Prevalence of Alzheimer's disease and related dementias among older US Medicare beneficiaries with and without HIV: a successive cross-sectional study

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BackgroundNearly 50% of people with HIV have at least mild cognitive impairment, even when they are taking suppressive antiretroviral therapy (ART). There is growing concern among HIV researchers that people with HIV will have a disproportionate burden of dementia as they age; however, there is no nationwide population-based research data on changes in trend over time in Alzheimer's disease and related dementias (ADRD) prevalence among older people with HIV versus people without HIV. MethodsWe used 100% of beneficiaries with HIV diagnosis and a 5% national sample of Medicare enrollees in 2007–19 from all 50 US states and District of Columbia. All individuals who reached age 65 years in the calendar year and had at least 3 years of fees for service coverage were included in the denominator. All ADRD cases were identified by International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) and International Classification of Diseases, tenth revision, clinical modification (ICD-10-CM) diagnosis codes. Prevalence of ADRD was calculated in successive cross-sectional cohorts for each calendar year. Joinpoint regression analysis was performed to compute the average annual percentage change (AAPC) in ADRD prevalence by sex and age groups (65–69, 70–74, 75–79, and ≥80 years) for people with and without HIV, respectively. FindingsWe identified 26 887 and 608 141 ADRD-prevalent cases in all years among 87 216 people with HIV and 2 289 831 people without HIV, respectively. In the overall sample, 55·6% of beneficiaries were female, 84·5% were White, and 8·9% were Black. Mean age at entering the cohort was 73·3 (SD 8·1), More people with HIV were male (65·7%; 34·3% female) compared with people without HIV (43·6%; 56·4%). Mean age was 72·6 (6·7) years for male beneficiaries without HIV, 74·0 (7·8) for female beneficiaries without HIV, 70·0 (5·7) for male beneficiaries with HIV, and 72·8 (7·7) for female beneficiaries with HIV. There were more Black beneficiaries among people with HIV than among people without HIV (7·6%, 8·4%, 30·7%, and 37·1%, respectively). The prevalence of ADRD increased over years among older age groups (≥70 years) especially for people with HIV and female beneficiaries. Among people aged 80 years or older, ADRD prevalence increased from 26·2% to 33·3% for male beneficiaries with HIV and 31·4% to 44·1% for female beneficiaries with HIV, and from 21·0% to 23·5% for male beneficiaries without HIV and 27·4% to 29·9% for female beneficiaries without HIV. The AAPCs for the entire study duration by age groups were highest among female beneficiaries with HIV (range 1·2% [95% CI 0·6 to 1·8] to 3·1% [2·3 to 3·9]), whereas AAPCs estimates among female beneficiaries without HIV ranged from 0% (–0·3 to 0·3) to 0·9% (0·3 to 1·4). InterpretationPeople with HIV had a higher prevalence of ADRD, which increased over time in both male and female beneficiaries, compared with people without HIV. However, the magnitude of the increase was more prominent in female beneficiaries and with increasing age, indicating an increase in the dementia burden over 13 years among people with HIV, especially those who are female and aged 80 years or older. The findings underscore the need to develop clinical practice guidelines that facilitate integration of dementia screening and evaluation into routine primary care of ageing people with HIV, thus targeting resources to the most clinically vulnerable population. Future research is needed to understand factors associated with the increase in dementia among people with HIV. FundingXY and ABB are supported by a research career development award (K12HD052023; primary investigator ABB). XY is also supported by Sustained Training in Aging and HIV Research (R25MH108389; primary investigators Dilip V Jeste and Scott L Letendre. TPG is supported by the MD Anderson Foundation Chair at Baylor College of Medicine and Texas Developmental Center for AIDS Research (P30AI161943; primary investigator TPG).