Key Challenges Await an Aging HIV-infected Population

Gerome V. Escota, MD, assistant professor of medicine,Washington University School of Medicine

Gerome V. Escota, MD

According to a new study, age-related health issues seem to affect people living with HIV infection (PLWH) in an accelerated or emphasized fashion due to comorbidities associated with HIV infection, however, it is unclear whether those comorbidities are the result of the infection, ART, or other socioeconomic and demographic factors.

The article, led by Gerome V. Escota, MD, published by the International Journal of Infection Diseases in November 2017, looks at the challenges and opportunities associated with an aging population of persons living with HIV infection.

As the population of PLWH increases in age, steps can be taken at the clinical and research level to improve aging outcomes and reduce risk factors for age-related diseases exacerbated by health vulnerabilities in PLWH.

Escota and colleagues with the Division of Infectious Diseases at the Washington University School of Medicine in Saint Louis, MO, explain that the introduction of potent antiretroviral therapy (ART) has significantly improved survival and life expectancy among PLWH.

In 2014, the Centers for Disease Control and Prevention (CDC) estimated that 45% of American PLWH were 50 years or older, and that estimation rose to over 50% in 2017.

Escota and colleagues are interested in the changing demographics and the "additional complexity of managing diseases commonly associated with aging" for PLWH. Escota notes that PLWH have increased rates of and risk of osteoporosis, frailty, diabetes, malignancy, chronic liver disease, chronic kidney disease, and cardiovascular diseases (CVD).

Despite a 50% decrease in CVD-related mortality in the general population, there was a 2-fold increase in deaths from CVD among PLWH.

There are multiple factors which may be contributing to CVD-related mortality among PLWH, including the HIV infection itself, ART toxicity, and increased rates of traditional factors including smoking, diabetes mellitus, hypertension and dyslipidemia.

An additional risk factor may result from treatment with abacavir, a nucleoside reverse transcriptase inhibitor (NRTI), which has been shown to increase risk of acute myocardial infarction for PLWH by 90%.

The article also cites data from Yale School of Medicine's Veteran's Aging Cohort Study which demonstrates a relationship between HIV infection and heart failure with preserved and reduced ejection fractions.

In addition to increased risk of CVD, PLWH have an increased risk of other diseases, disorders, and health related issues.

"PLWH are 6 times more likely to have low bone mineral density (BMD) and almost 4 times more likely to have osteoporosis compared to the general population," Escota notes.

Increased risk of infection-related cancers for PLWH are also an important health issue. The rates of AIDS-defining malignancy have decreased as a result of ART, but the rates of non-AIDS defining cancer continues to rise.

Some of the increased risk can be attributed to increased rates of smoking/tobacco use among PLWH (an estimated 40­—70%), according to Escota, but the increased risk factors for many malignancies is currently unclear.

PLWH also plays a factor in chronic liver and kidney diseases, as HIV hastens the progression of liver fibrosis, particularly among those patients with HIV and hepatitis B or C, which leads to higher rates of cirrhosis and hepatocellular cancer.

Despite a decline in HIV-associated nephropathy, once the most common cause of end stage renal disease for PLWH, rates for chronic kidney disease remain high. PLWH are at greater risk for age-related neurocognitive dysfunction, and common geriatric conditions such as frailty, depression, visual impairment, and urinary incontinence.

Escota and colleagues write that the growing rates of comorbid illness observed in PLWH cannot be entirely attributed to HIV infection alone, and it’s likely to represent a complex interplay of factors.

Current research focuses on the effects of HIV-associated inflammation on age-associated inflammation, to determine how each may be contributing to, or exacerbating, disease progression, and more research is required to understand how HIV effects both mortality and disease development among PLWH.

PLWH will face health difficulties as they age, but Escota and colleagues believe there are steps that can be taken now to increase likelihood of successful aging for this population.

Escota stated in interview with MD Magazine, that in lieu of a current cure for HIV/AIDS there are various options to ensure successful aging among HIV-infected individuals which includes early initiation of antiviral therapy regardless of the immune status (i.e. CD4 count) and the use of newer, simpler, and more tolerable antiviral medications that have yet to show an increase in the risk of developing chronic illnesses like renal, bone, and heart disease.

Clinicians are suggested to be more aggressive in applying primary prevention and screening guidelines for patients with HIV and that patient risk factors such as smoking, cholesterol, and hypertension, be more aggressively controlled and treated in PLWH.

According to Escota, successful aging for PLWH also depends on the strength of the partnership between the physician and the patient in promoting health (e.g. avoidance of smoking) and identifying and addressing proven risk factors for disease (e.g. smoking, substance abuse, obesity).

PLWH will undoubtedly face challenges as they age, however, according to Escota, there are opportunities that may help mitigate the challenges and ensure successful aging.

There are several unanswered questions that still remain about aging and HIV, including questions about "the relative contributions of the HIV itself, the antiviral medications patients are taking, the traditional risk factors that patients have (e.g. smoking, substance abuse), and the patients’ socioeconomic status to the over-all risk of developing chronic illnesses over time."

This question becomes more important in aging patients with a fully suppressed virus and good immune recovery which is attributed to medications patients are receiving.

Future studies are needed to help understand the pathogenesis of HIV and the development of age-related diseases.

Escota is concerned about health disparities for an aging population of PLWH, stating that the health disparity dominating the HIV landscape widens as the population ages. The inequality in the delivery of healthcare and preventive services, and the persistent social stigma against people living with HIV are some of the most important obstacles to overcome and achieve successful aging in the HIV-infected population.

The study, "Understanding mechanisms to promote successful aging in persons living with HIV" appeared in the November issue of the International Journal of Infection Diseases.

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