As HIV-infected patients live longer, more are developing chronic diseases typical of aging — but they appear to be doing so earlier and at a higher rate than the general population.
Since the advent of potent antiretroviral therapy (ART), the primary causes of morbidity and mortality among HIV-infected patients have shifted from AIDS-related illnesses to the chronic noncommunicable conditions typically associated with aging. Two research groups recently described the epidemiology of these conditions in HIV-infected patients.
Guaraldi and colleagues evaluated the prevalence of noninfectious comorbidities among 2854 HIV-infected patients receiving ART in Italy (mean age, 46; 71% with undetectable viral loads; median duration of infection, 16 years; median nadir CD4 count, 170 cells/mm3; median current CD4 count, 520 cells/mm3) and 8562 HIV-uninfected controls matched for age and sex. Compared with the controls, the HIV-infected patients had a higher prevalence of renal failure, bone fracture, and diabetes in every age range evaluated (40, 41–50, 51–60, and >60), as well as a higher prevalence of cardiovascular disease and hypertension at ages 60. They were also more likely, across all age strata, to have at least two of these conditions simultaneously (which the authors describe as “polypathology”). Of note, the HIV-infected patients appeared to develop polypathology at a younger age than controls, such that a 40-year-old HIV-infected patient had a risk similar to that of a 55-year-old HIV-uninfected person. Among HIV-infected patients, polypathology was significantly associated with increasing age, male gender, nadir CD4 count <200 cells/mm3, lipoatrophy, and lipohypertrophy.
In a separate study, Hasse and colleagues evaluated the incidence of AIDS-related and non–AIDS-related events among 8444 patients who were followed in the Swiss HIV Cohort Study between 2008 and 2010 (median age, 45; median nadir CD4 count, 190 cells/mm3; median current CD4 count, 528 cells/mm3). Approximately 30% of study participants were female, 23% had a prior AIDS diagnosis, and 69% had undetectable viral loads. During follow-up, there were 100 new AIDS-related events in the cohort versus 994 new non-AIDS events, including 39 strokes, 55 myocardial infarctions, 70 cases of diabetes, 115 non–AIDS-defining malignancies, and 160 fractures. Each of these non-AIDS conditions was significantly more common after age 50, even after adjustment for factors related to HIV disease progression and the development of comorbidities.
Comment: Many people still believe that HIV infection is confined to young adults, but the patients in these two cohorts were decidedly middle-aged — and experiencing all the same chronic conditions as their uninfected peers, though perhaps at a younger age and greater frequency. Soon, more than half of our HIV-infected patients will be older than 50, which means that as HIV clinicians, we’ll be spending an increasing amount of time providing primary care. As Hecht and colleagues noted back in 1999 , “optimal care of HIV infection requires a combination of disease-specific expertise and primary care skills and organization.” Now may be the time for many of us to take a refresher course in primary care for the HIV provider.