[Viva] Fwd: CATIE News - An aging epidemic

Wed Sep 3 03:29:42 PDT 2014

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     CATIE News - Bite-sized HIV and hepatitis C news bulletins
       CATIE News - An aging epidemic

In Canada and other high-income countries, the widespread availability of
potent combination anti-HIV therapy (commonly called ART or HAART) has
greatly reduced deaths from AIDS-related infections. ART is so powerful
that researchers increasingly expect that some young adults who become HIV
positive today and who begin ART shortly thereafter and who are engaged in
their care and treatment are likely to live into their 80s.
 An initially young epidemic

One of the first reports about the emerging HIV epidemic appeared in a
bulletin from the U.S. Centers for Disease Control and Prevention (CDC)
called *MMWR* (*Morbidity and Mortality Weekly Reports*) in June 1981.
Inside *MMWR* was a report from doctors in California who reported the
mysterious appearance of life-threatening infections in previously healthy
young men.

A month later, another issue of *MMWR* reported the very strange appearance
of skin lesions (called Kaposi’s sarcoma or KS) also in previously healthy
young men residing in California and New York City. At the time these
reports were issued they caused astonishment among doctors. Until those
reports, cases of KS in high-income countries were rare and did not occur
in clusters. Furthermore, prior to the arrival of AIDS, when KS had been
previously diagnosed it was typically seen in elderly men of Mediterranean
descent, in whom it generally caused mild disease in the feet or lower
legs. However, KS was different in the young men mentioned in *MMWR* and
other reports from the early 1980s in North America and Western Europe. In
these men, KS lesions could appear anywhere on the body and could quickly
spread to lymph nodes and affect internal organs. Although chemotherapy was
sometimes effective, the underlying immune deficiency caused by HIV
remained.
 Present and future

Fortunately, in high-income countries, KS is no longer as common as it was
in the early years of the HIV epidemic. If it does occur, sometimes the use
of ART alone is sufficient to make KS regress (though this regression can
be slow in some people). In the current era, only rarely is chemotherapy
needed in addition to ART to treat HIV-related KS.

Another change in the HIV epidemic is that today, thanks to ART, people are
living longer. Here are some examples from two high-income countries:
 Switzerland

Researchers reported that in 1990 the proportion of HIV-positive people who
were between 50 and 64 years was less than 3%. However, by 2010 that
proportion had increased to 25%.
 United States

The CDC estimated that in 2009 about one-third of HIV-positive people were
at least 51 years old. Furthermore, the CDC has forecasted that by the year
2020, more than 50% of HIV-positive people in the U.S. will be over the age
of 50.

The trends reported in these two countries are very likely occurring in
other high-income countries as well.
 New infections

It is not just the aging of people with longstanding HIV that is occurring.
Reports from the CDC suggest that a significant number of new cases of HIV
are occurring in people aged 50 or older. According to figures supplied by
the Public Health Agency of Canada (PHAC), about 18% of new HIV cases are
occurring among people aged 50 or older.
 The research needs of older citizens

The effect of these two trends—living longer with HIV and new HIV
infections occurring at an older age—will have implications for research.
Among HIV-negative people, growing older is associated with an increased
risk for complications affecting many organ-systems—such as cardiovascular
disease, kidney dysfunction, type 2 diabetes, thinning bones and so on.
Doctors and researchers call these other health conditions co-morbidities.
Researchers need to study the twin impacts of long-term HIV infection and
aging to assess their impact on overall health and well-being.

Due to these co-morbidities, it is likely that in addition to taking daily
ART, other medicines will have to be taken. Taking multiple medicines for
several conditions is called polypharmacy. This can be a problem for
elderly people for at least the following reasons:

   - potential drug interactions
   - adverse reactions (and distinguishing whether adverse reactions are a
   side effect of medicines or related to the aging process, HIV or something
   else.)
   - difficulty organizing pill-taking of different medicines every day

 As another example, the kidneys of older people are not as efficient as
those of younger people. Older people sometimes require adjustment to the
doses of their medications to reduce the risk of toxicity. It is possible
that as HIV-positive people age similar dose adjustments may be required.

The burden of coping with multiple conditions may be difficult for some
people as they strive to remain high functioning and yet are constrained by
the effects of aging. These and other issues related to aging may have an
impact on the overall health and mental and emotional well-being of aging
HIV-positive people.
 Aging on the research agenda

Scientists are beginning to grapple with the complexity of aging and HIV.
The U.S. Office of AIDS Research, part of that country’s National
Institutes of Health (NIH), has commissioned a report that outlines topics
relevant to HIV and aging that require study.

Canada’s premier agency that funds scientific research into health issues
is the Canadian Institutes of Health Research
<http://www.cihr-irsc.gc.ca/e/193.html> (CIHR). A key part of CIHR is the
Institute of Infection and Immunity. This institute has identified HIV and
aging as a priority under its Comorbidity Research Agenda
<http://www.cihr-irsc.gc.ca/e/43786.html> and is funding a number of grants
to explore different aspects of the challenge of aging with HIV.
 Health services

It is likely that as HIV-positive people grow older, healthcare providers
will have to adapt knowledge gained from the field of geriatrics to help
their patients. Aging patients generally need more visits to their family
doctor, screening for conditions that are common in this population, more
referrals to speciality care and more medicines. All of these will likely
be true for HIV-positive people as they age. Ministries of health and
policy planners will have to start estimating the costs of treating an
aging HIV-positive population to ensure that sufficient money is given to
community clinics and hospitals so they can continue to provide
high-quality care.

Our next *CATIE News* bulletin explores a report from researchers in
Alberta who are investigating the aging of the HIV epidemic and its
implications for the cost of
care.

*Resources:*

Report to the NIH about Aging and HIV
<http://journals.lww.com/jaids/toc/2012/07011>

The CIHR Comorbidity Agenda <http://www.cihr-irsc.gc.ca/e/43786.html>

CIHR’s HIV Comorbidity Research Agenda: Relevant Research Areas
<http://www.cihr-irsc.gc.ca/e/43785.html>

HIV and Aging <http://librarypdf.catie.ca/PDF/ATI-40000s/40221.pdf> –
Healthy living tips for people 50 and over living with HIV

HIV and Aging <http://www.catie.ca/en/webinar-series-building-blocks#aging>
– CATIE Webinar Series: Building Blocks

Factsheets on HIV and aging in Canada <http://www.cdnaids.ca/hiv-and-aging>
– Canadian AIDS Society

*—Sean R. Hosein*

REFERENCES:

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   3. Centers for Disease Control (CDC). Kaposi’s sarcoma and Pneumocystis
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