Ageing with HIV

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Presentation from our Positive Ageing Conference by Gordon Scott, Senior Consultant at NHS Lothian.

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Ageing with HIV

  1. 1. Ageing with HIV Gordon Scott GUM consultant
  2. 2. I’m very pleased to be giving this talk <ul><li>In the early years of the epidemic, patients would only ask questions like </li></ul><ul><ul><li>Will I live to see my 30 th birthday? </li></ul></ul><ul><ul><li>Should I cash in my pension now? </li></ul></ul><ul><ul><li>Will this be my last Christmas? </li></ul></ul>
  3. 3. Deaths due to AIDS <ul><li>AIDS was defined when a patient was diagnosed with a specific condition associated with immunosuppression caused by HIV </li></ul><ul><li>In these early years before highly active antitretroviral therapy (HAART), patients tended to die relatively quickly from AIDS-related causes </li></ul><ul><li>HAART has reduced HIV/AIDS-related mortality to extremely low levels </li></ul><ul><ul><li>Now usually seen in late presenters only </li></ul></ul><ul><li>Most people living with HIV therefore die of the same things that kill everyone else </li></ul>
  4. 4. What are the main causes of death in Scotland? <ul><li>Cancer </li></ul><ul><li>Heart disease </li></ul><ul><li>Stroke </li></ul><ul><li>All of these are more common as we get older </li></ul>
  5. 5. HIV versus non-HIV <ul><li>Although the risk of heart disease and other non-AIDS conditions increases with age in patients with or without HIV infection, these diseases are more common at all ages in HIV-positive populations compared to people without HIV </li></ul><ul><li>For example, the risk of heart disease is between 1.5 and 2 times greater for HIV versus non-HIV cohorts </li></ul>
  6. 6. SMART study <ul><li>Maybe taking ART long term is bad for you </li></ul><ul><li>Patients on ART stopped treatment when CD4 was greater than 350, and restarted when CD4 fell to less than 250 </li></ul><ul><ul><li>Compared to patients who continued ART </li></ul></ul><ul><li>There was a greater risk of dying in those who stopped and started ART </li></ul><ul><ul><li>Mainly non-AIDS related conditions </li></ul></ul>
  7. 7. Why might uncontrolled HIV have these consequences? <ul><li>Immunosuppressed patients have an increased risk of cancer </li></ul><ul><ul><li>There will be residual immune suppression even after starting treatment </li></ul></ul><ul><li>Untreated HIV causes inflammation </li></ul><ul><li>Inflammation increases the risk of atherosclerosis (furred up/hardened arteries) </li></ul><ul><ul><li>This can cause heart attacks and strokes </li></ul></ul><ul><li>Untreated HIV can cause dementia </li></ul>
  8. 8. Cardiovascular (Heart) disease (CVD) <ul><li>Commonest cause of death in Scotland </li></ul><ul><li>Although rates have fallen substantially over the last 20 years </li></ul><ul><li>Classic risk factors were identified in the Framingham study which started in 1949 </li></ul><ul><ul><li>Small town in Massachusets USA </li></ul></ul>
  9. 9. Framingham study <ul><li>The researchers recruited 5,209 men and women between the ages of 30 and 62 and began the first round of extensive physical examinations and lifestyle interviews </li></ul><ul><li>In 1971, the study enrolled a second generation (5,124) of the original participants' adult children and their spouses; and in 2002 the grandchildren of the original cohort were enrolled. </li></ul><ul><li>As people suffered heart attacks and/or strokes, researchers reviewed lifestyle factors, examination findings and blood test results with comparable neighbours </li></ul>
  10. 10. Framingham continued <ul><li>The major CVD risk factors were identified </li></ul><ul><ul><li>High blood pressure </li></ul></ul><ul><ul><li>High blood cholesterol </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Physical inactivity </li></ul></ul><ul><li>Although – do these calculations apply in other populations? </li></ul><ul><li>How relevant are the findings in patients with HIV? </li></ul>
  11. 11. Framingham CVD disease calculator Gender Male Age 35 Family history No BP Normal Lipids Normal Smoker No Diabetes No Risk 1% Gender Male Age 55 Family history No BP Normal Lipids Normal Smoker No Diabetes No Risk 4%
