An article in New York magazine in November profiled a number of HIVers and what could be called their accelerated aging. These people's portraits and very personal stories put real faces on this issue. It caused quite a buzz in my Midtown Manhattan practice.
We all recognize that we are blessed with antiretroviral combination therapies that have pushed the life expectancy to about 45 years for those newly diagnosed with HIV. Nationally about 25% of people with HIV are older than 50 -- about seven times more than the number of HIVers at that age in 1990. Here in New York City about 36% of people living with HIV are over 50. In San Francisco it is 40%. By 2015, 50% of HIVers in this country will be over 50.
People over 50 account for about 15% of all new HIV diagnoses. But they are often found later in the disease and are sicker than those diagnosed in their 20s. They tend to advance to an AIDS diagnosis more quickly and have less robust CD4-cell responses to medications, even when their viral loads remain undetectable.
One common explanation for this young-versus-old difference is the natural decline in the thymus, the organ that generates CD4 cells. It starts to shrink soon after we are born. Later in life, it makes not only fewer CD4 cells but also less-efficient ones.
However, superimposed on this scenario are recent findings that people with HIV have reduced cerebral blood flow, stiffer blood vessels, and frailer bodies than their HIV-negative peers. The current thinking is that these problems are caused by the prolonged inflammation and chronic immune activation from HIV and not from the direct effect of HIV [see my article, 'Maybe More Than a Gut Feeling,' in the September/October 2009 issue].
This would be consistent with autopsy findings that show that HIV cannot be found in the brains of those who died with HIV dementia. Rather, there is evidence of chronic inflammation. In addition, markers of chronic inflammation such as IL-6 and C-reactive protein are elevated in HIV patients -- even when viral loads are undetectable.
So does this mean it is useless to treat HIV? No. It may mean, though, that it is important to treat HIV as soon as possible.
As was demonstrated in North American AIDS Cohort Collaboration on Research and Design data, people who start HIV treatment sooner -- that is, when CD4 cells are still over 500 -- have 60% fewer deaths, including from heart, liver, and kidney causes, than those who wait longer. Interestingly, seven of the eight people pictured in the New York article each tested HIV-positive between 17 and 28 years ago, well before the first three-drug regimens were available. Therefore, it will be important to see if the effect of treating people earlier can mitigate some of this accelerated aging.
And don't forget what you can do on your own: Stop smoking, exercise more, don't take street drugs, reduce alcohol intake, and control your cholesterol, blood pressure, weight, and blood sugar. Just as interventions reduced the increase in heart disease after the introduction of the first protease inhibitors, all of these steps can help too.
Bowers is an HIV specialist and is board-certified in family medicine. He is in private practice in New York City. Learn more about Bowers at https://www.danbowersmd.com
