HIV and Aging

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On 9 September 2008, ACCM held the latest in its series of treatment information conferences in collaboration with the doctors and other health care professionals of the Montreal Chest Institute and the Montreal General Hospital IDTC: HIV and Aging: the cost of our success. Dr. Julian Falutz of the Montreal General Hospital’s Immunodeficiency Treatment Centre presented some very interesting information on HIV and aging, addressing the impact of medications and the disease itself on those living with HIV.

Nearly one third of all mortality worldwide is due to some complication related to HIV metabolic issues. However, people living with HIV (PHAs) under 45 and on treatment appear to have about the same mortality rate as HIV negative cohorts. PHAs over 45 are definitely experiencing the bulk of those complications. Compared to 10 years ago PHAs in the latter group are doing better.

Dr. Falutz suggested that PHAs with a CD4 over 500 and an undetectable viral load for over 5 years have the same mortality rate as the HIV negative population. However, he did stipulate that only a minority of patients on HIV treatment are able to reach this point.

One of the factors that impact on HIV and the body as we age is the age at which someone will begin treatment—as we age, CD4 increase is naturally slower. However, maintaining a sustained undetectable viral load evens the playing field with HIV negative cohorts.

Dr. Falutz also suggested something called the Telomere which is a sequence at the end of chromosomes. The length of the Telomere in blood DNA will predict how many times cells can make copies. Therefore, a longer Telomere means a longer life. Researchers are looking at how to use this information in working with PHAs.

In terms of the costs of the success of treatments, we know that liver (hepatic), heart (cardiovascular), kidney (renal), and non HIV-related cancer episodes increase with age. In the HIV positive population there is an increase in cancers of the: prostate, colon, anus, skin (melanoma), Hodgkins, and lungs. Links between HPV and cervical cancer in HIV positive women and anal cancer and HIV positive men have been shown to increase over time as well.

Metabolic abnormalities tend to show up the most in PHAs over time. Fat accumulation is most associated with metabolic risks. Fat releases hormones which creates a risk of the arteries hardening. As visceral adipose tissue (VAT) increases so does the risk of death. Waist size is often an indicator. VAT naturally increases in everyone with age. Lipids, deep fat, and hypertension play a strong role in chance of cardiovascular disease (CVD) and stroke.

It is important that a test called the Framingham Risk Score be done before starting treatment and then once a year afterwards. This test looks at the risk of CVD over the next ten years. It takes into account total cholesterol, HDL, LDL, blood pressure, smoking, family history. It’s also a test that can be done online easily if you have the levels of these things.

Bone demineralisation (BMD) is also a factor as we age. An HIV positive person not on treatment has (on average) a 40% BMD loss. An HIV positive person on treatment has a 60% BMD loss. However, Dr. Falutz was careful to point out that this increase was mostly due to the duration someone is HIV positive and not the treatment. Someone who is HIV positive longer is more likely to be on treatment. In general, HIV positive people tend to be undernourished, smokers, have low testosterone levels, and show a loss of calcium over time which can lead to BMD loss. This often results in an increase in fractures in PHAs.

Testosterone plays a crucial role as we age. As testosterone decreases over time the deep fat increases as does the risk of diabetes. Low testosterone is linked to hypogonadism in men and women. Testosterone levels tend to be more consistent in those who started treatment before CD4s became low.

The amount of HIV in the brain is not the only reason for cognitive problems. Age and diabetes are associated with cognitive problems and increase visceral fat can add to dementia.

So what can you do about any of this? This may sound a bit like a broken record, but, a proper diet, exercise (aerobic and weight resistance), and stopping smoking have a profound impact on aging, our bodies, ability to fight HIV, and ability to tolerate side effects related to medications. Physical activity can improve cognitive function and also increase Telomere length that was mentioned earlier.