HIV and aging: Time for a new paradigm

Yale University Schools of Medicine and Public Health, New Haven, USA.
Current HIV/AIDS Reports 05/2010; 7(2):69-76. DOI: 10.1007/s11904-010-0041-9
Source: PubMed

ABSTRACT The population of patients with HIV infection achieving viral suppression on combination antiretroviral therapy is growing, aging, and experiencing a widening spectrum of non-AIDS diseases. Concurrently, AIDS-defining conditions are becoming less common and are variably associated with outcome. Nonetheless, the spectrum of disease experienced by those aging with HIV remains strongly influenced by HIV, its treatment, and the behaviors, conditions, and demographics associated with HIV infection. Our focus must shift from a narrow interest in CD4 counts, HIV-RNA, and AIDS-defining illnesses to determining the optimal management of HIV infection as a complex chronic disease in which the causes of morbidity and mortality are multiple and overlapping. We need a new paradigm of care with which to maximize functional status, minimize frailty, and prolong life expectancy. A composite index that summarizes a patient's risk of morbidity and mortality could facilitate this work and help chart its progress.

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    • "The increased life expectancy of the HIV-1-infected population means that physicians are increasingly being faced with previously unrecognized comorbid conditions and antiretroviral-related complications. Atherosclerosis and cardiovascular events, loss of renal function, osteopenia/ osteoporosis, and non-AIDS-defining cancers are some of the emerging conditions observed in large observational cohorts, and their incidence seems to be higher than in the general population [1] [2] [3] [4] [5] [6] [7]. In addition, not only is HIV infection associated with AIDS-defining neurologic conditions with severe CD4 depletion, but also HIV-associated neurocognitive disorders seem more common in HIV-infected individuals despite achieving a successful immune recovery. "
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    ABSTRACT: Background. There are conflicting data on the prevalence of coronary events and the quality of the management of modifiable cardiovascular risk factors (CVRF) in HIV-infected patients. Methods. We performed a retrospective descriptive study to determine the prevalence of coronary events and to evaluate the management of CVRF in a Mediterranean cohort of 3760 HIV-1-infected patients from April 1983 through June 2011. Results. We identified 81 patients with a history of a coronary event (prevalence 2.15%); 83% of them suffered an acute myocardial infarction. At the time of the coronary event, CVRF were highly prevalent (60.5% hypertension, 48% dyslipidemia, and 16% diabetes mellitus). Other CVRF, such as smoking, hypertension, lack of exercise, and body mass index, were not routinely assessed. After the coronary event, a significant decrease in total cholesterol (P = 0.025) and LDL-cholesterol (P = 0.004) was observed. However, the percentage of patients who maintained LDL-cholesterol > 100 mg/dL remained stable (from 46% to 41%, P = 0.103). Patients using protease inhibitors associated with a favorable lipid profile increased over time (P = 0.028). Conclusions. The prevalence of coronary events in our cohort is low. CVRF prevalence is high and their management is far from optimal. More aggressive interventions should be implemented to diminish cardiovascular risk in HIV-infected patients.
    BioMed Research International 08/2014; 2014:823058. DOI:10.1155/2014/823058 · 2.71 Impact Factor
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    • "Isolated harm to single systems manifesting as liver disease, kidney disease, bone disease, and neuropathy has consequences in isolation, but their true effect on longterm health may become apparent only late in life when this redundancy begins to decline (Clegg et al., 2013). The fact that HIV infection and its treatment are associated with a series of biologic factors (e.g., inflammation, immune dysfunction, telomerase inhibition, mitochondria dysfunction), clinical factors (e.g., polypharmacy, multimorbidity), and social factors (e.g., social isolation, poverty) that influence aging suggest that a global population of well-treated individuals will confront unique challenges when older (Figure 3; Deeks, 2011; Justice, 2010; Ló pez-Otín et al., 2013). The impact that chronic low-level inflammation will have on the global population of antiretroviral-treated adults who are now expected to live for decades is not known. "
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    ABSTRACT: Combination antiretroviral therapy for HIV infection improves immune function and eliminates the risk of AIDS-related complications but does not restore full health. HIV-infected adults have excess risk of cardiovascular, liver, kidney, bone, and neurologic diseases. Many markers of inflammation are elevated in HIV disease and strongly predictive of the risk of morbidity and mortality. A conceptual model has emerged to explain this syndrome of diseases where HIV-mediated destruction of gut mucosa leads to local and systemic inflammation. Translocated microbial products then pass through the liver, contributing to hepatic damage, impaired microbial clearance, and impaired protein synthesis. Chronic activation of monocytes and altered liver protein synthesis subsequently contribute to a hypercoagulable state. The combined effect of systemic inflammation and excess clotting on tissue function leads to end-organ disease. Multiple therapeutic interventions designed to reverse these pathways are now being tested in the clinic. It is likely that knowledge gained on how inflammation affects health in HIV disease could have implications for our understanding of other chronic inflammatory diseases and the biology of aging.
    Immunity 10/2013; 39(4):633-45. DOI:10.1016/j.immuni.2013.10.001 · 19.75 Impact Factor
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    • "Risk factors affecting HRQoL in persons with HIV disease identified in previous research are disease progression, functional status (Campsmith et al., 2003; Rueda et al., 2012; Vidrine et al., 2005), comorbid health conditions (Havlik, 2009; Justice, 2010; Martin et al., 2008), and psychosocial issues such as stigma and disclosure concerns related to HIV disease (Emlet, 2006a, 2006b; Foster & Gaskins, 2009; Grov, Golub, Parsons, Brennan, & Karpiak, 2010). Gay and bisexual older adult men with and without HIV disease experience additional psychosocial risks, such as lifetime victimization due to stigmatized sexual identity, which are associated with poor physical and mental health (Fredriksen-Goldsen et al., 2011). "
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    ABSTRACT: PURPOSE: To identify risk and protective factors associated with mental and physical health-related quality of life, after controlling for key background characteristics, in a population of older gay and bisexual men living with HIV disease. Previous research examining quality of life among persons living with HIV rarely includes older adults. DESIGN AND METHODS: Survey responses from 226 gay and bisexual men aged 50 and older, and living with HIV disease, which were part of the Caring and Aging with Pride study, were analyzed using multivariate linear regression models. RESULTS: Findings reveal that comorbidity, limitations in activities, and victimization are significant risk factors for decreased physical and mental health-related quality of life. Stigma and HIV progression did not contribute to the overall outcome variables in multivariate models. Social support and self-efficacy serve as protective factors although social support was only significant with mental health-related quality of life. IMPLICATIONS: Comorbidity, functional limitations, and lifetime victimization are risks to quality of life among older gay and bisexual men with HIV disease. Self-efficacy and social support represent intrapersonal and interpersonal resources that can be enhanced through interventions to improve health-related quality of life.
    The Gerontologist 01/2013; DOI:10.1093/geront/gns191 · 3.21 Impact Factor
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