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Dec 18, 2014

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  • 1. HIV, Comorbidity and Aging:Time for a New Paradigm
    Amy Justice, MD, PhD
    International AIDS Meeting Satellite
    July 19, 2010

2. People with HIV are Living Longer
Deaths/1000 PY
Denmark: Ann Intern Med 2007:146:87-95 New York IDU: CID 2005:41:864-72Barcelona: HIV Medicine 2007;8:251-8
3. AIDS Events Are Decreased on cART
ART-CC Arch Intern Med 2005 165:416-423
4. Optimally Treated HIV Disease May Not Restore Full Life Expectancy
Risk-adjusted HIV negative
Mean age seroconversion of 33 years
Optimal care HIV postive
Losina et al CID 2009
5. Non AIDS Deaths More Common
6. Is This the Price of Success?
No surprise that older people have an increased risk of mortality
Younger people may now be living long to die from other causes
Or, is something more subtle going on?
7. More AIDS and Non-AIDS Events Among Rx. Sparing Arm (HR 1.7 in SMART)
Strategies for Management of Antiretrivoral Therapy NEJM 2006;355:2283-96
8. We need to adopt our research priorities to better understand the full role of HIV in causing a wide range of clinical diseases. Clinicians caring for patients with HIV need to become aware of the best means to try to prevent and to monitor for early signs of these [non-AIDS] outcomes.--SMART Investigators
AIDS 2008, 22:2409-2418
9. Short List of Aging Conditions Associated with HIV*
Lung diseases (COPD, pulm. hypertension, cancer)
Liver diseases (fibrosis/cirrhosis and cancer)
Renal diseases (insufficiency, failure)
Vascular diseases (MI, stroke)
Hematologic diseases (anemia, thrombocytopenia)
Neurological diseases (dementia, neuropathy)
Bone diseases (osteoporosis, avascular necrosis)
*See publications from, DAD, Kaiser, Pilgrim Health, SMART, VACS, etc.
10. Aging, HIV Infection and Outcomes
Justice AC.HIV and Aging: Time for a New Paradigm.Curr HIV/AIDS Rep. 2010 May;7(2):69-76
11. Major General Observations
HIV increases risk of many non AIDS conditions
HIV risk is modest compared to established risk factors, but increases over time
Care guidelines for non-AIDS condition may require adaptation for those with HIV
Some conditions may justify earlier ARV treatment
Selected ARV treatments likely cause some conditions, but effects are often less than those of HIV itself
12. How Do We Study Comorbidity and Aging in HIV?
Many questions cant be addressed in RCTs (Sample size, Interval of observation, Ethics)
Need large observational studies with demographically similar controls
Health systems with electronic records
Cross cohort collaborations (ART-CC, IeDEA)
13. The VA is Ahead of the Curve
Internal VA Data
14. What is the Veterans Aging Cohort Study?
Two nested Veteran cohorts, funded by the NIH
15. Virtual Cohort (VC)
CURRENT DATA SOURCES:National administrative, laboratory, pharmacy, cancer registry,MI quality of care, and all cause mortality (requesting Medicare)
SUBJECTS:41,753HIV infected; 83,506 uninfected
All individuals with HIV diagnoses
Age, race/ethnicity, region 2:1 matched controls
Last updated:September, 2008
SITES:All VA sites
BASELINE: 1998 (11 years of follow up)
HIV infected veterans at initiation of HIV care
Controls selected and followed in same calendar year
16. VACS 8

  • CURRENT DATA SOURCES (VC sources plus)

17. Consented for all clinical data 18. Records for sentinel events requested outside VA 19. All VA Electronic medical records including text fields 20. DNA and tissue bank 21. Annual self completed surveys 22. SUBJECTS: 3,600 HIV infected; 3,600 uninfected 23. Group matched: age, race/ethnicity, and site 24. SITES:Manhattan, Bronx, Washington DC, Baltimore, Pittsburgh, Atlanta, Houston, Los Angeles 25. BASELINE: 2002 (8 years)