  12. 12. Gender Male Age 55 Family history No BP Normal Lipids Normal Smoker Yes Diabetes No Risk 8% Gender Male Age 55 Family history Yes BP Normal Lipids High Smoker No Diabetes No Risk 16%
  13. 13. Does ART itself increase risk of CVD? <ul><li>Protease inhibitors increase lipids </li></ul><ul><li>(Efavirenz also increases cholesterol, but mainly good HDL cholesterol) </li></ul>DAD study
  14. 14. Recent French study (CHIC) presented at CROI conference <ul><li>CVD was associated with length of HIV infection regardless of ART </li></ul><ul><li>So maybe the DAD graph just reflects the increasing risk because you have had HIV longer </li></ul><ul><li>Another Californian study suggested that lower CD4 was associated with CVD </li></ul><ul><ul><li>Probably not surprising as this is usually a reflection of length of HIV infection </li></ul></ul>
  15. 15. What about abacavir? <ul><li>DAD study suggested increased risk of CVD in patients taking abacavir </li></ul><ul><li>Recent research (also presented at CROI) concluded that this was not so </li></ul>
  16. 16. What can you do? <ul><li>You can’t change your parents/ancestors! </li></ul><ul><li>You can stop smoking </li></ul><ul><li>Being on ART is better than not being on ART </li></ul><ul><li>You can get your lipids and BP measured, and take treatment if either or both are elevated </li></ul>
  17. 17. Reducing risk of cancer <ul><li>Stop smoking </li></ul><ul><li>Take up the offer of screening aimed at the general population </li></ul><ul><ul><li>Cervical smears for women </li></ul></ul><ul><ul><li>Breast screening </li></ul></ul><ul><ul><li>Bowel cancer screening </li></ul></ul><ul><li>?anal smears for men </li></ul><ul><ul><li>Anal cancer is more common </li></ul></ul><ul><ul><li>Less evidence for benefit of screening </li></ul></ul>
  18. 18. Bones <ul><li>HIV is associated with reduced bone mineral density </li></ul><ul><ul><li>Possibly secondary to inflammation </li></ul></ul><ul><ul><li>low testosterone levels, low body weight, smoking, and drinking alcohol may also play a role </li></ul></ul><ul><li>Low vitamin D levels are seen in some HIV patients </li></ul><ul><li>ART is clearly associated with bone loss </li></ul><ul><ul><li>Protease inhibitors </li></ul></ul><ul><ul><li>NRTIs </li></ul></ul><ul><li>But no convincing evidence of increased fracture rate </li></ul>
  19. 19. Brain – risk of dementia? <ul><li>Some studies from the USA say that half of patients with HIV have “neurocognitive impairment” </li></ul><ul><li>However recent studies from London suggest otherwise </li></ul><ul><ul><li>Only 19% HIV-positive adults stable on ART showed any effect (compared to 16% HIV-negative) </li></ul></ul><ul><ul><li>Young people born with HIV performed as well as HIV-negative controls </li></ul></ul><ul><li>Anxiety and depression can affect performance in assessment, and may explain previous findings </li></ul>
  20. 20. Frailty <ul><li>There is some association between HIV and frailty </li></ul><ul><ul><li>Reduced strength </li></ul></ul><ul><ul><li>Exhaustion </li></ul></ul><ul><ul><li>Slowness </li></ul></ul><ul><ul><li>Unplanned weight loss </li></ul></ul><ul><ul><li>Reduced physical activity </li></ul></ul><ul><li>Probably reflects degree/duration of immune failure and inflammation </li></ul>
  21. 21. What should you do? <ul><li>The same things everyone should do </li></ul><ul><ul><li>Don’t smoke </li></ul></ul><ul><ul><li>Alcohol in moderation </li></ul></ul><ul><ul><li>Maintain a healthy weight/good diet </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Have blood pressure and lipids measured </li></ul></ul><ul><ul><ul><li>Accept recommended treatment </li></ul></ul></ul>
  22. 22. Is there anything specific to HIV that you should do? <ul><li>Earlier treatment confers long term benefit with regard to non-AIDS mortality </li></ul><ul><li>Definite benefit from starting with CD4 of around 350 </li></ul><ul><li>Possible benefit if CD4 is 350-500 </li></ul><ul><li>Maybe even a minor benefit between 500 and 650 </li></ul><ul><li>Discuss this with your doctor </li></ul>
  23. 23. Enjoy life as much as you can <ul><li>Otherwise you could end up being miserable for a lot longer than you had expected! </li></ul>

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