Project Inform forum focuses on HIV and aging
by Liz Highleyman
Aging has become a key focus for people with HIV and their health care providers, but much remains to be learned about the medical and psychosocial aspects of the aging process in this population, which was the topic of a recent forum sponsored by Project Inform.
"We're facing a paradox," said Matt Sharp, Project Inform's new director of treatment and prevention advocacy. Having lived with HIV for more than 20 years, Sharp, 53, described himself as one of the lucky survivors.
"Many of us are thriving and we're dealing less with AIDS-specific issues, but now we're dealing with issues that come with age," he noted.
Due to effective antiretroviral therapy, life expectancy of HIV-positive people in the United States has increased dramatically – more than doubling between 1996 and 2005, according to one recent study – but still does not equal that of the general population.
By the year 2015, nearly half of HIV-positive people in the U.S. will be over age 50. In San Francisco, that figure already stands at 40 percent. While about 15 percent of newly infected individuals are over 50, people who have lived with the virus for years or decades face distinct challenges.
At the forum, held September 24, Sharp reviewed some of the chronic conditions facing people with HIV as they age, including cardiovascular disease, liver disease (often related to hepatitis B or C), kidney impairment, non-AIDS cancers (including anal and cervical cancer caused by human papillomavirus), bone loss (osteoporosis), neurocognitive decline, and "frailty," characterized by weight loss, weakness, and increased risk of disability and death.
With opportunistic infections and cancers now seldom seen among people on antiretroviral treatment, management of age-related chronic conditions has become a mainstay of HIV medicine.
A growing segment of HIV research aims to tease out the causes underlying the apparent acceleration of the aging process in long-term survivors.
Many of these problems have been blamed on antiretroviral therapy over the years, and various drugs do appear to play a role. But it is increasingly clear that long-term HIV infection itself wreaks havoc on the body in ways that are not fully understood.
"For the last 10 years we've been so excited about therapy helping people live longer that we've gotten a bit selfish," said Dr. Steven Deeks of San Francisco General Hospital. "We now want people to live a normal lifespan with completely restored health, but we're not there yet."
Even low-level so-called undetectable virus in people on effective treatment – which in fact can almost always be detected using ultrasensitive tests – can trigger persistent immune activation. In addition, HIV damages the gut lining during early infection, allowing bacteria to leak out and ignite system-wide inflammation. Antiretroviral therapy dramatically reduces immune activation and inflammation, but does not bring back the normal pre-HIV state.
Furthermore, having a lower CD4 T-cell count has been linked to higher risk of non-AIDS diseases among people who are well above the 200 cell "danger zone" for opportunistic infections, or even the current 350 cell threshold for starting treatment. And while CD4 counts usually rise after starting treatment, the new cells may not work as well as those that were lost.
Chronic low-grade inflammation appears to be the common denominator underlying all these conditions, according to Deeks. It is also increasingly implicated in age-related disease among HIV-negative people, demonstrating that long-term viral infection is only part of the puzzle.
While researchers continue to study the interactions between long-term infection and the aging process, HIV-positive people can take steps now to prevent disease and improve their overall health. These include quitting smoking, eating a healthy diet, getting more exercise, and avoiding or reducing use of alcohol and recreational drugs.
"You don't need to join a gym to exercise, you just need to get your blood moving for 30 minutes a day," said Sharp. He also emphasized the need for cancer screening – including anal Pap smears and colon cancer tests – and vitamin D and calcium supplements to maintain strong bones.
As with diabetics, Deeks said, HIV-positive people should be treated aggressively to prevent cardiovascular events – the leading cause of death for older people regardless of HIV status. This includes "getting cholesterol not just down to normal, but as low as possible." As an added benefit, the cholesterol-lowering statin drugs also have a general anti-inflammatory effect, but they can interact with some antiretrovirals.
Looking to the future, researchers are exploring therapies (such as IL-7) to boost T-cells, nutritional therapy to protect the gut, anti-inflammatory drugs to control chronic immune activation (potentially including the recently approved antiretroviral drug maraviroc), and strategies to eradicate the last bit of latent virus.
Shifting the focus to psychosocial issues, Peter Carnini from New Leaf: Services for Our Community discussed the isolation and lack of social support older people with HIV often experience. Many older gay men feel invisible, he said, and there is a "disconnect" between older and younger HIV-positive men in the community.
Long-term HIV survivors, he added, may struggle with what he called "fragmented life narratives" as they live longer than they ever expected, having not made plans for the future such as completing their education or saving money.
Other common issues facing older HIV-positive men include estrangement from families of origin, "survivor guilt," post-traumatic stress related to dealing with a life-threatening illness and frequent bereavement, changes in sexual desire and function, and difficulties with employment, finances, and insurance. Many of these issues, he noted, seem to be more acute for men of color.
"Often when we hit 40 or 50, it becomes a little more difficult to make friends, we don't go out as often, and isolation sets in," Carnini concluded. "Older gay men with HIV need to become more visible. This won't happen if you put your dinner in the microwave and turn on TV. It isn't going to change unless we change it."