Living Longer with HIV Brings New Challenges

The decline in acquired immune deficiency syndrome (AIDS) in individuals infected with the human immunodeficiency virus (HIV) is good news. However, as HIV-infected individuals live longer, it is becoming clearer that they face new challenges.

“Here in the [United States], there are continued declines in rates of opportunistic infections. Life expectancy of HIV-treated individuals is approaching that of the general population. There’s a range of long-term complications that have stepped in to take the place of what used to be the domain of opportunistic infections. These include cardiovascular disease (CVD), diabetes mellitus, non-AIDS cancers, osteoporosis, depression, cognitive disorders, chronic renal disease, chronic obstructive pulmonary disease, and frailty,” said Judith Currier, MD, from the University of California, Los Angeles, during her session at ID Week.

A modeling study done in The Netherlands that had used data from the ATHENA cohort predicted that by 2030, 54% of HIV-infected patients will be medicated to treat non-communicable diseases, with 28% of these patients taking more than three drugs. Other evidence has indicated an increased risk of CVD, non-calcified coronary plaque, and heart failure in HIV-infected individuals.

“These data really show us that we have to be prepared in the future in terms of our workforce and healthcare systems to take care of these problems, unless we find ways to prevent and decrease their occurrence,” Dr. Currier said.

As HIV-infected individuals live longer, the possible longer-term detriments of antiretroviral therapy (ART) have become more germane. “We are talking about the use of ART for decades, so we really do need to understand if there is a difference in the agents we select for therapy,” said Dr. Currier.

To address the issue, Dr. Currier and colleagues performed a sub-analysis of the A5260 phase III, prospective, multi-center, randomized, open-label trial. In the trial, 1809 ART-naïve, HIV-positive subjects were randomized to three non-nucleoside reverse-transcriptase inhibitor sparring regimens. The sub-analysis involved 328 subjects randomized to receive atazanavir/ritonavir, raltegavir, or darunavir/ritonavir who were followed-up for 96 weeks. The data hinted at a protective effect of atazanavir for CVD.

Ironically, for an infection associated with wasting in those who develop AIDS, individuals living with HIV may be at risk of obesity. A study of 14,084 HIV-positive subjects (83% men) being treated with ART chronicled a rise in the prevalence of obesity from 9% to 18% after 12 years. The change occurred soon after initiation of ART, with 22% of those with a normal body mass index at baseline being obese after 3 years of therapy.

“So what are we going to do to reduce these problems? There’s been a lot of research looking at ways of reducing non-AIDS events. These include lifestyle interventions; smoking cessation should top the list. A number of studies have suggested that being a smoker with HIV accentuates the negative outcomes associated with smoking. So, if you can do one thing to help your patients with HIV to reduce their risk of chronic disease, get them to quit smoking,” Dr. Currier advised.

Understanding the causes of non-HIV events will improve outcomes in the next several decades. Interventions that work need to be used now.

SOURCES

• Photos and tape of IDSA presentation
• Legarth RA et al. J Acquir Immune Defic Syndr 2016 71:213-218
• Smit M et al Lancet Infect Dis 2015 15:810-818
• Koethe J et al. AIDS Res Hum Retro 2015 32:50-58

PRESENTATIONS

John Enders Lectureship

Complications of HIV Infection: Progress Through Collaboration; Judith Currier, MD, MSC, University of California, Los Angeles

​Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at hoyle@square-rainbow.com.