Aging HIV-Infected Population Faces Unique Challenges

As the population of people living with HIV infection (PLWH) is living longer, age-related health issues are affecting these individuals in an accelerated or emphasized fashion. It is unclear, however, if this is the result of comorbidities, antiretroviral therapy (ART), or other socioeconomic and demographic factors. To this end, investigators in a new study led by Gerome V. Escota, MD and colleagues from the Division of Infectious Diseases at the Washington University School of Medicine in Saint Louis, Missouri, looked at the aging HIV-infected population and determined how to “define and measure successful aging,” as well as how to mitigate the challenges that are arising in this population.

In 2014, the Centers for Disease Control and Prevention estimated that 45% of American PLWH were 50 years or older; that estimation rose to over 50% in 2017. As PLWH are getting older, they are experiencing increased rates and risk of osteoporosis, frailty, diabetes, malignancy, chronic liver disease, chronic kidney disease, and cardiovascular diseases (CVD). For example, despite a 50% decrease in CVD-related mortality in the general population, there was a 2-fold increase in deaths from CVD among PLWH.

Multiple factors 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 be treatment with abacavir, a nucleoside reverse transcriptase inhibitor, which has been shown to increase the risk of acute myocardial infarction for PLWH by 90%.

In addition to increased risk of CVD, PLWH have an increased risk of other diseases, disorders, and health-related issues. Dr. Escota notes that “PLWH are 6 times more likely to have low bone mineral density and almost 4 times more likely to have osteoporosis compared to the general population.”

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. According to Dr. Escota, some of this increased risk can be attributed to increased rates of smoking or tobacco use among PLWH (an estimated 40% to 70%); however, the increased risk factors for many malignancies is currently unclear.

An HIV infection also plays a factor in chronic liver and kidney diseases, as the virus 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.

The investigators also found that despite a decline in HIV-associated nephropathy—once the most common cause of end-stage renal disease for PLWH—rates of chronic kidney disease remain high.

PLWH are also at a greater risk for age-related neurocognitive dysfunction, and common geriatric conditions such as frailty, depression, visual impairment, and urinary incontinence.

Despite these statistics, Dr. Escota and colleagues write that the increasing 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 has focused on the effects of HIV-associated inflammation on age-associated inflammation, to determine how each may be contributing to or exacerbating disease progression; however, more research is required to understand how HIV affects both mortality and disease development among PLWH.

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

In an interview with Contagion^®’s sister publication, MD Magazine, Dr. Escota stated that in lieu of a current cure for HIV there are various options that are available to ensure successful aging among this population. These include:

• Early initiation of ART regardless of the immune status (ie, 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.

The investigators suggest that clinicians should be more aggressive in applying primary prevention and screening guidelines for PLWH and that patient risk factors such as smoking, cholesterol, and hypertension, be more aggressively controlled and treated.

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

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

An earlier version of this article was originally published on MDMagazine.com.