Why we won’t die of AIDS

A study in France has found that, whatever older people with HIV die of, it probably won’t be AIDS.

In recent years one of the increasingly hot topics in the HIV community has been the realisation that people with HIV are living into older age – and that this means they will start developing the health conditions of older people.

At the recent European AIDS Conference in Cologne, a new set of European HIV treatment guidelines was presented.¹ We’ll look at them in detail in the next issue. But what was interesting was that, while the guidelines for HIV treatment changed very little, a big new section was added on managing all sorts of other conditions.

Diabetes, liver disease, high blood pressure, depression, osteoporosis – most of them common conditions that affect the general population, and most of which become significant as we age.

Antiretroviral therapy works and is simpler and more potent than ever. Yes, not everyone is ready to take it or needs it. Yes, there are still side-effects and some of these may intensify or even set off certain conditions.

But in future, the tricky medical issues in HIV medicine will be, for most patients, about everything but antiretroviral (ARV) treatment. The guidelines suggest that in the future, for most of us, our dodgy tickers and our brittle bones are likely to matter more than our CD4 count.

There was a fascinating study presented at the European Conference that backed this up.

A study of 149 people with HIV aged over 60 found that over a four-year period more of them died than would have been expected in the general population - but not a single person died of an AIDS-defining condition.²

Most studies of people with HIV have taken 50 as the threshold of older age, but in the French study all patients were over 60, the average age was 65, and nearly 10% were over 80 (the oldest was 86). Starting an ‘ageing cohort’ at 60 may give a more reliable guide to the diseases we may have to look out for as we age.

Between 2004 and 2008, 21 of these patients died. This 14% mortality rate is higher than in the general population, but it’s not vastly higher. For instance, the four-year mortality rate in men aged 70 in the UK is 11.1% and in women 7.1%.³ (In France, which has a better life expectancy than the UK, it would be slightly lower.)

The most striking finding of the study was that not a single patient in the group developed a new AIDS-defining condition over the four years, and only two experienced the relapse of an existing condition (Kaposi’s sarcoma and lymphoma). This is despite the fact that one-third had had an AIDS diagnosis in the past.

Test results also bore witness to the success of ARV therapy. In 2004, 70% of the group had a viral load under 50 copies/ml; by 2008 this had increased to 96%. Average CD4 counts increased from 372 to 494 cells/mm³ in the same period.

So what did the 21 patients die of? Eleven deaths, more than 50%, were due to non-AIDS defining cancers. Another four (19%) died of cardiovascular disease (CVD), three (14%) of liver disease, and three of other causes including one of dementia.

Many of those still living had multiple health problems. Even though CVD was not the main cause of death, it was by far the most common cause of illness. Half the group (74 patients) suffered from a CVD-related ‘event’ such as a heart attack, angina or a stroke during the four years. This may indicate that CVD will become a more important cause of death as the cohort ages.

A quarter of the patients had kidney disease, one in five had arthritis or bone problems, one in six had cognitive or neurological problems, more than one in seven had diabetes, and one in eleven had liver problems.

One in six (15 patients) also currently had some form of non-AIDS-defining cancer. These high rates of cancer are of concern. Last month’s piece on how HIV causes AIDS (How does HIV make us sick? issue 191) found evidence that, despite HIV therapy, chronic HIV infection leaves ‘gaps’ in the immune system, and that HIV may continue to smoulder, causing a low-key version of the inflammation that is thought to lie behind CD4 depletion.

In patients on ARVs it does not cause this, but may continue to damage nerve cells and the linings of arteries, and it may damage the immune machinery that nips cancers in the bud.

What this means is, while we may have to a large extent won the fight against classic AIDS, there is an awful lot of HIV research still to be done before we can all expect to live as long as anyone else.