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CROI 2016 took place from Feb 22-26, 2016 in Boston, MA. The two medical directors for our site were in attendance and have provided brief summaries of some of the key abstracts pertaining to HIV care in older adults. As usual there is so much information and new research at CROI—it’s impossible to cover it all so we encourage everyone to check out the online materials as well once they are available.
Some of the key sessions relevant to HIV care in older adults are below:
There were several studies looking at the effects of HIV on aging. In a large European cohort study patients with HIV and over 75 years of age were compared to a group aged between 50-74.Compared to the younger group, the geriatric group had more non-HIV associated co-morbidities, had lower BMI, slightly lower CD4 count, to be a non-smoker and to be HCV negative. The geriatric group had equivalent immunologic success, indicating that ART can be as successful in the geriatric population as in the younger group.
Abstract 709: Ageing With HIV: Emerging Importance of Chronic Comorbidities in Patients Over 75
Allavena et al. France.
In a presentation from the group at Kaiser Permanente in California, life expectancy in HIV-infected patients compared to a non-infected cohort was analyzed. The news was good. The gap has narrowed but there is still about a 13 year difference between the two groups. Interestingly, looking at subgroups, those who began ART with a CD4 count of ≥ 500 cells narrowed the gap to 9 years, and non-smokers reduced that gap by half. This is further evidence that smoking cessation in our HIV-infected patients is one of the most important lifestyle modifications that providers can stress.
Abstract 54: Narrowing the Gap in Life Expectancy for HIV+ Compared With HIV- Individuals.
Marcus at al. Kaiser Permanente
There was a lot of information on PrEP at CROI this year. We still wish there was more data looking specifically at PrEP use in older adults and potential complications like bone and renal effects. Be sure to check out our new chapter “PrEP and the Older Adult with HIV” under Clinical Recommendations which summarizes what we know and how PrEP could be important for older adults.
PrEP and Renal Function
A couple of interesting abstracts explored the issue of PrEP and renal function. Gandhi et al. looked at the data from the iPReX open label extension trial of MSM and transgender women using hair concentrations of tenofovir and creatinine levels as markers of adherence and renal function respectively. Creatinine levels declined in all participants and a linear relationship was seen between hair concentrations of drug and decline in eGFR. If the baseline eGFR was less than 90 at baseline then the eGFR on PrEP declined more. Age >40 as well as exposure to the drug more than 4x per week were risk factors for a greater fall in eGFR.
Abstract 866: Higher Cumulative TFV/FTC Levels in PrEP Associated With Decline in Renal Function.
Gandhi et al. UCSF, U. Mich., Chicago, Brazil, Boston.
In the US PrEP Demonstration project, Liu et al. found that eGFR declined on average 2.8% with TDF-FTC PrEP but by week 12 the renal function stabilize. More than 4 doses of PrEP per week, older adults, and lower baseline eGFR were associated with a decline of eGFR to less than 70 with PrEP.
Abstract 867: Changes in Renal Function Associated With TDF/FTC PrEP Use in the US Demo Project
Liu et al. UCSF, Colorado, Miami, NIH, GW.
Looking at data from the Partners PrEP Trial, Mugwanya found that proximal tubular dysfunction was rare in people taking PrEP, although some proteinuria was common. Proximal tubular dysfunction was not predictive of a significant decline in eGFR.
Abstract 868: Rare Incidence of Proximal Tubular Dysfunction With Tenofovir-Based Chemoprophylaxis
Mugwanya et al. UWash Seattle, CU, Mt Sinai, NY, Kenya, Canada. PrEP and STIs
Current recommendations for STI screening during PrEP recommend baseline screening and then every 6 months or when symptomatic. In an LGBT health center, 21% of patients initiating PrEP had an STI, including 11% at the visit when PrEP was begun. Between 11-21% of people tested positive for an STI at each follow up visit and 77% of these were asymptomatic. Using the CDC guidelines, 24% of the STIs would have been missed. Many of these were asymptomatic anal STIs. The authors recommend routine STI screening at each 3 month visit.
Abstract 869: STI Data From Community-Based PrEP Implementation Suggest Changes to CDC Guidelines
Golub et al, NY, Hunter
PrEP and Bone
This study was based on data from a substudy of bone mineral density within the iPrEx trial, where 498 participants (median age 25), had DXA scans every 24 weeks while on PrEP, and either 24 weeks after stopping PrEP or at the time of enrollment into the iPrEx open label extension (iPrEx OLE). Many had full recovery of BMD at 6 months (esp. at the spine) and all had full recovery by the time of enrollment into iPrEx OLE. When they examined age <25 compared to ≥25, the older group had full recovery at the spine at 6 months but only partial recovery at the hip compared to the younger group.
Abstract 48LB: Recovery of Bone Mineral Density After Stopping Oral HIV Preexposure Prophylaxis.
Grant et al. UCSF, Thailand, Brazil, South Africa, Peru.