The burden of growing old with HIV

This article has been commissioned and funded by ViiV Healthcare
Author: Dr Mike Youle, Royal Free Hospital, London

1374529706

As people grow older, the incidence of age-associated conditions - such as chronic kidney disease and cardiovascular disorders - increases. In people living with HIV (PLHIV), the prevalence of these diseases is higher than in the general population,1 and in some cases they may progress more rapidly, be more severe or have a worse prognosis.2

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The high rates of polypharmacy, likelihood of co-morbid conditions and greater potential for antiretroviral-related toxicities create special challenges in the care of older PLHIV. In addition to selecting appropriate combination antiretroviral therapy (cART), encouraging an active, healthy and social lifestyle can help PLHIV stay well.

Research suggests that nearly three-quarters of PLHIV are concerned about future toxicity-related complications, and that most are open to reducing the number of antiretrovirals they take, provided their viral load remains suppressed.3

My four top tips for older PLHIV
Dr Mike Youle

I’ve outlined my main messages to help motivate PLHIV to improve their own health by encouraging them to make positive lifestyle choices.

  1. Watch what you eat, and exercise regularly
    Keeping to your ideal weight and exercising regularly will help prolong your life and make you healthier, slowing the development of diabetes, heart disease and other age-related conditions. As you age, you need less food, so buy good quality and eat small amounts. More nuts, fish, olive oil and vegetables are a good start. Exercise does not need to be excessive - short bursts of high intensity interval training, such as on an exercise bike, may be an ideal way for older people to maintain their health4 – don’t just sit around all day.
  2. Stop smoking
    If you smoke, stop now. PLHIV are 2-4 times more likely to develop lung cancer, and 25 times more likely to develop lower respiratory tract infections, than people without HIV.5,6 Don’t believe that you can’t stop smoking. Almost everyone can – so persevere. It’s worth it and you will feel much better.
  3. Be aware of drug interactions
    As we age, we usually end up taking more medicines for an increasing number of reasons.7 Keep an up-to-date list of your medicines, and show it to anyone who wants to give you more medicines. They, or you, can check for any interactions between your HIV and non-HIV medications on the Liverpool University website, www.hiv-druginteractions.org.*
  4. Keep up with your friends – and make new ones
    Loneliness, isolation and lack of human company are common in older people, particularly those with chronic illnesses, and can lead to depression.8 It is vital to maintain and develop social networks as you age, and there are many ways of doing this. Find out what works for you, but always ask for help. Your social network is as important to your health as the medicines you take.

HIV and ageing

In the past, HIV infection almost inevitably led to AIDS and, ultimately, death, and the likelihood of reaching conventional old age was low for many PLHIV. However, effective combination antiretroviral therapy (cART) and other advances have transformed the outlook for PLHIV, such that they now have a near-normal life expectancy. Indeed, a 20-year-old PLHIV receiving cART* can expect to live to approximately 78 years.9 In the UK, almost four in ten of those receiving care for HIV are now aged 50 years or older.9

Older PLHIV can be considered as two distinct groups. The first includes PLHIV who have lived with HIV infection for many years, in some cases over 30 years. For many of these patients, the medical consequences of ageing are now becoming a reality. The second comprises individuals diagnosed with HIV infection at an older age. These PLHIV face the prospect of dealing with a new medical diagnosis as they grow older.

*20-year-old patient starting cART in 2008–2010 with a CD4 cell count of ≥350 cells/mm3 after 1 year of treatment.

Issues affecting PLHIV at older ages

Ageing is associated with an increased burden of co-morbidities. As a consequence of this, and other biological changes associated with ageing, older PLHIV may have:10

  • A higher medication burden (i.e. polypharmacy)
  • An increased likelihood of drug-drug interactions
  • More contraindications to specific antiretrovirals, which can potentially limit treatment options
  • An increased risk of certain drug toxicities
  • Declining renal, cardiac or other vital organ function

Additionally, older PLHIV sometimes have a complex past history of antiretroviral use, which can reduce the number of viable HIV treatment options that are available for future use.

We know that older PLHIV worry about the effects of ageing on their health. In a recent survey, among PLHIV who discussed the subject of ageing with their doctor, it was the patient who had initiated the conversation in 60% of cases.11 Moreover, research suggests that nearly three-quarters of PLHIV are concerned about future toxicity-related complications and that most are open to reducing the number of antiretrovirals they take, provided their viral load remains suppressed.12

So, shouldn’t we be listening to our patients’ concerns?

