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Expert Review

The Aging HIV Patient

HIV 2011

Chapter 1: Aging in HIV – Overview

Anita Rachlis, MD, MEd, FRCPC
University of Toronto, Toronto, ON

Age-related diseases, such as atherosclerosis and osteoporosis, are being observed at a younger age in patients infected with human immunodeficiency virus (HIV) than in those without infection. The apparent acceleration in aging may be related to several causes, including persistent upregulation of the inflammatory response and the adverse effects of antiretroviral therapies. The acceleration of aging processes threaten to shorten the lifespan of patients with HIV even when immune function has been improved and the viremia remains optimally suppressed. The individual risk for specific diseases varies, but it has become important to direct attention toward opportunities to modify or circumvent the potential for irreversible damage to target organs. In general, the average age for symptomatic manifestations of processes common to aging individuals, such as bone mineral loss and neurocognitive decline, appears to be at least one decade earlier when those with HIV infection are compared to those without. In Canada, where the population of HIV-positive individuals over the age of 50 is increasing, strategies for anticipating and modifying these risks are expected to be an increasingly important part of HIV management.

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Chapter 2: Cardiovascular Disease

Dominique Costagliola, PhD
Université Pierre et Marie Curie, Paris, France

Early death from cardiovascular (CV) complications in aging individuals infected with HIV is a growing challenge in chronic HIV management. There are numerous factors that have converged to increase CV risk in individuals infected with HIV compared to age-matched individuals without infection. These include a greater prevalence of CV risk factors, the adverse effects of several antiretroviral agents that appear to contribute to CV risk, and a direct or indirect effect of HIV itself. In HIV patients with otherwise well controlled viremia, CV disease is expected to become an increasingly important cause of preventable death. The effort to modify the impact of this potential crisis depends on heightened awareness of the risks in HIV patients and aggressive monitoring and intervention for modifiable risk factors. Individualization of therapy will be increasingly important when attempting to reduce CV risks in the context of sustained HIV suppression.

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Chapter 3: Renal Impairment

Derek M. Fine, MD
Johns Hopkins University, School of Medicine, Baltimore, MD

Chronic kidney disease (CKD) is a significant threat to the long-term survival of individuals infected with human immunodeficiency virus (HIV). Although the introduction of highly active antiretroviral therapy (HAART) dramatically reduced the risk of end stage renal disease (ESRD) from HIV-specific causes, as it did many of the other complications of uncontrolled HIV, it attenuated but did not eliminate the development of compromised renal function from causes indirectly related to HIV infection. Until recently, the risk of renal failure as a complication of HIV has been concentrated in African-Americans, who have demonstrated an increased susceptibility to HIV-associated nephropathy, but the incidence of renal impairment in aging individuals with otherwise well-controlled HIV infection is climbing. In the setting of HIV infection, therapies traditionally employed to preserve renal function, such as renin-angiotensin-aldosterone system (RAAS) inhibitors, are appropriate, but other steps should be considered. This may include preferential use of antiretroviral agents with the least potential to exacerbate renal dysfunction. Close monitoring of renal function is appropriate because of variability in the individual risk for renal disease and progression of nephropathy once it is established.

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Chapter 4: Neurocognitive Deficit

Bruce James Brew, MD
University of New South Wales, Sydney, Australia

Cognitive decline is an insidious and frequently progressive complication of human immunodeficiency virus (HIV) infection. While the introduction of highly active antiretroviral therapy (HAART) largely eliminated the dementia associated with end-stage acquired immunodeficiency syndrome (AIDS), cognitive impairment remains a common complication of HIV even in those with well controlled viremia. The incidence and the severity of HIV-associated neurocognitive disorders (HAND) are rising with an aging HIV population – a potential consequence of both increased susceptibility in older individuals and progressive impairment with longer duration of infection. The clinical challenges posed by this complication are substantial. The relative ability of specific antiretroviral therapies to cross the blood brain barrier to reduce central nervous system (CNS) viral load, and the specific, perhaps genetic, susceptibility of individual patients are among factors that may explain the variable risk of cognitive impairment. In addition, HIV-independent variables may also be important in some individuals. Clinical sensitivity to changes in cognitive function through periodic assessments is appropriate in the context of strategies to understand and prevent HAND.

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Chapter 5: Osteoporosis

Greg Bondy, MSc, MD, FRCPC
University of British Columbia, Vancouver, BC

The accelerated loss of bone density in patients with HIV infection threatens a significant health crisis in Canada and other countries with aging HIV-infected populations. There appears to be an important interaction between traditional osteoporosis risk factors and bone loss related specifically to HIV and its therapies. Consistent with accelerated aging across other organ systems, HIV-related loss of bone mineral density is a progressive condition detected soon after infection. It may persist independent of HIV suppression, and it can be exacerbated by some antiretroviral drugs. Strategies to diminish the impact of bone mineral loss depend on early screening and aggressive efforts at preventing or modifying the underlying processes. The rising rates of fracture in aging individuals with HIV infection have intensified attention on this complication, but the scope of this complication is expected to enlarge with the demographic shift that is increasing the proportion of HIV-infected individuals in the age range of vulnerability.

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The information and opinions expressed herein are those of the participants and do not necessarily reflect those of Xfacto Communications Inc. or the sponsor. The distribution of this meeting report was made possible through industry support under written agreement that ensures editorial independence. The content is for educational purposes and should not be taken as an endorsement of any products, uses or doses. Physicians should consult the appropriate monograph before prescribing any drugs. Distribution, reproduction, alteration of this program is strictly prohibited without written consent of Xfacto Communications Inc. Copyright 2021. All rights reserved. The Medical XchangeTM

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