The Role of Aging in HIV-Related Hospitalizations and Complications

While many in the field of infectious disease research and medicine have noted the decline in new investigators and practitioners entering the workforce, the HIV Medicine Association and the Infectious Disease Society of America Foundation have teamed up to do something about it. Over the summer, they announced a program to fund 15 medical students in the U.S. for clinical learning and research projects, each to be paired with an experienced mentor to support the student's research area of interest.

This is the first in a series of interviews with a mentor/mentee pair. We spoke with David Riedel, M.D., associate professor at the Institute of Human Virology and University of Maryland School of Medicine, and his mentee, Shruti Gujaran, a second-year medical student at the University of Maryland School of Medicine with interests in rural and urban infectious disease health care management, as well as local and global women's health.

Jeanine Barone: Why were you specifically interested in mentoring Shruti on aging among patients with HIV?

David Riedel, M.D.: When I reviewed with her HIV-related "aging" hypotheses and my work on HIV and cancer, her eyes just lit up! She seemed to grasp the concepts intuitively and immediately went off to read more about the field. I feel that strong mentorship during this project will be an excellent way for Shruti to continue her engagement in HIV throughout her medical school years and will increase the likelihood that she continues on a career path that includes HIV care and treatment research.

JB: Can you discuss what you are seeing in your clinical practice with regard to chronic non-HIV/AIDS-related diseases among older patients with HIV?

DR: Over the last decade, I have seen a dramatic shift in the age of many of my patients. Many people living with HIV are now older than 50 years old. Additionally, they are often being affected by aging-related complications and comorbidities like cancer, bone disease, cardiovascular disease, and frailty that normally affect people much older.

JB: Does HIV acquisition itself lead to increased consequences among older patients of, for example, hypertension or hyperlipidemia?

DR: HIV appears to accelerate the aging process, but it is unclear if it is an accelerated aging process or premature aging. Patients living with HIV tend to have a higher risk for these other conditions, and these conditions are tending to occur at earlier ages. Most guidelines for screening (e.g., for cancer) do not account for this early aging process in patients living with HIV, and it is unclear exactly how often or when we should start screening for these comorbid conditions. The implications are whether we should be screening at much earlier ages for these conditions, and then, when they do occur, co-management of these other conditions with other specialists and additional medications significantly complicates patients' lives.

JB: Among older HIV patients, do you believe there needs to be additional or more aggressive preventive or management strategies?

DR: Yes, the clinical and research communities need to do much more to address the premature aging process in our population. Trials to look at more aggressive preventive, screening, and management strategies are all warranted given the high prevalence of these conditions.

Cancer is a particularly important one, as it has become one of the most common causes of morbidity and mortality in the HIV population. Yet, patients living with HIV have always been excluded from cancer treatment trials. And so, we do not always know what is the best cancer treatment regimen for patients living with HIV, as it may be different from that of HIV-negative patients. We also don't know the true impact of combining cancer treatments (for example, chemotherapy) with antiretrovirals, which is unfortunate so many years into the epidemic. It has also been shown that patients living with HIV [and] diagnosed with cancer are often not treated with the guideline-driven cancer treatments as often as their HIV-negative counterparts with cancer.

JB: Is the topic of aging in this population and the effects on disease states a neglected area of concern/research?

DR: Yes, as was noted at the IAC conference this week, there was a lack of emphasis on aging during the opening talks. Aging is neglected because it is not a very exciting topic like [pre-exposure prophylaxis] (PrEP), or 90-90-90, or other catchy new foci of the international establishment. Geriatricians, in general, are underpaid and hard to find, yet they are vital practitioners with the aging of the general population. It is not a topic that anyone is talking much about. I suspect the same is true for the HIV population.

JB: [Shruti,] I know you are interested in infectious diseases. But, as a medical student, why specifically are you interested in this topic of how aging among patients with HIV is implicated in complications and hospitalizations?

Shruti Gujaran: Becoming involved with the Jacques Initiative (JI), an organization that facilitates greater access to HIV and [hepatitis C] (HCV) care through a variety of avenues has been the highlight of my time in medical school. As a community-based outreach volunteer, I have had the chance to interact with a diverse group of people and learn more about Baltimore's community. At each session, a partner and I talk to local community members, answering questions about HIV or HCV, or administering free tests to those that request one.

Throughout the year in medical school, we were also learning about the changes the body experiences as it ages, which also fascinated me. With Dr. Riedel's guidance, we were able to design a project that incorporated the aging [HIV positive] population. By continuing the conversation on the impact of age on people living with HIV, I hope that we can help shape what chronic disease management looks like in universities like Maryland by offering a more in-depth reservoir of information for health care professionals.

JB: Have you discussed with your peers [in medical school] your interest in this topic of the effect aging may have on hospitalization and complications in those with HIV, and what were their reactions?

SG: Absolutely. Aging is a significant topic throughout medical education. For each system we study, we are also exposed to how that system is affected over the decades. When I talk about my project with my classmates, many of them are interested in how it could affect longitudinal health care access and what that would mean for other populations with chronic diseases. People are often interested because learning about long-term effects of HIV on the aging body isn't something we're exposed to often, and many people don't know much about the field of HIV research outside what we learn in class.

JB: How do you think we can get more young people interested in working with HIV populations, either from a clinical or research science perspective?

SG: I feel that HIV research may not be getting as much attention currently in media or culture as it once did. As a result, exposure to current narratives is limited and not many people know how the field of HIV research and management has changed over the last few decades. I think when practicing physicians like Dr. Riedel show passion in their work, it inspires students to follow in their footsteps. Hearing lectures and seminars from prominent physicians from the [Institute of Human Virology at the University of Maryland] has been an opportunity that has shaped my future. When physicians are active with their student body on campus or via social media, I feel that this type of exposure is what could be most effective in inspiring future students to research HIV and its associated topics.

This transcript has been lightly edited for clarity.

Jeanine Barone is a scientist and journalist with an eclectic background. She's a nutritionist and exercise physiologist who regularly writes about travel, health, fitness, and food for numerous top-tier publications. Jeanine enjoys active travel, especially long-distance cycling and cross-country skiing.