For many older PLHIV, it may be possible to reduce the overall number of antiretroviral medications without compromising virological control. Recently, a two-drug antiretroviral regimen consisting of Tivicay® (dolutegravir; DTG) plus lamivudine (3TC) was shown to be non-inferior to a standard three-drug cART regimen in achieving and maintaining virological control.13 Switching to such a regimen may be a good option for adherent, older PLHIV with sustained virological control.13

In two randomised, double-blind trials (GEMINI-1 and GEMINI-2), 1,441 treatment-naive PLHIV were randomised to receive once-daily DTG (50 mg) plus 3TC (300 mg), or standard therapy with DTG (50 mg), tenofovir disoproxil fumarate (TDF; 300 mg) and emtricitabine (FTC; 200 mg).13

At week 48, a pooled analysis of both trials found that 655/716 patients (91%) who received the two-drug regimen, versus 669/717 (93%) who received the three-drug regimen, achieved a viral load <50 copies/mL.13 The adjusted treatment difference was -1.7% (95% confidence interval, -4.4 to 1.1), indicating non-inferiority of two-drug therapy.13 Numerically, more drug-related adverse events occurred with the three-drug regimen than with the two-drug regimen (169 [24%] of 717 versus 126 [18%] of 716 patients).13

Case example

Name: G.H.
Gender: Male
Ethnicity: White British
Age: 59 years old

Medical history

  • Diagnosed with HIV in 2013, aged 52 years, after developing shingles
  • Viral load 194,306 copies/mL and CD4 cell count 230 cells/mm3 at diagnosis
  • Started on darunavir/ritonavir 800 mg/100 mg plus TDF/FTC once daily
  • Viraemia was undetectable at 12 weeks, and has remained so ever since
  • Within the last six months, he has been diagnosed with hypercholesterolaemia, gout and osteoporosis, and is now receiving atorvastatin, allopurinol, a calcium/vitamin D supplement and alendronate
  • Recently, he has developed symptoms consistent with angina and is currently awaiting a cardiology appointment for further investigation
  • He is concerned about the long-term risks associated with taking multiple medications, how his other conditions will affect his HIV and vice versa and how he will keep track of his medication

What would you do?

  • Undertake an assessment of the risk of drug-drug interactions?
  • Refer to an HIV pharmacist for help with managing polypharmacy and optimising adherence?
  • Simplify his cART regimen?
  • Adopt a watch-and-wait approach?

My approach

  • He now has three co-morbidities in addition to HIV and these will require medication for a prolonged period. In addition, a diagnosis of ischaemic heart disease, if confirmed, would likely add to the medication burden and potentially require intervention
  • It would be sensible to reduce the risk of current or future drug-drug interactions by switching away from a boosted protease inhibitor, and from TDF, which should not be used in people with osteoporosis14
  • He has no history of virological failure
  • As an older PLHIV, one option could be to reduce the number of antiretroviral medications taken – for example, by switching to an evidence-based two-drug regimen where appropriate. This would achieve his objectives of taking fewer drugs, and may reduce drug-drug interactions15

Follow-up

  • The patient’s cART regimen was switched to DTG plus 3TC, with follow-up planned in three months’ time
  • He was advised to take his calcium supplement and DTG at opposite ends of the day; taking them at the same time reduces DTG exposure16
  • He was also referred to the hospital’s clinical pharmacy team, for practical help with managing his medicines

 

In summary

As an HIV care provider, there is a lot you can do to help older PLHIV live well for many years to come. Every time you see them, ask yourself: how I can make their life simpler and safer, considering their future health and well-being?

Fewer drugs could mean fewer potential interactions. In this regard, avoiding cART regimens that contain boosting agents is paramount – and, furthermore, this is achievable in most individuals by using unboosted regimens, including a dolutegravir-based two-drug regimen.

About the author
Dr. Mike Youle is an HIV physician at the Royal Free Hospital, London, UK. In addition to caring for patients, he runs JUSTRI, a not-for-profit organisation that educates and produces resources. Coming of Age, a guide for those ageing with HIV, and The Right Time, a resource for those looking after ageing PLHIV, can be downloaded from www.justri.org. (This link will take you to a non-ViiV Healthcare website. ViiV Healthcare does not recommend, endorse or accept liability for sites controlled by third-parties.)

 

References

  1. Schouten J, et al. Clin Infect Dis 2014;59(12):1787-97.
  2. Wyatt C. Top Antivir Med 2017;25(1):13-6.
  3. ViiV Healthcare Report. January 2019.
  4. Hwang CL, et al. Exp Gerontol 2016;82:112-9.
  5. Mani D, et al. Clin Lung Cancer 2012;13(1):6-13.
  6. Benito N, et al. Eur Respir J 2012;39:730-45.
  7. Edelman EJ, et al. Drugs Aging 2013;30:613-28.
  8. Shankar A, et al. Health Psychol 2011;30(4):377-85.
  9. ART Collaboration. Lancet HIV 2017;4:e349-56.
  10. Public Health England. Available from: assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/ file/759408/HIV_annual_report_2018.pdf [Accessed October 2019].
  11. Mpondo BCT. J Aging Res 2016;2016:2404857
  12. Young N, et al. ID Week 2017. Poster #1393.
  13. Cahn P, et al. Lancet 2019;393(10167):143-55.
  14. NHS England. Available from: www.england.nhs.uk/wp-content/uploads/2017/03/f03-taf-policy.pdf [Accessed October 2019].
  15. Cattaneo D, et al. Exp Opin Drug Metab Toxicol 2019;15:245-52.
  16. Tivicay® Summary of Product Characteristics. Available at: www.medicines.org.uk/emc/product/5248/smpc [Accessed October 2019].

PM-GB-DLM-WCNT-190001 | October 2019