was 76.5±48.5 months, ranging from 0.63 months to 195.6 months.

In the first 12 months studied, there were four deaths with underlying causes related to HIV infection and the probability of survival was 96.4% (95%CI 90.68; 98.63) (Figure 1).

Discussion

During the period studied, the majority of elderly people monitored were between 60 and 69 years old, male, had been diagnosed with HIV infection under the age of 60, had no partners and had low education levels. The majority of the elderly people had not been hospitalized due to complications related to HIV infection or opportunistic infections, had a low viral load according to the last test recorded on their medical records, had no treatment failure and had to change their treatment regimen at least once. Average survival time was greater than 76 months.

It can be seen that males have always been among those most vulnerable to HIV infection and although the phenomenon of feminization has occurred in the history of the epidemic, the proportion of men living with HIV is still greater than the proportion of women, as found in this study. In relation to age group, Brazil (¹⁰10 Ministério da Saúde (BR), Secretaria de Vigilância em Saúde e Ambiente. Boletim epidemiológico: aids e DST ano III, no 01. Brasília: Ministério da Saúde; 2014 [cited 2022 Nov 22]. Available from: https://antigo.aids.gov.br/pt-br/node/73.
https://antigo.aids.gov.br/pt-br/node/73... ) has seen a sharp increase in cases of infection among the elderly.

Another important factor was that the majority of elderly people were between 60 and 69 years old. These can be classified according to age group into youngest-old people (¹¹11 Santos VP, Lima WR, Rosa RS, Barros IMC, Boery RNSO, Ciosak SI. Perfil de saúde de idosos muito velhos em vulnerabilidade social na comunidade. Rev Cuid. 2018; 9(3):2322-37.) and those who were diagnosed as having HIV infection under 60 years old. The greater proportion of elderly people diagnosed before the age of 60 demonstrates that reaching old age is the result of progress in access to antiretroviral therapy, which has been a right guaranteed by Brazil since 1996. The Ministry of Health (¹²12 Brasil. Ministério da Saúde. Envelhecimento e saúde da pessoa idosa. Brasília: Ministério da Saúde; 2006. [cited 2024 Oct 30]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/evelhecimento_saude_pessoa_idosa.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... ) recognizes that increased survival, as a result of the use of antiretroviral drugs, has enabled many people living with HIV to reach old age.

However, almost 40% of the elderly people monitored were diagnosed over the age of 60, which may, on the one hand, be a reflection of the increase in the occurrence of infection in this age group, as identified by other authors (¹³13 Nakamura AS, Tanaka MA, Bonafé SM. Aids e infecção pelo HIV no Brasil: uma revisão bibliográfica dos grupos populacionais [Internet]. In 8º EPCC - Encontro Internacional de Produção Científica Cesumar; 2013; Maringá, Paraná: CESUMAR; 2013 [cited 2022 Sep 25]. Available from: http://www.cesumar.br/prppge/pesquisa/epcc2013/oit_mostra/amanda_sayuri_nakamura.pdf.
http://www.cesumar.br/prppge/pesquisa/ep... -¹⁴14 Dornelas J Neto, Nakamura AS, Cortez LER, Yamaguchi MU. Doenças sexualmente transmissíveis em idosos: uma revisão sistemática. Cien saude colet. 2015; 20(12):3853-3864. ), or difficulty in accessing services, which delays diagnosis and compromises care, as identified in a survey in the state of Alagoas (¹⁵15 Melo GC, Carvalho ACA, Moreira AS, Paixão JTS. Tempo de sobrevida e distância para acesso a tratamento especializado por pessoas vivendo com HIV/Aids no estado de Alagoas, Brasil. Rev Bras Epidemiol. 2021;24(supl.1):e210019.). Furthermore, studies show that among the elderly requesting an HIV test only happens in the late stage of the disease, after the possibility of other diseases has been discarded (¹⁶16 Slinkard MS, Kazer MW. Older adults and HIV and STI screening: the patient perspective. Geriatr Nurs. 2011;32(5):341-9.-¹⁷17 Linley L, Prejean J, An Q, Chen M, Hall HI. Racial/ethnic disparities in HIV diagnoses among persons aged 50 years and older in 37 US States, 2005-2008. Am J Public Health. 2012;102(8):1527-34.).

We also found that a greater proportion of elderly people are resident in the municipality of Jaboatão dos Guararapes, live alone, without partners and have low education levels. A study (¹⁸18 Nicaretta RJ, Ferretti F, Portella MR, Ferraz L. Itinerário terapêutico de idosos vivendo com HIV/Aids: perspectivas da história oral. Physis. 2023(33):e33013.) about family and care of elderly people living with HIV revealed that positive HIV diagnosis among people aged 60 or over emphasizes the importance of care and a support network due to the need to rebuild bonds that break down following diagnosis.

Furthermore, poor access to education can influence older people’s understanding of the risks of the disease and prevention methods (¹⁹19 Vieira CPB, Costa ACSS, Dias MCL, Araújo TME, Galiza FT. Tendência de infecções por HIV/Aids: aspectos da ocorrência em idosos entre 2008 e 2018. Escola Anna Nery. 2021;25(2):e20200051.). In addition, a low level of education is associated with poorer living conditions, food, housing, transportation, access to health services in general and social discrimination. Survival and adherence to antiretroviral treatment have been associated with lower levels of education (²⁰20 Alencar RA, Ciosak SI. Late diagnosis and vulnerabilities of the elderly living with HIV/AIDS. Rev esc enferm USP. 2015;49(2):0229–35. ).

