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status strongly associated with mortality. The presence of cardiovascular and cancer morbidity and mortality in
anaemia and poor nutritional status are interconnected, OPLWH. 8
and in this cohort the presence of anaemia was associated
with the risk of dying. Unfortunately, height and thus body The VL suppression in this cohort was lower than
mass index (BMI) and/or mid-upper arm circumference previously reported in SA. 9,10,16 Moreover, VL suppression
(MUAC) measurements were not routinely measured in was attained in 86% – 89.5% of older adults in other settings
the care of this study’s participants. Haemoglobin levels after 12–60 months of treatment. It was perturbing that
were also not readily available for this cohort. The weight only 81.9% of this cohort had a suppressed VL, especially
(median and IQR) nevertheless correlated well with that of as a larger proportion of them were on second-line
participants in another South African study. Nutritional treatment than found in another South African cohort
9
status is one of the components that needs to be assessed in (5.2% versus 0.88) ; and female participants, who are
16
a comprehensive geriatric assessment (CGA). This tool historically more adherent to treatment, had lower VL
includes 11 components that address biomedical, social suppression rates. Only 5.2% of the cohort were on second-
and economic concerns for HIV care providers relating to line ART. The rest were still on a NNRTI-based regimen.
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OPLWH. Recent hospitalisation is a known risk factor for Moreover, over 85% of those with an unsuppressed VL
dying in OPLWH, and this was echoed in this study. A were still on an NNRTI-based regimen. HIV treatment and
meta-analysis showed that those who underwent a CGA monitoring guidelines in SA have changed since this study
whilst hospitalised were more likely to be alive after 12 was conducted. The new guidelines define a suppressed
months than those who did not. An explanation for this VL as < 50 copies/ml. If these criteria were used to assess
25
27
may be that the teams who performed CGA were more VL suppression, only 59% of this cohort would be
experienced and specialised than the teams who typically suppressed. Although high-range low-level viraemia (VL
worked on the wards. Long-term follow-up also appeared 400 copies/mL – 999 copies/mL) in this cohort was low
to be more comprehensive in the participants who (8.4%), a previous study performed in SA showed a five-
underwent CGA in the hospital setting. This is a novel tool times increased risk of virological failure in participants
in HIV care; it has been used successfully in other who had VL readings in this range. It is imperative to
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disciplines and may prove to be a crucial tool in the HIV monitor these patients closely and act appropriately if and
care sphere pertaining to the ageing population in years to when true virological failure (VL ≥ 1000 copies/mL) and
come. Hence, there are ample reasons for incorporating attenuated CD4 cells count responses develop. Appropriate
26
anthropometric measures, including those related to action, that is changing to a second-line ART regimen,
nutritional status and anaemia, into the clinical guide for seemed to be lacking in this cohort. There was, likely,
the care of OPLWH. However, clinicians in better resourced
settings are struggling to adhere to CGA recommendations treatment failure and the development of resistance to ART
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and its rollout to resource-constrained settings may come in this cohort. This may hamper the 90–90–90 UNAIDS
with challenges, such as lack of experience with the tool, target of achieving a 90% VL suppression rate in all age
time and resource limitations and insufficient evidence for groups globally by 2030. South Africa currently stands at
29
its effectiveness in African settings. 87% VL suppression in 54% of all PLWH. More attention
should be given to OPLWH in order to attain the UNAIDS
Even in this reasonably small cohort, the prevalence of HPT goals and ensure their overall well-being and prevent the
and DM were high compared with other studies. 9,17 In these spread of drug-resistant HIV.
studies, the prevalence of HPT ranged from 21.5% – 33.3%,
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the latter percentage being for participants aged ≥ 70 years. Malaza et al. found that the median CD4 cell count in
3
In our study population, there were 55.5% of OPLWH on OPLWH was 367 cells/mm after a median duration of
16
treatment for HPT. The differences may be due to the other 2.3 years on ART. Similarly, Fatti et al. found that OPLWH
3
studies actively measuring participants’ blood pressure at had a median CD4 cell count of 377 cells/mm after 3 years
ART initiation, whereas the current study relied on clinical on ART. The median CD4 cell count increased by
3
records and could not account for what might have come 256.5 cells/mm from the baseline in this cohort. Fatti et al. 16
first: HIV or HPT. The same could be said about DM, where also found that the median CD4 cell count increased from
3
the prevalence ranged from 2.2% – 6.3% in the other cohorts, about 100 cells/mm after 6 months to over 300 cells/mm 3
compared to 7.9% in the current cohort. Again, conclusive after 48 months, since ART initiation. It is well-established
interpretation of these results is elusive because the current that CD4 cell recovery is attenuated in OPLWH compared to
study inception was not at ART initiation. It is well younger PLWH. 16,30 In this study, it was evident that higher
established that ART and ageing both accelerate recent CD4 cell counts were more likely in those who had
cardiovascular disease risk in older adults. Added to the been taking ART for > 5 years (OR = 3.15, 95% CI 1.34–7.40,
8
cardiovascular disease burden of HPT, DM and CKD, it p = 0.009) and those on the usual first-line ART (OR = 2.78,
stands to reason that older adults require tailor-made 95% CI 1.04–7.42, p = 0.041). The former may have been an
interventions to address their cardiovascular health. The obvious finding because of improved immune reconstitution,
administration of a novel polypill (including a statin, aspirin the sooner a patient is initiated on ART, but further work
8
and anti-HPT medications) is a potential option to reduce may be needed to evaluate the latter.

http://www.sajhivmed.org.za 271 Open Access