IAS 2013 Keynote Looks at Aging with HIV
The 7th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention kicked off Sunday in Kuala Lumpur, Malaysia. The first day featured the release of new World Health Organization (WHO) antiretroviral therapy guidelines, discussion of drug policy and its impact on the global HIV and hepatitis C epidemics, and a keynote address on HIV and aging.
This is the first year the IAS meeting has been held in Asia, where the HIV epidemic is largely driven by injection drug use. Malaysia was selected in part because of its successful implementation of harm reduction programs that have dramatically reduced HIV incidence among people who use drugs, according to local conference co-chair Adeeba Kamarulzaman.
New HIV Treatment Guidelines
On June 30 WHO released updated treatment guidelines recommending that people with HIV worldwide should start antiretroviral therapy (ART) when their CD4 count falls below 500 cells/mm3. This is an increase over the current global initiation threshold of 350, and matches current U.S. guidelines. Earlier treatment has benefits both for the health of individual people with HIV and for public health by lowering the risk of transmission.
Raising the CD4 threshold “could avert an additional 3 million deaths and prevent 3.5 million more new HIV infections between now and 2025,” according to a WHO press release describing the changes.
WHO also added a recommendation that all HIV-positive adults starting treatment for the first time should be offered the same regimen: efavirenz plus tenofovir plus either emtricitabine or lamivudine, preferable as a single-tablet regimen (Gilead Sciences’ Atripla or a generic equivalent).
The new changes are not without controversy. Many people eligible for treatment under the old guidelines are not yet receiving it, and expanding coverage will add to costs in the short term. Earlier treatment could potentially do more harm than good in countries that still use older, more toxic antiretrovirals. Finally, the recommendation contradicts a drug label warning that pregnant women should not take efavirenz because it may raise the risk of birth defects. Recent studies do not support this concern, but advocates said the contradiction is confusing and may lead pregnant women to stop treatment.
HIV and Aging
Steven Deeks from the University of California at San Francisco gave the conference keynote address Sunday evening, focusing on HIV and aging—and in particular, how persistent inflammation in people on ART with undetectable viral load raises the risk of non-AIDS conditions such as heart disease.
These other diseases are becoming far more important than AIDS for people with HIV who have consistent access and good response to treatment, and management of age-related conditions will become an increasingly important aspect of HIV medicine worldwide in the coming years, according to Deeks.
“For people with drug-susceptible virus who are motivated to take the drugs and who have life-long access to therapy, AIDS is no longer the problem,” he said. Instead, “HIV is looking a lot like other chronic diseases,” characterized by persistent low-level immune activation and inflammation.
People with treated HIV have increased levels of multiple markers of inflammation—including interleukin 6 and D-dimer—that predict excess risk of cardiovascular disease and other non-AIDS conditions, as well as death. One study found that HIV-positive people in their fifties have as many co-morbid conditions as HIV-negative people ten to fifteen years older. “It looks like [HIV] adds a decade in terms of age-associated conditions,” Deeks said.
These conditions, so far mostly studied in the U.S. and Europe, “are now playing out in developing world,” he continued. Added co-morbidities and the shift to chronic disease management could overburden already stretched health care systems.
But fortunately, we can do something about it. “I spend my time in the clinic talking about exercise, management of lipids, a Mediterranean diet, and so forth,” he said. “That is the future of HIV care.”
At another level, we know a lot about mechanisms of inflammation and why it might cause disease, and there are multiple drugs in the pipeline to try to reverse the process, as well as increasing evidence that starting ART early rather than late may help prevent long-term inflammation.
Ultimately, Deeks concluded, the various problems associated with chronic HIV disease—excess inflammation, heart disease, overburdened health systems, not being able to afford lifelong therapy—could all be addressed by a cure.
This past weekend Deeks co-chaired a two-day “Towards an HIV Cure” pre-conference symposium with IAS president Françoise Barré-Sinoussi and Sharon Lewin from Monash University. The meeting featured “a lot of cutting-edge research,” he said, some of which will be presented later in the week.
Making an analogy with the development of antiretroviral drugs, Deeks suggested that cure research is where ART research was in the late 1980s. But “going after free virus [in the blood] was a lot easier than virus hidden in cells,” he emphasized. “We have to find some ways get in there without harming the patient.”
The full IAS 2013 program is available online. Follow conference news on Twitter using hashtag #IAS2013.
Liz Highleyman (liz (at) hivandhepatitis.com) is a freelance medical writer and editor-in-chief of HIVandHepatitis.com.Related