Old patients with HIV are the new group with unique needs

DURBAN, South Africa – In the early days of the AIDS epidemic, the life expectancy for those diagnosed with HIV was two years from the time of diagnosis.

In the era of antiretroviral therapy, Johnson & Johnson's chief scientific officer, Paul Stoffels, told the audience at the 2016 International AIDS Conference this week, "people can see their kids and their grandkids grow up, if therapy is done well."

One of the consequences of that spectacular success is that there is now a new demographic group of HIV patients – those old enough to be at increased risk of the multiple diseases of aging.

The medical community as a whole is still catching up with the concept of elderly patients with HIV, and what their particular health care needs are, in part because such patients do not fit neatly into the categories in which the community is accustomed. In those categories, an infection is an acute disease, and a chronic disease is something other than an infection.

"The advent of HIV is really changing the concept of what communicable diseases are," Tolullah Oni, senior lecturer and public health medical specialist at the University of Cape Town, told the audience at the meeting.

There is plenty of awareness that HIV often co-occurs with other infections, in particular hepatitis C and tuberculosis (TB).

But in a study by Oni and her team involving patients who had hypertension, type 2 diabetes, HIV or TB, HIV most frequently co-occurred with hypertension. Of the 20 percent of HIV patients who had a second chronic disease, 75 percent were hypertensive.

In the more general landscape of chronic co-morbidities, diabetes "features rather prominently," and ischemic heart disease, COPD and depressive disorders are also common, Oni said.

Such patients are invisible to the health care system. The HIV community, in turn, does not have the elderly on its radar, even though with the advent of Viagra, clusters of HIV infections have been reported in nursing homes more than once.

In Japan, 20 percent of newly diagnosed infections are in the age group of 50 to 59, but prevention efforts are aimed at young populations.

And doctors who treat diseases of aging are not necessarily aware of the interaction between HIV and other diseases – in part because such data are only now beginning to be available.

"We are just at the early, early years, [of the demographic intersection between HIV and the elderly], and we really don't know exactly what we're going to find," Andrew Grulich, head of the HIV prevention program at the University of New South Wales' Kirby Institute, told the audience.

The good news is that the most common cancers such as breast or prostate cancers are not associated with HIV, and at this point there is no reason to think they will be more common in HIV-infected patients.

HIV-infected individuals do, however, tend to get cancer at an earlier age than those who are HIV-negative. Currently, the greatest discrepancy in cancer rates between the two groups is for individuals in their forties, though Grulich said that might change as both the HIV-infected cohort and the general population age.

But for other cancers, especially those that are associated with infections, HIV patients have a massively increased risk. The rate of Kaposi sarcoma in HIV patients is a thousand times that of the general population, and the rate of non-Hodgkin's lymphoma is increased by a hundredfold.

Other cancers have a more modestly increased risk that may be behaviorally mediated. Men who have sex with men, for example, have a higher risk of anal cancer that Grulich attributed to sexual behavior. HIV-positive drug users have an increased risk of lung cancer, likely because as a group, they have high rates of cigarette smoking.

While cancer is rare, diabetes is an epidemic. And it is a condition where HIV-infected individuals can't seem to win. Untreated HIV infection can lead to metabolic syndrome, and high blood fat levels are common in HIV-positive persons.

"However, the greatest risk for diabetes seems to be with the antiretrovirals themselves," Melissa Frasco, research epidemiologist at Precision Health Economics, said at the conference.

Antiretroviral (ARV) regimens that include either protease inhibitors or nucleoside reverse transcriptase inhibitors increase the risk of developing type 2 diabetes.

To top it off, ARV and some blood sugar control drugs interact, increasing the risk of underdosing or overdosing one or both drugs.

Oni said the fragmented delivery of health care services has important implications for disease control.

Studies have found that patients in chronic care for both HIV and a noncommunicable disease "tend to prioritize HIV," because they like HIV services better. That suggests that the medical community as a whole should try to approach disease prevention in a more integrated manner, starting with "better integrated research across the chronic care cascade. However, "in order for that to transpire, you would have to have an HIV clinic that is monitoring your blood pressure and optimizing that treatment as well. And that is not the case."

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