Antiretroviral therapy (ART) has resulted in longer lifespans for the 27.4 million people living with HIV (PLWH) globally who have access to it. But with those years gained comes a higher risk for age-related comorbid conditions and a higher “pill burden” than for people living without HIV (PLWoH). That reality reflects findings from data presented at the 2021 virtual IDWeek conference, held by the Infectious Diseases Society of America and other leading infectious disease organizations.
A poster session presented by Girish Prajapati, M.B.B.S., M.P.H., a director at Merck & Co., showed a cross-sectional comparison of people in the United States using Medicare—PLWH and PLWoH—and concluded that PLWH experienced more comorbidities, including kidney and liver disease, neuropsychiatric conditions, and COPD, partly because of exposure to HIV, and partly due to the antiretroviral treatment (ART) that has extended their lives.
The sample was taken from Medicare administrative data for PLWH and PLWoH for Part A, B, and D claims provided by the Centers for Medicare and Medicaid Services for the calendar year 2018. The PLWH group included 86,856 people with at least one HIV diagnosis code in medical claims and at least one pharmacy claim for an anchor antiretroviral drug—NNRTI, protease inhibitor (PI), or integrase inhibitor (INSTI)—during that year. These data were then compared to records from a random sample of 552,645 PLWoH on Medicare.
The data comparison showed that PLWH were slightly less likely to have three or more comorbidities: 70% of PLWH versus 71.7% of PLWoH. But that doesn’t tell the whole story. What’s striking is that the PLWH in the study were more likely to be younger—much younger—with a mean age of 57.4 versus 71 years of age for PLWoH. The data also showed that PLWH compared to PLWoH on Medicare were more likely to be men (75% vs. 42%), more likely to be Black (42% vs. 10%), and—probably the most important reason for the age disparity—eligible for Medicare due to disability (83% vs. 27%). The PLWH group was also more likely to receive low-income subsidies (77% vs. 31%).
What’s more, researchers found that the PLWH group had more neuropsychiatric conditions, chronic kidney disease, liver disease, COPD, hepatitis B, and hepatitis C. So it’s not surprising that the PLWH group had, on average, a higher polypharmacy, or “pill burden,” even beyond ART. The number of unique medications taken was 12.6 versus 9.4 (PLWH vs. PLWoH) for all drugs and 10.3 versus 9.4 for non-ART drugs.
The two groups tended to experience different ailments as well. The prevalence of mental health conditions, substance use, kidney disease, liver disease, and lung disease were higher among PLWH. However, PLWH had lower rates of autoimmune conditions, cardiovascular and cerebrovascular disease, hypertension, hyperlipidemia, diabetes, and osteoporosis than PLWoH.
Prajapati concluded that, for the Medicare fee-for-service population, clinicians need to “consider comorbidities and comedications in HIV management, including ARV regimens, to minimize medication burden and drug interactions,” he said, “which might improve clinical outcomes.”
Living Longer but Taking More Medications
In a related abstract presented at IDWeek 2021, Princy Kumar, M.D., chief of the division of infectious diseases and travel medicine at MedStar Georgetown University Hospital, shared data showing that multimorbidity and polypharmacy, already common in PLWH, have increased steadily over the past five years.
Using the Optum Research Database, researchers conducted a retrospective analysis of commercial and Medicare Advantage users aged 18 years and over for each calendar year from 2014 to 2018. All were PLWH who had at least one pharmacy claim for ART or medical claim with an HIV/AIDS diagnosis, plus continuous health plan enrollment for 12 months.
Some trends stood out: First, PLWH are living longer—an increase in mean age from 48.9 to 52.4 years—and the proportion of women was growing, from 17.2% to 20.3%. The percentage of Black PLWH increased as well, from 26% to 29%. What’s concerning is that multimorbidities, defined as greater than two non-HIV conditions, and polypharmacy, defined as greater than five non-ART medications, increased significantly over the five-year period. There was also a statistically significant increase of hypertension, hyperlipidemia, neuropsychiatric conditions, and type 2 diabetes over those five years.
Kumar bottom-lined the research, urging clinicians to consider “the comorbidity profile in HIV management, including selection of appropriate ART” to prevent adverse drug interactions and improve patients’ overall health outcomes.
Recent Centers for Disease Control and Prevention (CDC) data show that nearly half of the population with an HIV infection diagnosis in the United States are at least 50 years old. These two IDWeek presentations add to a growing body of research illustrating what it’s like to age with HIV. Now, in a time of ART, life expectancy for PLWH still falls short of that of PLWoH.
The perhaps more optimistic news is that PLWH are likely to die from age-related causes not related to HIV/AIDS, including cardiovascular, kidney, liver, and bone diseases; cancer; and Alzheimer’s disease. The more grim news is that the years gained from ART come with the cost of getting age-related illnesses earlier than their PLWoH peers, whether due to chronic immune activation from long-term HIV infection, long-term use of virus-suppressing ART, or—as more studies are indicating—both.