Behavioral and Clinical Characteristics and Outcomes of Treatment Among Older Patients Receiving Medical Care for HIV Infection in Iran

Document Type : Original article


1 Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Global Health and Socioepidemiology, Graduate School of Medicine, Kyoto University, Kyoto 215789652, Japan

3 Black Dog Institute, University of New South Wales, Sydney, Australia


Background: Although the number of new HIV infections continues to decline in Iran, the number of HIV-infected patients aged ≥50 years continues to rise due to the introduction of new treatment and longer survival. The higher prevalence of medical comorbidities and treatment failure in this population is a critical challenge in HIV treatment. In the present study, prevalence of comorbidities, rate of response to treatment, and results of HIV drug resistance tests were explored in older patients.
Methods: A cross-sectional study was conducted at a tertiary referral HIV center in Tehran, Iran. The data for all the HIV-positive patients older than 50 years old were collected by reviewing their medical records within the last 15 years. Data included demographic and behavioral characteristics, immunologic and virologic response, rate of treatment failure, and HIV resistance.
Results: The records for 100 patients with a mean age of 62.5 (range 50-79) years were reviewed and analyzed. Medical comorbidities were observed in 20% of the patients, with HCV co-infection, diabetes mellitus, and neuropsychiatric impairments being the most common. Complete immunologic and virologic responses were respectively observed in 88 and 97% of patients. The treatment regimen was modified in 66 patients, with drug side effects being the reason in 63 patients (95.4%). HIV drug resistance tests showed a low rate of resistance (<10%) to all drugs used in this population.
Conclusion: Our findings highlight the high prevalence of comorbidities in older HIV-positive individuals in Iran. A thorough endocrine and neuropsychiatric assessment at each visit is recommended for these patients. Access to an appropriate psychosocial support system will ensure earlier detection of HIV infection and comorbidities in the older population, and will undoubtedly improve the treatment outcome and quality of life among them.


Iran faces the largest HIV epidemic in the Middle East (1). The official reports estimated a total of 75,700 People Living with HIV (PLWH) in 2014 though the real number may be much higher. Barriers to HIV-related research in the developing world, particularly in the Middle East, are manifold including cultural, political, and legal issues (2). In recent years, the introduction of Highly Active Antiretroviral Therapy (HAART) increased the survival of PLWH and with a tremendous decline in mortality, there is a growing population of older PLWH (3).
In addition to the rapidly increasing population of HIV-infected individuals aged ≥50 years, the proportion of newly infected individuals over the age of 50 has also increased in the past two decades (4). Despite the similar trend in the Iranian population, there is evidence that this age group may not be aware of their infection and delay diagnostic tests and treatment (5). Moreover, the strong stigma of HIV infection in the Middle East will undoubtedly hinder access to proper treatment in the most vulnerable populations such as older PLWH (6).
Although HIV mortality has dramatically decreased in older PLWH (3), the infection in older individuals is associated with a higher prevalence of comorbidities and related mortality along with reduced CD4 response to HAART (7-9). Studies suggest that even among well-managed PLWH over 50 years, the median survival is still remarkably lower than the younger population (3).
There is no report on behavioral and clinical characteristics as well as treatment outcomes among older PLWH in Iran. Considering the HIV infection as a critical public health issue in Iran and the unique challenges of HIV treatment as well as HIV and aging in older PLWH, this study was conducted to extend the current knowledge on a cohort of older PLWH treated at a national HIV center by characterizing the comorbidities, behavioral risk factors, treatment adherence, and response to treatment among this population. It was hypothesized that the prevalence of medical comorbidities in this population is high and the rate of immunologic and virologic response to treatment would be lower in this age group.

Materials and Methods
Study setting
In a cross-sectional study, the medical records of 100 older PLWH who visited a tertiary referral HIV center in Tehran, were reviewed and the data on patient’s sociodemographic characteristics, comorbidities, immunologic and virologic response, and treatment resistance were retrieved from March 2004 to February 2018. Patients were included in the study if they were HIV-seropositive on their 50th birthday. Patients with only one visit and those with incomplete records were excluded.

