Aging with HIV: Where do we stand after CROI 2013?

Getting old may be tough, but it sure beats the alternative. More and more I am reminding my HIV+ patients, and myself, of this truism as together we reach the milestones of middle age: knee braces, colonoscopies, and misplaced car keys. However, these men and women, having dodged the early reaping of HIV worry that both time and the virus are catching up with them.

The Centers for Disease Control (CDC) estimate that over half of those living with HIV in the US will be older than 50 years of age by 2017.1 San Francisco, hit earliest by HIV, has already seen the median age of the HIV-positive population push past 50.2 With the graying of the domestic epidemic patients and their healthcare providers are now focused on how HIV influences the aging process. To believe the lay press, growing older with HIV will not be pretty - with handfuls of pills, heart attacks, and broken bones, awaiting the golden years.3

The scientific literature feeds a similar story of “premature” or “accelerated” aging for those living with HIV. For example, a recent, oft-quoted, Italian paper published in Clinical Infectious Diseases comparing HIV-positive and -negative cohorts suggests that people living with HIV can expect to experience some conditions associated with aging a decade earlier than would be expected.4 Not surprisingly, patients are petrified - suffering a double helping of the age-phobia pervasive among baby-boomers.

However, the clinical data are confusing and there are challenges to trying to ascertain the contribution of HIV to aging, including the difficulty of identifying an appropriate control group with whom to compare HIV-infected individuals. The Italian study, for example, included HIV-infected patients from a single clinic while the HIV-negatives came from a large national electronic cohort. While the controls were matched to HIV-infected cases based on age, sex, and race there was no adjustment for traditional risk factors for cardiovascular and other age-related conditions, except for the presence of hypertension. The word ‘smoking’ is nowhere to be found in the article, despite rates of tobacco use among HIV-positive folks that are known to be double to triple those seen in the general population.

A more compelling picture of a virus-immune activation-organ disease connection is found in some of the more basic science work, where elevated levels of immune responses and markers of inflammation are seen to decline with HIV treatment but, in some patients, persist despite evident control of viremia. Such chronic activation of the immune system and low-level inflammation have been linked to cardiovascular disease (CVD) outside of HIV. But do these findings translate in actually increased excess rates of CVD or other diseases? If so, by how much? Is it a drop in the proverbial bucket or akin to smoking two packs a day?

We don’t really know the answers to these questions and in this data vacuum we float, grasping at the bits of information that passes our way, hoping to latch on to something substantial. Unfortunately, the studies that sound the loudest alarm get the most attention.

In my view, the steady beat of studies make clear that people living with HIV face a heightened risk for diseases that are hallmarks of our built-in obsolescence. Much, I dare say most, of this is at the hands of mundane contributors associated with lifestyle and perhaps the more difficult to measure stress of living with poverty, discrimination and stigma. These factors do not absolve HIV (or its treatment) of responsibility and there may be a contribution of these to organ dysfunction in people living and aging with the virus. It will be the next phase of research that will hopefully place all of this in perspective. Meanwhile, we carry on – vigilant in screening and diligent in following standard disease prevention guidelines. Our patients on the other hand also need to be reassured and to be calm, but not to carry on with behaviors that enhance the odds of diagnosis of serious non-AIDS events. That alone may not make all the difference but a difference it will make.

Speaking of getting older, NCATEC at UNC is now entering its third year. We have worked to move beyond our initial baby steps and are taking bigger strides toward making us a go-to resource for professional HIV training in North Carolina. Clearly there are changes and challenges facing HIV care in our state. With implementation of healthcare reform it is anticipated that primary care providers, rather than specialists will see more HIV+ patients. At the same time, funding for the AIDS Drug Assistance Program (ADAP) may shrink, removing an important safety net for our most needy patients. Our ATEC is committed to working with healthcare providers of all experience levels to provide the highest quality of care possible and do so in a manner that sensitive to the lives our patients live, despite the headwinds. Our team will precept you at UNC clinics or come to your clinic. We will organize a workshop or webinar on HIV 101, HCV, culturally competent care, adherence, substance abuse, PrEP - you name it. This website is now getting populated with high quality videos of key thought leaders presenting on the most pressing topics in our field. We have even grander ideas and will roll these out over the coming months. Let us know how we can help you.

 

References

  1. Justice AC. HIV and aging: time for a new paradigm. Curr HIV/AIDS Rep. 2010 May;7(2):69-76 (Estimated 50% of HIV+ population in US will be >50 years of age by 2015, subsequently updated to 2017).
  2. Scheer S, et al. 6th IAS; Rome, Italy; July 17-20, 2011. Abst. TUPE131.
  3. France, D. Another Kind of AIDS Crisis. New York Magazine. Nov 1, 2009. http://nymag.com/health/features/61740/
  4. Guaraldi G, et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clin Infect Dis. 2011 Dec;53(11):1120-6