Ageing, long-term complications and nutrition

AGEING

At a forum put on by the Terrence Higgins Trust (THT) from the UK and the AIDS Community Research Initiative of America (ACRIA) from New York, I heard figures on HIV and ageing which were not dissimilar to those we have here in Australia.

For example, 40% of New York’s HIV positive population are currently over the age of 50 and by 2015 the figure will have risen to 50%. I also heard how many more MSM over the age of fifty are becoming newly infected in the UK and the US – a particularly worrying trend because of the viral progression and immunological damage that occurs more easily in this age group.

Lisa Powers from THT spoke about 50 Plus, a survey of older PLHIV [1]Person (or people) Living with HIV. This term is now preferred over the older PLWHA. in the UK. The people interviewed talked about how uncertain they were about their health. Long-term survivors reported how, after experiencing a new lease of life with HAART [2]Highly Active AntiRetroviral Therapy ??? aggressive treatment of HIV infection using several different drugs together. in the late nineties, life had become unpredictable again. Half her cohort [3]In epidemiology, a group of individuals with some characteristics in common. A cohort study is a special kind of clinical trial which looks at a treatment or treatment strategy in a cohort of people. talked about problems with mobility and difficulties with self-care. And because they had never had access to life insurance schemes, superannuation or mortgages, most of them experienced ‘permanent financial anxiety’ or poverty.

Because of better health outcomes, HIV agencies in the UK have moved away from providing services to PLHIV, and many people now find themselves quite isolated. Local councils offer outings for the elderly but those surveyed didn’t feel comfortable joining in with the ‘little old ladies’.

Those surveyed also found that the UK health system was increasingly pushing them into care from their local GP rather than from HIV specialists. More often than not, these GPs were not trained to pick up on HIV or ageing co-morbidities.

Powers cited training for aged care workers as crucial to avoid any replication of the AIDSophobia and homophobia that occurred with health care workers in the eighties.

Dr Stephen Karpick from ACRIA reinforced how important it is that HIV agencies cater for the social support needs of older PLHIV. He reminded us that many do not have families to rely on and need their friendship networks to survive. He also provided data showing that without regular contact with carers, adherence to treatment drops off and mental health deteriorates. Sometimes, he said, even a phone call once a week can ameliorate depression in this group.

BONES

In a session on the longterm complications of ART, Dr Paddy Mallon from Ireland said that there was evidence of lower bone mineral density (BMD) in about half the HIV positive people studied in cohorts to date.

Lower BMD leads to a greater risk of osteoporosis and osteopenia in HIV positive people and contributes to a higher prevalence of fractures occurring at an earlier age (50s and 60s), compared to the rest of the population where it usually only occurs from the 70s onwards.

Nearly all antiretroviral [4]A medication or other substance which is active against retroviruses such as HIV. regimens contribute to the bone loss experienced.

Dr Mallon said it was uncertain whether vitamin D supplements will help to solve the problem, although he acknowledged that they were beneficial to general health.

HEART

Another presentation in this session looked at our increased cardiovascular risk.

Dr George Behrens from Germany argued that while the DAD study showed cardiovascular disease only contributed to 10% of deaths, clinicians needed to look at risk factors in positive people at a younger age and, where possible, to change therapy to reduce the risk.

We now know that HIV infection itself contributes to systemic inflammation in the body and that some drugs contribute to this as well. Protease inhibitors such as indinavir and lopinavir add to the risk but the research is still unclear about the role of abacavir.

Diet modification to reduce lipids, giving up smoking and managing diabetes [5][Diabetes mellitus] A disorder in which sugars in the diet cannot be metabolised into energy due to a lack of the enzyme insulin. Late-onset diabetes mellitus may be a long-term side effect of some anti-HIV drugs. and blood pressure abnormalities are important interventions, he said.

BRAIN

On the sensitive subject of HIV in the brain, Dr Victor Balfour from the University of California, San Francisco (UCSF) claimed that cognitive impairment is the ‘silent epidemic’ of HIV. He cited some positive cohorts where 39% of those studied showed some impairment when commencing treatment.

The good news is that HIV-associated dementia is rare, affecting only one or two percent of the population. HIV-Associated Neurological Disorder (HAND) is more prevalent, with some people finding multi-tasking particularly difficult. For example, a job that might take someone with no cognitive problems eight hours to do, may take someone with HAND ten hours to achieve.

Stopping smoking, getting regular exercise, staying at work or getting involved with thinking tasks were all cited as practical ways we can improve brain function.

Contrary to some perceptions, there are things we can do.The PowerPoint presentations and excellent rapporteur summaries (well worth a read) are available at:www.pag.aids2010.org [6]

NUTRITION

I attended a workshop on nutrition and metabolic disorders run by Nelson Vergel, a long-term positive man from the US and author of the popular survival manual Built to Survive. People come to him, he said, for advice on two essential problems: losing weight and gaining it.

For those needing to gain it, the most essential thing to do is to get your viral load [7]A measurement of the quantity of HIV RNA in the blood. Viral load blood test results are expressed as the number of copies (of HIV) per milliliter of blood plasma. undetectable. Even then, gaining weight on treatment may well take time – on average only a 10% increase is seen per year.

He recommends supplements such as glutamine, juven (an oral amino acid formulation) and creatine which increases lean body mass. Some people benefit from testosterone and anabolic steroids and he also cited megestrol (Megace) as a useful appetite enhancer. For nausea he recommends the pure and simple ginger root.

All HIV drugs have some effect on cholesterol [8]An essential component of cell membranes and nerve fibre insulation, cholesterol is important for the metabolism and transport of fatty acids and the production of hormones and Vitamin D. Cholesterol is manufactured by the liver, and is also present in certain foods. High blood cholesterol levels have been linked to heart disease and may be a side effect of some anti-HIV medications. so diet is important for everyone. But it is particularly important for those who are experiencing weight gain.

Research shows that HIV positive people gain the greatest benefit from a low sugar/low carbohydrate [9]Any of a number of compounds, including sugars and starches, which are important as sources of energy. Along with fat and protein, one of the main constituents of food. diet. Soluble dietary fibre is important too — meaning more fruit, vegetables, greens and nuts.

Your main meal of the day should consist of half a plate of vegetables, a quarter of protein and a quarter of carbohydrates.

The Mediterranean diet also has a lot to recommend it as it helps improve bad cholesterol levels (LDL). LDL levels have also been shown to have a link to visceral obesity.

He holds out hope for tasamorelin (Egrifta), the new growth hormone which has yet to be approved in the US, for reducing visceral fat, particularly the ‘lipo [10]A metabolic disorder in which fat in the face, arms, legs and buttocks is lost and/or fatty deposits appear in the abdomen, breasts and neck. belly’.

Nelson Vergel was less sure about the role of vitamins. While a Thai study of HIV positive women showed a 50% reduction of deaths for people taking vitamins A, B12 and E, it was difficult to know the appropriate dose that works, he said.

A single multi-vitamin tablet once a day is probably sufficient for most people, he said.

David Menadue received a partial education grant from Tibotec to attend AIDS 2010.