La Dra. Caroline A. Sabin, del University College de Londres, también intervendrá en la sesión inaugural del XI Congreso Nacional de GeSIDA para hablar sobre mitos en torno al envejecimiento y el VIH. De ello nos habla, entre otros temas, en esta entrevista.
The title of your paper awakes our curiosity when talking about dispelling myths of aging and HIV. What can you advance of your intervention in our congress?
The last decade has seen huge improvements in our ability to treat people living with HIV. As a result, people with HIV are no longer dying from traditional AIDS-related events but are instead living to a similar age as their HIV-uninfected counterparts. Because of this, some people with HIV are starting to experience the same age-related conditions (e.g. heart disease, cancers) that we would expect to see in a similarly-aged population of people without HIV.
There is some concern that these age-related conditions may occur more frequently, or at a younger age, in people with HIV. However, in my presentation I will show that the evidence that is provided to support these concerns may be flawed with studies being inappropriately analysed. As in the general population, lifestyle factors, such as smoking, recreational drug use and lack of exercise, may also contribute to a higher risk of some of these conditions. I propose that an increased focus on the prevention and management of these lifestyle risk factors could have a greater impact on the health of people with HIV than further modifications or additions to antiretroviral therapy.
Will the approach to comorbidities and the problem related to aging be, from now on to the next decades, one of the main areas of work around HIV?
Yes, I believe that this will be the case. Current antiretroviral therapies are extremely effective for the majority of people living with HIV, and are simple to take with relatively few toxicities. Although there are still improvements which can still be made – for example, longer-acting treatments would be beneficial to many people – I believe that we should be focussing now on trying to identify the underlying causes of some of these non-HIV conditions and to develop prevention tools that may reduce their incidence. Although many of these conditions may be occurring at a similar frequency to what we would expect (because of the lifestyles of this population) they are still a major cause of morbidity and mortality, and so a greater awareness of the potential role of lifestyle-related factors on the risk of these conditions, would be helpful.
Multi-morbidity is a very topical concept, both in people with HIV as well as in the general population. We know that some of these conditions tend to cluster together and if we can identify shared risk factors, then this may help us to understand why these conditions are occurring, allowing us to develop more effective prevention tools and to establish appropriate care pathways.
Finally, our studies tend to include people who have been living with HIV, and who have been successfully treated with antiretroviral therapy, for a long period of time. One of the things that we still don’t know is whether the outcomes that we see in this group of individuals are the same as those that we will see in people who have only recently been diagnosed with HIV at an older age, but who start treatment soon after diagnosis. This is something that we must monitor in the coming years.
What will the future hold due to a greater life expectancy of people with HIV?
As people with HIV survive to older age they will undoubtedly start to experience these age-related conditions. Whilst unfortunate, this is an indication of the success of our current HIV treatment strategies. However, most healthcare systems are not adequately set up for an ageing population of people with HIV, and we therefore need to think carefully about how healthcare systems are developed and the resources that are provided for this.
In many settings, there is still a lack of clarity about who is responsible for managing some of these age-related conditions – should it be the general practitioner, who is used to dealing with these age-related conditions or should it be the HIV physician who may be more aware of potential interactions with HIV and/or it’s treatment? So, we need clearly defined healthcare pathways for people with HIV to ensure that when an age-related condition is identified, the person is then able to rapidly access appropriate care and support.
Your work is relevant in the field of statistics associated with the study of HIV. What value do cohorts have to know HIV better? Are recognized the value and utility they have?
Whilst randomised trials are the best approach for measuring the effectiveness of new treatments and/or interventions, people recruited into randomised trials are often highly selected and may not represent the wider population of people living with HIV. Cohorts are an extremely powerful tool that we can use to tell us what is happening to this wider population and allow us to identify trends in health outcomes that may not be seen in trials because of their limited follow-up time. Over the past 30 years, cohort studies have told us a huge amount about HIV infection, how the health of people with HIV can be monitored, and how life expectancy of people with HIV has changed. Cohorts are now able to tell us about these non-HIV outcomes, such as age-related conditions, and how they cluster together.
However, cohorts are not without their limitations, and they must be analysed and interpreted with caution if we are to correctly interpret the huge amount of data they provide.
Given your experience in handling statistical data in this area, wat trend do you predict that HIV infection will follow in the coming future? And on a global scale?
We are entering a new era of HIV prevention, with the increasing availability of pre-exposure prophylaxis (PrEP) and the knowledge that a person with an undetectable HIV viral load cannot transmit HIV to their partners (U=U). As a result, I expect that the demographic patterns of new HIV infections will change, with a reduction in new infections in the group traditionally at greatest risk of HIV, men who have sex with men, but perhaps little change in the rate of new infections in other groups at risk of HIV. Many of these continue to be under-served groups who may find it difficult to access healthcare and our traditional prevention tools may be inappropriate. Thus we need to think carefully about public health interventions to ensure that all people with HIV are able to live long and healthy lives.
Globally, we are already seeing a huge increase in non-communicable diseases in the general population in many low- and middle-income settings where these events were previously rare. In these countries, HIV, even when effectively treated, will place a huge additional burden on healthcare resources. Thus, we must continue to undertake research to identify healthcare models which can be applied in low- and middle-income settings, to ensure that all people are able to benefit from optimal healthcare.