In the early days of AIDS, a diagnosis of HIV meant that you would be dead of AIDS in 18 months. But these days, doctors tell newly diagnosed HIV patients to plan for retirement.
“We're thinking about HIV now not as a death sentence but as a lifelong, chronic condition, similar to diabetes or high blood pressure,” says Dr. Brad Hare, medical director of the HIV clinic at San Francisco General Hospital.
Dr. Hare is part of a team that's developing new research and standards of care for patients who are approaching old age – a new frontier in HIV.
The Centers for Disease Control and Prevention predicts that by 2015, over half of people living with HIV will be over 50 years old. New diagnoses contribute to that number, but many will be patients who have lived for decades with the virus.
While older patients signal the success of treatment, they also present new challenges. Doctors have discovered that HIV can accelerate aging, forcing patients to confront diseases of old age such as dementia, osteoporosis, and heart disease ten years before their time.
Background
When HIV/AIDS emerged in the early 1980s, there were very few effective treatments. A diagnosis was essentially a death sentence.
Fortunately, antiretroviral drugs (ART) transformed the treatment of HIV in the mid 1990s. “Now treatment is very effective at stopping the virus from replicating and spreading,” Dr. Hare said.
Treatment is individualized for each patient. Doctors prescribe a combination of ARTs, but often these drugs are combined into one pill.
“Pills have gotten easier on the body, and stronger against the virus,” said Dr. Hare. “The consequence of that is that people are living longer.”
There are still complications – the virus can become resistant to drugs, and there are side effects. But for the most part, as long as a patient consistently manages their care, they can now expect to live a long life being HIV-positive.
Accelerated Aging
As patients began entering old age after living with the disease for decades, doctors started to see diseases that are typically associated with aging – dementia, kidney failure, osteoporosis, and heart disease, to name a few.
Treatment for these diseases is complicated by the presence of HIV. Because the patients are on life-sustaining medication, doctors needed to be careful of bad drug interactions, just as they would for any other patient dealing with two infections.
But there's a twist. Dr. Hare told dailyRx: “Diseases that are common in old age are showing up earlier.”
Dr. Hare gave the example of treating three men with HIV who needed coronary stents for heart disease. That procedure is typical for patients who are in their 60s or 70s. These patients were in their 50s.
People with HIV tend to age faster. Dr. Hare says that scientists now believe that accelerated or premature aging is due to the chronic inflammation associated with long-term treatment.
It's also suspected that ART, the life-saving drugs, may contribute to the development of old age diseases.
When researchers in the lab look at cells belonging to older people with HIV, their cells appear to belong to people who are ten years older than the patient, said Dr. Hare.
Doctors began to notice these issues 5 to 10 years ago, Dr. Hare said, as patients who had been infected in their 20s and 30s reached older ages. Now the question is how to prepare newly diagnosed HIV-positive individuals for the consequences of living with HIV.
The Complications of a Longer Life
A long life for those with HIV is of course, a positive development. But how does knowing what happens to older people with the virus change the course of treatment?
“First and foremost, our main goal with HIV treatment remains the same,” said Dr. Hare. “Our goal is to have people on medications that make the virus undetectable.”
But there's a catch. “When people develop other conditions, it impacts treatments,” he added. Doctors have to make appropriate changes in treatments if drug interactions become an issue, or treat the other condition differently than they would a normal patient, because he or she has HIV.
“If there's organ damage from other conditions, like kidney failure, we may have to consider other options.”
Regardless of the challenges, it's very possible for HIV-positive patients to have good outcomes – or regain good health – when it comes to their secondary diseases, if their HIV is under control. “My patients who had bypass last year are doing great,” said Dr. Hare.
But it's not only physical diseases that affect HIV-positive patients. Many of the survivors of the devastating AIDS epidemic of the 1980s and 1990s have experienced massive losses – witnessing their friends dying through the years while they live on.
Because, during its height, the epidemic heavily affected the gay community, many of Dr. Hare's patients in San Francisco are men who have been estranged from their families and remain childless. “There are psychosocial impacts,” he said. “There's depression and isolation.”
That's why part of the program that Dr. Hare and his colleagues are developing involves building community and support groups for people with HIV and AIDS.
Planning for a Long Life
Until recently, HIV-positive individuals didn't have much to plan for. With an expected life span of 18 months, concerns about 401Ks and the next career move didn't enter the picture.
Now things are different.
“I tell newly diagnosed people that they have to plan for retirement. Expect to be 60 and 70,” Dr. Hare said.
That means not only financial planning for retirement, but living a healthy lifestyle that will decrease their likelihood of disease, just like anyone else.
“[Patients with HIV] have an additional reason to stay attuned,” said Dr. Hare, “because HIV plays into the aging process.”
An important aspect that Dr. Hare and his colleagues are working on is knowing when and what conditions to screen patients for. For example, patients may need to be screened for the risk factors of heart disease and cancer.
“If you identify these conditions early they are much more manageable,” he said.
Despite the evolving focus on aging patients, the mainstream perception of HIV is one of a life-ending disease. Dr. Hare told dailyRx that doctors often inform patients that their diagnosis does not mean that they have under two years left to live.
“On the flip side, I don't think it should lead to complacency,” he said. Prevention is still key. If anything, the discovery of the accelerating aging process should emphasize the fact that HIV is a life-changing illness that has long-term health effects.
