From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA. Inflammation and Its Role in HIV Pathogenesis and Aging Sara Gianella-Weibel, MD Assistant Professor of Medicine University of California San Diego San Diego, California Slide 2 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA. Financial Relationships With Commercial Entities Dr Gianella Weibel has no relevant financial affiliations to disclose. (Updated 11/18/19) Slide 3 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA. Learning Objectives Upon completion of this webinar, learners will be able to: • Describe the changing face of the HIV epidemic • Describe the complexity of older adults with HIV • List factors that contribute to unsuccessful aging • List the main factors associated with inflammation • Describe how to best care for aging PWH
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From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Inflammation and Its Role in HIV Pathogenesis and Aging
Sara Gianella-Weibel, MDAssistant Professor of Medicine
University of California San Diego
San Diego, California
Slide 2 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Financial Relationships With Commercial Entities
Dr Gianella Weibel has no relevant financial affiliations to
disclose. (Updated 11/18/19)
Slide 3 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Learning Objectives
Upon completion of this webinar, learners will be able to:
• Describe the changing face of the HIV epidemic
• Describe the complexity of older adults with HIV
• List factors that contribute to unsuccessful aging
• List the main factors associated with inflammation
• Describe how to best care for aging PWH
Slide 4 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Describe the Changing Face of the
HIV Epidemic
Slide 5 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
“We just felt it was time that people saw the truth about AIDS” Kay Kirby
Photography by Therese Frare, 1990, no copyright infringement is intended
Slide 6 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Background
The development of antiretroviral therapy (ART) for the treatment of HIV is one of the greatest
achievements of modern medicine.
Slide 7 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Slide 10 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Projected Age Distribution of PWH
Smit, Lancet ID, 2015
Slide 11 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Describe the Complexity of Older Adults with HIV
Slide 12 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Multi-Morbidity is Increasing
Smit, Lancet ID, 2015
70-80% people aging with HIV (50 years and older) have at least one co-morbidity other than HIV
Slide 13 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Farahani, International Journal of STD & AIDS, 2016
Non-AIDS
infection
16.3%
Non-AIDS Causes of Death (2005-2015)
Slide 14 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Accelerated Aging in PWH
Pathai et al, J of Gerontology 2013
Slide 15 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Greene JAIDS 2015
Includes Geriatric Syndromes
Slide 16 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Contributes to Disability
Johs CID 2017
• HAILO (observational study of ACTG A5322) evaluated 1015 participants with median age 51 years
• At least 1 IADL impairment was reported in 18%
Slide 17 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
… And Medical Cost
Zingmond Plos One 2017
• Study examining Medicare expenditures for 9767 PWH aged 40+ in California in 2010• 89.3% male, 56.9% white, 52.4% were >50 years• Average cost $47,036 for Californian with HIV and medications account of 2/3 of that cost
Slide 18 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
List Factors that Contribute to Unsuccessful Aging
Slide 19 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
Possible Reasons for “Unsuccessful
Aging” among PWH
Adapted from Deeks and Phillips, BMJ, 2009
Genetics andLifestyle
ARTToxicity
PersistentInflammation
UnsuccessfulAging
Slide 20 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
SMART Study: Interrupting ART
Increases the Risk of Heart Disease
% w
ith
a M
ajo
r C
VD
Even
t
DC VS
Death from CVD 7 4
Non-fatal clinical MI 12 12
Non-fatal silent MI 11 5
Non-fatal stroke 8 3
CAD requiring surgery
for invasive procedure22 14
All major CVD events 48 31
El-Sadr, NEJM, 2006
2752 1306 713 379 10
2720 1292 696 377 10
No. at
Risk
0.5 1.5 2.5 3.50 1 2 3 40
Years from Randomization
5
10
2.5
7.5
Intermittent ART
Continuous ART
Slide 21 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.
T Cell Activation Declines with ART
Hunt et al, JID, 2003; PLoS One, 2011
Slide 22 of 43 From S Gianella Weibel, MD at New Orleans, LA, December 4-7, 2019, Ryan White HIV/AIDS Program CLINICAL CONFERENCE, IASUSA.