Personally I wouldn't use it; I'd just write some quick code with Twilio (using Twilio functions or a companion app running on Heroku for the business logic) and let them handle it. Less maintenance overhead.
irl maintenance is pretty straightforward. I do it as a side thing to my main job.
It's quite a legacy application and is not easily scalable nor made highly available.
The world is also moving to hosted communications (Twilio, etc) so there is less and less need for a local PBX, thus less demand for Asterisk.
You scale horizontally using proxies (kamailio dispatchers), (what you would call "reverse proxies in the http world), and use external storage / database / logic.
Correct, but don't forget many hosted communications services use asterisk internally.
Twilio did use Asterisk in the past, although I believe they have switched to something else.