As the earliest patients to be diagnosed with HIV age, early screening has become critical to address the impact of comorbidities in older patients with HIV.
This is the second in a two-part series on comorbidities in patients with HIV. In Part One, Nel Jason L. Haw, PhD, MHS, MS, discussed comorbidities in patients with perinatally acquired HIV. In Part Two, Physician’s Weekly (PW) talked with Dr. Haw about comorbidities among the earliest patients to be diagnosed with the virus in the early 1980s.
PW: Why study comorbidities in the oldest-surviving patients with HIV?
Dr. Haw: As life expectancy improves among people with HIV who are receiving effective ART, we need to better understand the quality of that longevity, which includes the development of non-AIDS-associated comorbidities.
In the United States, there are now almost 300,000 people with HIV who are aged 60 and older, and we expect that number to continue increasing in the next decade or so. Most older people with HIV also have at least one non-AIDS-defining comorbidity. With such a great burden, clinical care for older adults with HIV, as well as research in this population, should extend beyond HIV-related services and should also focus on comorbidities.
What is known about factors that complicate aging with HIV?
The traditional risk factors associated with aging among people without HIV, such as smoking, physical activity, and diet, also affect people with HIV. Studies have shown that the rates of comorbidities among people with HIV is much higher than among people without HIV, so HIV or ART may also have an impact on top of these traditional risk factors. We have a large body of research now that discusses potential HIV and ART-mediated pathways that lead to the development of these comorbidities. Examples include chronic inflammation caused by HIV viremia that are known to be associated with cardiovascular diseases and metabolic complications related to long-term ART use.
The most significant comorbidities in patients with HIV diagnosed early in the epidemic and are now in their 60s and 70s are cardiovascular events, kidney disease, liver disease, cancer, and bone-related diseases such as fractures and osteoporosis.
What are the greatest unknowns for clinicians?
A lot of work is currently underway around this. One unknown is knowing when to intervene in the prevention and management of comorbidities and if certain drugs for the management of comorbidities interact with ART or are safe to use among people with HIV.
One breakthrough is the REPRIEVE trial. Those results showed that pitavastatin may be initiated among people with HIV with low-to-moderate cardiovascular risk. The benefits gained from the statin exceeded expectations and will likely result in changes to the 2019 American College of Cardiology/American Heart Association statin therapy guidelines based on the REPRIEVE trial results.
What unmet needs exist for both clinicians and patients?
When attending to people with HIV, clinicians should be more mindful about screening for comorbidities and do so as early as possible. Additionally, when screening for risk factors, clinicians should go beyond individual circumstances and examine social determinants of health. Many of the societal barriers people with HIV face as a function of living with HIV impact their ability to cope with and access services related to the management of these comorbidities.
What are the most important avenues for research?
We need to continue studying underlying mechanisms of how comorbidities develop among people with HIV throughout the life course. We also need to describe how different risk factors at the individual, community, and structural levels contribute to the development of these comorbidities. Understanding both allows us to develop effective interventions that provide the necessary support to improve the QOL, not just the longevity, of people with HIV.
Is there anything else you would like to mention?
I want to underscore again that clinicians need to be more diligent about screening for these comorbidities and consider screening earlier than physicians have been taught to in medical school or seen in standard guidelines. It is also important to understand how these comorbidities impact QOL. With successful treatment, patients with HIV have reached middle/older age, but are now dealing with the more traditional comorbidities of age that may be more complex due to the virus and/or ART. Being diligent with screening will address the QOL impact of these comorbidities, not just their medical burden.
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