In relation to clinical characteristics, we found a greater proportion of elderly people with undetectable viral loads, which may be a result of good adherence to treatment and few treatment failures. It is known that an undetectable viral load and a T-CD4 lymphocyte count above 350 favor (²¹21 Lemos-Jordão AJJM, Silva HRT, Cruz WO, Lemos G, Ataíde JB, Tabosa JCF, et al. Infecções oportunistas em pacientes soropositivos para HIV assistidos no Hospital Universitário Alcides Carneiro. Cien Saude Colet. 2021;10(3):32-45.) patients having a better defense response against infectious agents that can affect them, improving morbidity and mortality rates associated with the outcomes of opportunistic infections.

Another aspect found in the results was that the majority of elderly people had not had opportunistic infections, although a small proportion of them were affected by these diseases. It is important to highlight that in addition to a high viral load and a decrease in CD4+ T cells, aspects related to socio-environmental conditions, can contribute to the emergence of opportunistic infections in immunocompromised individuals, such as water supply, sanitation, hygiene habits, having pets, among other contexts (²²22 Brito FPG, Aragão HT, Oliveira MLL, Santana JT, Madi RR, Lima SO, et al. Perfil de infecções oportunistas em pacientes com HIV/AIDS em serviço de atendimento especializado do Município de Aracaju, SE, Brasil. Braz. J. Hea. Rev. 2021;4(3):10509-10525.).

Regarding changes in treatment regimens, just over half changed antiretroviral regimens at least once during the period assessed. A survey (²³23 Vasconcelos MMLM, Arruda EAG, Ibiapina AP, Costa LFL, Araújo ALMV, Medeiros MS. Simplificação terapêutica com lamivudina e dolutegravir em pacientes vivendo com HIV no Ceará (Estudo LAMDO). RSD. 2022;11(9):e59711932251.) conducted with people living with HIV in the state of Ceará highlights that it is essential to take into account that any regimen change must be analyzed carefully, in order to maintain the safety and effectiveness of the treatment.

Occurrence of hospitalization was the only variable that remained in the regression model with significant association with the survival of the elderly. It was found that the largest proportion of elderly people did not have a record of hospitalization due to complications related to HIV infection, and those who had not been hospitalized during the study period had a higher survival rate.

Therefore, hospitalization may be the result of treatment failure or non-adherence to treatment. This shows that the results corroborate the findings of a case-control study in a municipality in the state of São Paulo (²⁴24 Lopes LM, Andrade RLP, Arakawa T, Magnabosco GT, Nemes MIB, Netto AR, et al. Fatores de vulnerabilidade associados às internações por HIV/aids: estudo caso controle. Rev Bras Enferm. 2020;73(3):e20180979.), which found that some programmatic vulnerabilities, such as irregular use of antiretrovirals, treatment dropout, not attending clinical follow-up appointments, are risk factors for hospitalization due to HIV/AIDS.

Regarding the average survival time found in the study, despite the increase in HIV cases among the elderly, it can be seen that the universal supply of antiretroviral drugs contributed to greater survival (²⁵25 Cooperman NA, Arnsten JH, Klein RS. Current sexual activity and risky sexual behavior in older men with or at risk for HIV infection. Aids Educ Prev. 2007; 19:321-33.). Age at diagnosis is an important predictor of survival. People diagnosed with HIV in younger age groups had a significantly higher average survival rate than those who were older. The age factor was found to be a negative indicator for those diagnosed when they were in the 41-60 and over 60 age groups, as they had lower mean and median survival rates (²⁶26 Zuber JFS, Muller EV, Borges PKO. Sobrevida de pessoas vivendo com HIV/AIDS na região dos Campos Gerais, Paraná 2008-2018. RSD. 2021:10(1):e14810111444. ).

It is essential to conduct studies on mortality due to HIV/AIDS. A survey of deaths from HIV/AIDS-defining and non-HIV/AIDS-defining illnesses in Brazil between 2000 and 2018 demonstrated that the existence of high mortality rates due to defining diseases may be a reflection of inequalities regarding death due to this health condition (²⁷27 Cunha AP, Cruz MM. Análise da tendência da mortalidade por doenças definidoras e não definidoras de HIV/aids Segundo características sociodemográficas, por Unidade da Federação e Brasil, 2000-2018. Epidemiol Serv Saúde. 2022; 31(2):e2022093.).

Among the limitations of this study, the use of data from medical records, which were not always well filled out and lacked information, hindered the analysis of some variables, such as income, education and adherence to treatment. However, this research provides support that can contribute to identifying the need to implement new sources of information monitoring for providing care to users of the Specialized Care Service.

Future research, involving more health centers and other territories, may point to new findings related to the context of health policy and the planning of specific interventions to improve the quality of life of elderly people living with HIV.

This research revealed the survival characteristics of the elderly in follow-up that Service we studied. In the first year of study, probability of survival was greater than 96%. Survival ranged from less than one month to more than 195 months (more than 16 years). Among the sociodemographic and clinical factors studied, only occurrence of hospitalization showed significant association with the survival of the elderly. The elderly people monitored were mostly men, were in the youngest-old age group, were diagnosed with HIV before the age of 60, lived alone and had low education levels. Most of them had not been hospitalized, nor did they present opportunistic infections during the period analyzed. Although the study was conducted in just one Service, these results can contribute to the targeting of care strategies for elderly people living with HIV.

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