Treating HIV Comorbidities in the Fight to End the Epidemic

Preventing the spread of new HIV infections was in the news earlier this month with the launch of Ready, Set, PrEP, part of President Donald Trump’s Ending the HIV Epidemic: A Plan for America. A top goal of this program is to reduce HIV transmission by 75% over the next 5 years and by 90% in 10 years.

This means, however, that when 2030 arrives, there will still be 1 million people living with HIV in the United States, wrote researchers from the National Institutes of Health in a recent issue of JAMA. Especially important is investigating and treating their numerous comorbid conditions, which they face a higher risk of due to their longer life spans, despite being on antiretroviral therapy (ART), and they often develop these comorbidities at younger ages.

Some of these conditions are kidney disease, cancer, liver disease, cardiovascular events, and osteoporosis/fractures. Using 2003-2013 data, the authors were able to show higher occurrences of these conditions in persons with HIV taking ART compared with an HIV-negative control group:

• Kidney disease: 8.8% vs 2.8%
• Cancer: 8.0% vs 4.1%
• Liver disease: 6.2% vs 2.4%
• Cardiovascular events: 6.7% vs 4.0%
• Osteoporosis/fracture: 7.6% vs 6.4%

Another critical area to examine is neurocognitive disorders. Yes, effective treatments have led to a decreased prevalence of HIV-associated dementia; however, impairment persists even when the viral load is suppressed to an undetectable level, and the reasons for that remain unclear, the authors pointed out.

What can be done? They suggest more clinical trials and research advances into the cause and development of the comorbid conditions, as well as efforts to reduce healthcare disparities.

For example, the REPRIEVE trial is investigating statin use and cardiovascular disease risk in individuals with HIV, and the START trial results showed how despite the benefits of immediate initiation of ART postdiagnosis, doing so has a greater effect on bone mineral density loss compared with deferring treatment. In addition, even though the safety and effectiveness of direct-acting anti-viral medications to treat comorbid hepatitis C have been proven, these medications are not widely available—and they need to be. These are just a few examples.

“Establishing a better understanding of these comorbidities and how to manage them will be essential to reduce the burden these conditions place on individuals and the health care system,” the authors concluded.

Reference

Lerner AM, Eisinger RW, Fauci AS. Comorbidities in persons with HIV: the lingering challenge [published online December 11, 2019]. JAMA. doi: 10.1001/jama.2019.19775. Accessed December 12, 2019.