Sociodemographic variables included age, sex, body mass index (BMI), level of education, employment status, marital status, number of children, and length of time since HIV diagnosis. Behavioral variables were reported by patients and included smoking, drug use (injection and non-injection) for non-medical purposes, sexual preference and activity, and vaccination history.
Medical and clinical care variables included medical comorbidities, treatment status as indicated by documented ART prescription, the prescribed drug combination, adherence to the treatment protocol, immunologic response to treatment, adverse effects of the treatment, any change in drug regimen as well as the reason for the change, the most recent CD4 cell count (cells/mm3), and complications of HIV infection including opportunistic infections. Only significant medical comorbidities were included in the study; co-infection with HCV, myocardial infarction, congestive heart failure, diabetes mellitus, hypertension, hemophilia, any tumor or malignancy, renal failure, psychiatric disorders, thyroid disease, lung disease, and dementia were the most important comorbidities.
Immunologic response to HAART was defined as the increase in CD4 cell count to more than 500 cells/mm3.
Virologic response was defined as the decrease in plasma level of HIV RNA to lower than 500 copies/ml.
Both values were recorded at six months following the treatment initiation. The results of HIV drug resistance tests were also recorded.

Ethical considerations
The protocol of the present study was reviewed and approved by the Institutional Review Board (IRB) of Tehran University of Medical Sciences (Ethics code: IR.TUMS.VCR.REC.1398.557). The medical records of patients were only used to retrieve the data on the variables analyzed in the present study. The information sheet and data file were stored as encrypted documents and were accessed only for the purpose of analysis in the current study. The identity information was not disclosed, neither collected in the present study.

Statistical analysis
The descriptive statistics were employed to describe the patient’s sociodemographic characteristics and the distribution of comorbidities as well as treatment regimen and outcome. SPSS software version 22.0 was used for statistical analysis.

Table 1 summarizes the patients’ demographic and behavioral characteristics. One hundred patients with a mean age of 62.5 (range 50-79) years were included in the final analysis. Seventy-two patients (72%) were male and 28 were female. The proportion of patients infected via intravenous drug use (62%) was almost twice the proportion of sexually infected patients (32%). About half of the patients were married. Of the total study population, 68 reported receiving the pneumococcal vaccine according to the national guidelines, 65 influenza vaccine, 45 HBV vaccine, and 39 other vaccines.

Medical comorbidities
Table 2 represents the medical comorbidities of the study population. As it has been shown, HCV co-infection, psychiatric disorders, and diabetes mellitus with the equal number of four (4%) were the most prevalent comorbidities among older PLWH in this study. In total, 20 out of 100 patients were suffering from medical comorbidities.

Treatment, drug resistance, and outcome
Table 3 illustrates the initial treatment regimens for the patients. All patients were undergoing HAART treatment at their latest visit, per national guidelines. The immunologic and virologic response following six months of treatment were observed in 88 (88%) and 97 patients (97%), respectively. The initial drug regimen was modified in 66 patients (66%), with side effects being the reason in 63 instances (95.4% of all regimen changes), and absence of virologic response in 3 cases (4.5%). Of 66 patients for whom the drug regimen was modified, EFV-3TC-TDF (16.6%) and TDF-3TC-ATV/r (13.6%) were the most common second-line drug combinations. . 3TC (Lamivudine), FTC (Emtricitabine), and NVP (Nevirapine) had the highest resistance among HIV infected patients in this study.

Table1. Demographic and behavioral characteristics of the study population


Number of patients *







Marital status










Mode of HIV transmission

   Sexual contact

   Intravenous drug use

   Blood products





Reason for HIV clinic visit


   Opportunistic infections

   Sexually-transmitted diseases

   Referrals from other clinics






Household variables

   Living  alone

   HIV infected person in household






* Since the total number of patients is 100, the numbers reflect the percentage as well

Table 2. The distribution of medical comorbidities in the study population

Medical comorbidity

Number of patients *

HCV co-infection


Psychiatric disorders


Diabetes mellitus




Ischemic heart disease




Hemophilia A


Chronic lymphoblastic leukemia


Thyroid disease


Chronic renal failure





* Since the total number of patients is 100, the numbers reflect the percentage as well

Table 3.  The distribution of HAART regimens for the study population

Drug regimen

Number of patients














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