The complexity of the needs of
people living with HIV will continue to increase as the population ages, and
clinicians need to go beyond thinking about co-morbidities to consider
multi-morbidities – clusters of medical conditions which complicate one another
– when caring for these people, Dr Edouard Battegay of University Hospital
Zurich told the International Congress on Drug Therapy in HIV Infection (HIV Glasgow) on Tuesday.
Following analysis of multi-morbidity
in the general population, University of Zurich researchers found that medical
conditions tended to cluster into eight groups, and that individuals tended to
fall into one of these clusters. For example, they found a strong relationship
between dementia, depression and hip fracture, but much less frequent overlap
between coronary heart disease and hip fracture and depression. Instead, people
suffering from cardiovascular problems tended also to suffer frequently from
thyroid dysfunction and chronic obstructive pulmonary disease.
These patterns of clustering
indicate which groups of specialists might need to work together more
frequently, and who needs to be involved in the care of people with HIV.
Dr Battegay suggested that among
people living with HIV, a number of clusters of multi-morbidity present with
greater frequency, such as HIV infection, depression and pain, or HIV,
depression and non-adherence. HIV and hypertension overlap with cardiovascular
disease, and may also overlap with pain. Further research is needed to examine
these clusters of multiple morbidity, so as to help in the development of
algorithms for the management of multiple morbidity, such as those recently issued
by the European AIDS Clinical Society.
Research from France also presented
at the conference showed that by the time people living with HIV reach middle
age, a high proportion already have complex medical problems requiring
multidisciplinary management. The study found that just over half were at high
risk for serious kidney disease, 46% were at high or very high risk of a
cardiovascular event in the next five years and 56% had hypertension.
Investigators from the Aquitaine
regional cohort wanted to establish a clear understanding of the evolving
medical needs of HIV-positive patients in the modern antiretroviral therapy era. They therefore
analysed cross-sectional data gathered from patients enrolled in the
prospective ANRS CO3 Aquitaine cohort to see how the spectrum of health
problems observed in HIV-positive patients changed between 2004 and 2014.
A total of 2138 patients had study
visits in both 2004 and 2014. Most (71%) were male, 40% were men who have sex
with men and the median age in 2014 was 52 years. Sixty-two per cent of the
cohort was over 50 years of age in 2014.
HIV markers improved over the ten
years of the study. The proportion of patients with an undetectable viral load
increased from 51% in 2004 to 91% in 2014 (p < 0.0001). This was accompanied
by a significant increase in the proportion of patients with a CD4 cell count
above 500 cells/mm3, from 44% in 2004 to 72% in 2014.
However, there was a significant
increase in the proportion of patients diagnosed with age-related
co-morbidities and taking therapy for these ailments.
Prevalence of chronic kidney disease
increased from 4% to 18%; fractures from 1% to 7%; cardiovascular disease events
from 4% to 14%; use of blood thinning agents from 1% to 8%; therapy with
aspirin from 1% to 8%; hypertension from 19% to 56%; diabetes from 8% to 19%;
use of anti-diabetic therapy from 2% to 6%; prevalence of elevated lipids from
14% to 54% and use of statins from 9% to 24% (all comparisons, p < 0.0001).
Of particular concern, the
proportion of patients with a Framingham High Risk score (5-10%) for
cardiovascular disease increased from 13.1% to 26.5%, while the proportion with
a Framingham score above 10%, indicating a risk of one in ten or more of having
a cardiovascular event – either stroke or heart attack – in the next five years
had jumped from 5.3% to 19.9%. In other words, one in five of the cohort are
now at very high risk of a cardiovascular event, compared to one in twenty ten years ago.
Similarly, the proportion of
patients with the highest risk of kidney disease, as measured on the D:A:D
renal risk score had risen from 29.9% in 2004 to 50.5% in 2014, indicating the
importance of selecting antiretroviral regimens that minimise the risk of
further loss of kidney function.