Special Report: The Aging AIDS Epidemic
More normal life spans present next hurdle
Experts discuss longevity with HIV infection
HIV researchers and experts agree that the biggest challenge facing HIV clinicians in coming years will be juggling HIV treatment with treatment for comorbidities related to long-term HIV infection and aging.
"We have a more sober view now of the benefits and limitations of treatment," says Gerald Friedland, MD, professor of medicine and epidemiology and public health at the Yale School of Medicine in New Haven, CT. Friedland also is the director of the AIDS program at Yale New Haven Hospital.
"Matching patients to individual drugs and regimens will become more precise and appropriate," he says. "The array of therapeutic options and the simplicity of treatments will increase, and I also think the way in which we use the drugs will be tempered by a balance of efficacy and side effects and toxicity."
At the same time, clinicians will need to treat patients for more than their HIV disease, experts note.
"People are living longer with HIV, and they’re getting the kinds of diseases that middle-aged people get," says Judy Sackoff, PhD, director of surveillance and the deputy director of the HIV Epidemiology Program at the New York Department of Health in New York City.
"So women are going through menopause and having health conditions and health issues that middle-aged people have," she explains. "It’s striking to think of the thousands of women over age 50 who have HIV and are becoming menopausal, Sackoff notes. It’s a whole new issue in the gynecological sphere."
As the number of older people with HIV infection increases, researchers will be able to study how comorbidities impact or are impacted by HIV disease.
For instance, investigators may test hypotheses of whether non-HIV cancers progress more rapidly, says Amy Justice, MD, PhD, section chief of general medicine at West Haven (CT) Veterans Affairs Healthcare System. Justice also is an associate professor of medicine at Yale School of Medicine.
"Also, lung disease and diabetes are interacting with our immune systems, so there are all kinds of speculation on how having HIV may modify these conditions," she adds.
"We have a study of 6,000 veterans, half with HIV and half matched without HIV, to understand how much of what is driving the outcome of care with the folks with HIV is their HIV and how much is the rest of the picture for them, whether they have diabetes, are overweight, or have psychiatric conditions, or are addicted to drugs," Justice says.
This is the area where health care professionals have the greatest opportunity to continue to improve outcomes for HIV patients, she notes.
"People spend a lot of time looking at this drug regimen or that one, but I think that’s not going to be as big a deal in the long run as how we manage these other conditions," Justice points out.
Long-term HIV patients often do have complications related to their antiretroviral medications, but it’s not always clear how these health issues will impact comorbidities, such as heart disease, says Michael Hickson, MD, chief medical officer and senior vice president at Housing Works in New York City. He has many long-term HIV patients in his clinical practice.
"I have seen lipodystrophy and lipoatrophy and increased cholesterol and lipid profile, but we are not sure whether that translates into increased cardiac risk," Hickson adds. "That’s a big debate."
What clinicians do know is that patients experiencing lipodystrophy and other complications may need therapies tailored to helping them cope with those disorders, including diet adjustments, exercise, and perhaps even antidepressants, he says.
Hickson also has seen more lymphoma cancers among his HIV patients. "It’s probably because of the constant immune stimulation by the virus, and maybe in the process of that constant stimulation, cancer cells are not as well controlled. And that may be why we see increased incidence."
If his theory is on target, then it’s likely clinicians will see increases in other cancers and perhaps faster progression among HIV patients, he speculates.
"They may develop cancer at age 50 instead of 60 because they are HIV-positive," Hickson continues. "We may see more cancers, not only lymphomas and Hodgkin’s and Burkitt’s, but other types of cancers, such as lung cancer and breast cancer."
The medical problems facing HIV patients have shifted away from opportunistic infections to side effects and comorbidities, including cardiovascular disease, diabetes, hepatitis C, and others, Friedland says.
"So in some ways, HIV infection is — I won’t say it’s more complicated — but it’s differently complicated," he explains. "We don’t deal as much with death and dying, which was hard and complicated, but the amount of skills you need to deal with HIV disease is on the increase. It’s a full-time job."
HIV clinicians may see increases in dementia among long-term and older HIV patients, although research so far has provided no clear answers.
"I think we may see an increase in dementia," Hickson notes. "The neurons are cells that don’t regenerate at all, and we know that HIV gets into all cells and not just CD4 cells, so in time we might see an increase in dementia among people who have had HIV infection for a long time."
At least one study that looked directly at this issue found no differences in cognitive function between younger and older HIV-infected patients.1
"We were looking at some of the main cognitive domains that are affected by HIV in younger individuals: attention; verbal and learning memory; information processing; speed and visual-spatial processes; abstraction and executive functioning; and motor processes," explains Frances L. Wilkie, PhD, research professor at the University of Miami School of Medicine, department of psychiatry.
"In this particular study, we didn’t find any differences between older and younger patients," she says.
"However, we did find that in some of the measures, such as the measure of attention where it was performed on computer task and reaction times, the older population of people had slower reaction times if they had lower CD4 counts and higher plasma HIV viral loads," Wilkie adds.
"Looking at some research work that’s actually using complete comprehensive neuropsychology test battery, you do find some effects of age," she notes. "They appear to be more adversely impacted by HIV than younger people."
One issue that clinicians and HIV researchers find difficult to address is whether HIV patients will be able to live more than a few decades with the disease.
"Most people involved in HIV care right now think highly active antiretroviral therapy’s (HAART’s) effectiveness is a time-limited phenomenon unless we come up with substantially new treatment — new classes of drugs," Justice says. "My suspicion is those classes will be limited, too."
Given the reality of a finite number of drug classes and the difficulty that people have adhering to HAART for long periods of time, it’s likely that people will succumb to HIV disease eventually, she points out.
"Yes, there is an interval of time; and for some people, it may be as long as they would have had anyway because of other things that are going to kill them," Justice adds.
"For others, they may fall off the ledge in some window of time — whether it’s 20 years or 30 years remains to be seen."
1. Wilkie FL, Goodkin K, Khamis I, et al. Cognitive functioning in younger and older HIV-1-infected adults. J Acquir Immune Defic 2003; 33(2):S93-S105.