Helping your patients age well with HIV

Living longer is something to celebrate, but chronic disease comes quicker. A free package of treatment algorithms is available for GPs.

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The good news is that people with HIV are living into old age – something unimaginable 40 years ago, when mortality within 12 months of diagnosis was 50%.  

The less good news is that people with HIV are far more susceptible to age-related comorbidities such as cardiovascular, metabolic, liver and kidney diseases, cancer, neurocognitive problems, bone disorders and frailty, according to a presentation at the ASHM HIV & AIDS Conference in Sydney last week. 

“Today we actually can celebrate aging in people with HIV, because we have well tolerated antiretroviral treatment, and people with HIV on treatment experience increased life expectancy with a reduction in AIDS-related complications,” Professor Jennifer Hoy, director of HIV medicine at Melbourne’s The Alfred, told the audience. 

By 2030, it is projected, 75% of people living with HIV in Victoria will be over 50.  

However, she said, thanks to chronic immune activation and inflammation, toxicity of antiretroviral drugs such as tenofovir and azidothymidine, and higher rates of smoking and substance use, as well as the normal ageing process, “what we see is a greater prevalence of age-associated conditions”. 

Professor Hoy, who has 30 years’ experience in research and patient care, cited a study showing 30% of HIV-negative 60-64-year-olds had two or more age-related conditions, while for HIV-positive people in the same age bracket the proportion was 60%.  

While it was “magic” to have reduced HIV treatment from 24 pills a day to just one, a new pill burden had arisen from the medications needed to manage comorbidities.  

About a decade ago, an audit by then PhD student Janine Trevillyan – now head of clinical virology and HIV services and deputy director of infectious diseases at Austin Health – revealed that HIV-positive outpatients were not being screened for cardiovascular disease or its risk factors, nor being treated for them, at the usual rate. 

There was a reluctance among HIV clinicians to initiate treatments for common comorbidities, Professor Hoy said, as they were sexual health specialists, even though they were providing most primary care for HIV-positive patients.  

On the other hand, the non-HIV-specialist GPs were less aware of the increased chronic disease risk.  

Seeing this need, Professor Hoy and a large team of colleagues developed a set of freely available algorithms for screening and managing a list of comorbidities, which is now up to version 6.1 and can be found on The Alfred’s website. (You can also find it here.) 

The document covers  

• Assessing and reducing CVD risk, and when and how to modify antiretroviral therapy in the presence of elevated risk 
• Vaccinations 
• Dyslipidaemia  
• Hypertension 
• Diabetes 
• Kidney injury 
• Liver health 
• Bone health 
• STIs 
• Neurocognitive impairment  
• Cancer prevention and screening  

Each condition is covered in two pages using tables and flow charts. Dyslipidaemia, for example, covers who, when and how to screen; when to start a statin, and when to stop; lipid targets on therapy; daily drug doses; and when to refer.  

The section on neurocognitive impairment, which is too complex for a two-page guideline, provides email addresses for two of the developers so clinicians can seek case-by-case advice.  

“I’m happy to provide these algorithms to everyone,” Professor Hoy said. “There’s no point in reinventing the wheel. It took us a year to update the last algorithm.” 

She cautioned that clinicians should check with their local specialists about referral guidelines as they might be Alfred-specific.  

To people living with HIV she recommended being proactive about their care, asking their GPs to be screened and self-screening with a CVD risk calculator.  

“You need to stop smoking – you really do need to stop smoking – you need to reduce alcohol intake, eat healthily and exercise more. But most importantly, enjoy your senior years.” 

The HIV/AIDS Conference ran in Sydney this month back-to-back with the 25^th IUSTI World Congress.