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The Graying of the HIV/AIDS Epidemic in the U.S.

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Presentation on theme: "The Graying of the HIV/AIDS Epidemic in the U.S."— Presentation transcript:

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2 The Graying of the HIV/AIDS Epidemic in the U.S.

3 Effects of Aging on the Course of HIV Infection - and Vice Versa - James R. Minor, Pharm.D CAPT, USPHS, Retired June 2012

4 Disclaimer

5 Objectives Describe the clinical issues affecting older HIV+ patients Describe ‘immunosenescence’ and its impact on the course of HIV infection in older patients Summarize HIV-associated, non-AIDS conditions and co-morbidities

6 HIV/AIDS in Older Persons [50 years of age or older]

7 Persons 50 years of age+ account for: 15% of all new HIV infections/year 20% of all new AIDS diagnoses 35% of all deaths due to AIDS 25% of persons living with AIDS [up from 17% in 2001] The Numbers [US]

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9 Common AIDS and Non-AIDS Complications Organ systemCondition / complication AIDS- defining Non-AIDS- defining Cardiovascular Cardiomyopathy√ Myocardial infarction√ Nervous Toxoplasmosis√ Primary lymphoma√ HIV-associated neurocognitive disorder or dementia (HAND or HAD) √ Pulmonary Tuberculosis (pulmonary or extrapulmonary) √ Pneumonia (recurrent, or Pneumocystis spp.)√ Candidiasis (bronchi, trachea, lungs)√ RenalHIV-associated nephropathy (HIVAN)√ BoneReduced bone mineral density√ Malignancies Invasive cervical cancer (oncogenic HPV)√ Invasive anal cancer (oncogenic HPV)√ Non-Hodgkin’s lymphoma, Kaposi’s sarcoma √

10 HIV+ persons have a substantially shortened life span, largely due to increased risks of ‘non-AIDS’ complications and comorbid diseases : renal, bone, metabolic, liver, malignant diseases, and neurocognitive decline

11 Risk of non-AIDS morbidity is higher among ARV-treated HIV+ individuals than in their age- matched, uninfected peers for reasons directly related to the disease or its treatment

12 All these degenerative comorbid diseases have a negative impact on overall functioning and Quality of Life, and are thought to be related to accelerated or premature aging

13 ‘Immunosenescence’

14 Age-related changes in the adaptive immune system that are associated with increased morbidity and mortality ‘Immunosenescence’ - Definition -

15 Adaptive immune system changes with aging: Decreased number and function of hematopoietic stem cells Thymic dysfunction, involution Decreased circulating naïve T cells Decreased CD4/CD8 ratios Increased proinflammatory cytokines: IL-6, TNFα, CRP, cystatin C Increased pools of senescent CD28- ‘memory’ cells * ‘Immunosenescence’

16 Senescent T Cells With aging or in the presence of chronic viral infection, CD28- T cells become resistant to apoptosis and become pro- inflammatory in effector function This contributes to increased systemic inflammation and collateral harm to multiple organ systems

17 HIV-associated inflammation and ‘immunosenescence’ have been implicated as causally related to the premature onset of multiple end-organ diseases

18 HIV-associated immunosenescence contributes to persistent immunodeficiency and early onset of age- related diseases Further investigation into these pathways may lead to novel therapeutic interventions useful in both HIV-infected persons and in uninfected geriatric populations ‘Immunosenescence’ - Summary -

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20 Prevention and Public Health Challenges in Older HIV+ Persons Many older persons are sexually active but may not be practicing safer sex Older women are at higher risk due to age-related genital changes Many older persons may know less about HIV/AIDS and less likely to protect themselves or to get tested Discrimination and stigma facing older HIV+ may delay testing, diagnosis and entry in treatment

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22 HIV and Aging: Overall Framework

23 Renal Disease

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25 Untreated HIV disease [persistent viral replication] is associated with higher risks of kidney disease – suggesting that HIV replication directly or indirectly affects the kidneys Many antiretroviral agents [ARVs] are also nephrotoxic

26 Bone Disease

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28 Prevalence of osteopenia and osteoporosis is at least 3x greater in HIV+ subjects than in HIV uninfected controls Persistent inflammation is probably causally related to bone disease, as many biomarkers of inflammatory bone disease are higher in HIV disease [IL-6, TNF… ] Other contributory factors: ART, vitamin D deficiency

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30 Metabolic and Cardiovascular Complications

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36 HIV, Aging and Increased Risks of Malignant Diseases

37 Non-AIDS Related Cancers Higher cancer rates in long-term ARV- treated patients is strongly related to the degree of immunodeficiency HIV-associated immune deficiency may be the primary factor driving an excess risk of many non-AIDS cancers Increasing prevalence 0f HCV- and HPV- related malignancies

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39 Kaposi’s Sarcoma

40 Neurocognitive Functional Defects

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42 HIV-Associated Neurocognitive Disorders [HAND] and Dementia [HAD]: A Hidden Epidemic ??

43 Neurocognitive Decline HIV-associated inflammation is believed to be a major factor in comorbid CNS disease Debate: Is ongoing CNS disease due to inadequate CNS penetration of ARVs [allowing ongoing viral replication] OR to residual, low-grade inflammation ??

44 HIV and Aging: Overall Framework

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46 The ‘double insult’ of aging and HIV infection to the hematopoietic system can contribute to many of the factors associated with immunosenescence: chronic inflammation, reduced ability of the immune system to mount effective response to infections, vaccines, other stressors

47 Novel therapeutic strategies aimed at preventing or reversing immunologic defects and changes related to immunosenescence will be necessary if HIV-infected patients are to achieve normal life spans

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51 Acknowledgements

52 The Graying of the HIV/AIDS Epidemic in the U.S.

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54 Linkage to Care - US and EU There are still a significant number of patients who are undiagnosed, not linked into care and not on therapy

55 Keys to Achieving Long-Term Objective of Ending the HIV/AIDS Pandemic * Efficiently identify greater numbers of HIV+ people earlier in the course of disease through expanded voluntary HIV testing programs, and link them to appropriate care and antiretroviral treatment Find innovative approaches to curing HIV/AIDS by eradicating or permanently suppressing the virus in infected people, thereby eliminating the need for lifelong antiretroviral therapy Scale-up implementation of proven HIV prevention strategies, develop additional effective prevention strategies, such as a vaccine, and build on current successes in pre-exposure prophylaxis, microbicides and ‘treatment-as-prevention’ to achieve a sustainable and comprehensive, combination HIV prevention strategy * NIH/NIAID, 31 May 2011

56 “HIV testing should be the fifth vital sign” Carl Dieffenbach, Director, DAIDS, NIAID 1 June 2011

57 HIV Prevention – Recent Milestones - Two populations are disproportionately affected by HIV –Men who have sex with men (MSMs) –Women - nearly half of the adults living with HIV. CAPRISA-004: 39% reduction in new HIV infections in women with the use of topical 1% Tenofovir gel; first trial to prove efficacy of PrEP iPrEx: 44% reduction in new infections when TDF/FTC was used daily as pre-exposure prophylaxis (PrEP) in MSMs


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