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Increasingly providers of clinical care for people living with HIV are spending less time managing drug resistance and associated short term ART toxicities and more time managing age associated illnesses (Deeks 2013). This shift in care is underlined by reports that most deaths for this population are a result of non-AIDS related illnesses. This caused many to ask – are people infected with HIV aging faster? The words “accelerated aging” are often used to describe the aging trajectory of the older adult with HIV. This perception was reinforced by multiple research reports which show older adults are developing illnesses typically associated with aging and in some cases at an earlier age than would be expected.
In 2010 Martin and Volberding (Martin 2010) remind us that accelerated aging in the HIV older adult is an “intriguing” hypothesis, and, that we should not allow it to become ingrained in the culture of HIV before it has been supported. Yet, by 2015 the common perception exists that accelerated aging is manifested in older adults with HIV.
Testing the hypothesis “Does HIV cause accelerated aging?” requires finding comparison groups that are adequate to yield valid results. Researchers must control as many variables as possible in order to isolate the HIV effect. But, as a group, HIV-infected adults evidence a constellation of characteristics that are unique, all of which can exert significant impact on a person’s health status. Those variables include: history of drug addiction/use, smoking and alcohol use, HCV infection, sexually transmitted infections, stigma-driven social isolation, chronic unmanaged depression, post-traumatic stress disorder (PTSD), financial, housing and food insecurity, as well as care barriers fueled by gender, race/ethnicity and sexual identity. HIV infection is largely occurring within economically underprivileged minority communities wherein good nutrition and emphasis on regular exercise is largely absent. This panoply of variables as well as the state in which a patient resides (has ACA been embraced or not) are examples of primary predictors of health disparities and outcomes. Effectively controlling for these variables is a challenge whose resolution is most often elusive.
In studies where those variables are optimally controlled, including recent studies from Denmark (Rasmussen 2015) as well as the large VACS cohort studies, there is little evidence to support the accelerated aging hypothesis. But in those optimally controlled studies, together with data from multiple research reports, the evidence of multimorbidity in HIV infected older adults being the rule and not the exception emerges. Similarly, in a 2015 JAIDS Letter to the Editor (Harper 2015) the author concludes that “current data are not consistent with an accelerated ageing hypothesis” and that cumulative data do support the view that an increased risk of age-related comorbidities occurs. In addition, The Body Pro HIV 2015 Year in Review article concludes that the concept of accelerated aging is not supported (Body Pro 2015). A leading researcher on HIV and Aging, Amy Justice, using the large VACS cohorts, has consistently counseled against concluding that accelerated aging was occurring. An extensive review of this issue by this Commentary’s authors reaches the conclusion that accelerated aging is not supported (Karpiak 2016).
Multiple research reports confirm that the older adult HIV populations (US and globally) are exhibiting a significantly higher frequency of multimorbidity. Multimorbidity is defined as having two or more chronic diseases. The need to manage multimorbidity in the older adult HIV infected population is causing inexorable tectonic shifts in how care delivery is provided. It is hypothesized that this increase in multimorbidity is related to the inflammatory cascade that occurs due to HIV infection. Even in well-managed HIV patients with sustained undetectable viral loads, inflammatory biomarkers remain elevated. However, this elevated inflammatory state is also influenced by being co-infected with HCV and the presence of other risk factors listed earlier. With this present state of knowledge, there is no doubt that early ART should be initiated in all HIV-positive patients to reduce the cumulative effects of chronic inflammation. This aggressive action should be paired with cardiovascular risk factor reduction, especially smoking cessation, and appropriate screening for cancers, renal disease, and osteoporosis.
Management of this elevated risk for developing multimorbidity is the major issue for the older adults with HIV and their health care teams. The medical system must adapt in a more comprehensive way to respond to the needs of this aging and growing older adult population who will dominate the epidemic. Finally, improvement in the current health care system is necessary to provide better treatment, prevention and comprehensive care to HIV-infected older adults. Part of that improvement requires embracing geriatric care principles and changing the misdirected perception that accelerated aging is occurring.
The authors Stephen E Karpiak PhD and Richard Havlik, MD, MPH, are members of the Editorial Staff, HIV-Age.org. Dr. Karpiak is the Senior Director for Research at the ACRIA Center on HIV and Aging and on faculty at New York University. Dr. Havlik is a retired Laboratory Chief from NIH (National Institute on Aging).