NCD Complications in HIV Patients
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NCD Complications
in HIV PatientsEsteban Martinez
Hospital ClínicUniversity of Barcelona
BarcelonaSPAIN
[email protected] D.C., USA, 22-27 July 2012www.aids2012.org
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3000ACTIVE PATIENTS
New patients
Deaths
Data from Hospital Clinic, Barcelona
This means long-term exposure to ARTand higher risk for non-HIV-related conditions
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HIV infection has changed from a fatal disease into a chronic condition
www.aids2012.org
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Martinez et al. HIV Medicine 2007; 8: 251-258
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• Significant reduction in mortality for HIV-infected patients over this period (P<0.001; χ2 test for trend), but not for the general population (P<0.936; χ2 test for trend)
Annual incidence of mortality in the Hospital Clínic HIV-infected cohort compared with general population aged 16-65 years in Catalonia
HIV-infected cohort
General population
Mortality in HIV-infected adults is still higher than that in general population
www.aids2012.org
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Ruppik M, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 789.
Causes of death in participants from the Swiss HIV Cohort Study in 3 different time periods, and in the Swiss Population in 2007
Years of Death of HIV+ Persons Versus Swiss Population
AIDS-related deaths have decreased, but non-AIDS-related ones have increased
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Non-AIDS-related NCDs in HIV+patients are higher with older age
Hasse B et al. Clin Infect Dis 2011; 53: 1130-1139
Swiss HIV Cohort Study
www.aids2012.org
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The following co-morbidities were analysed: Hypertension, Type 2 Diabetes, Cardiovascular Disease and Osteoporosis.Co-morbidities prevalence was higher in cases than controls in all age strata (all p-values <0.001).
Comorbidities not only more common with increasing age but also occur earlier in HIV
Co-mobidities prevalence in cases and controls, stratified by age categories.
Guaraldi G et al. Clin Infect Dis 2011; 53: 1120-1126www.aids2012.org
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ARR 1.75
p <0.0001*
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18-34 35-44 45-54 55-64 65-74
Age Group (Years)
Triant V et al. J Clin Endocrinol Metab 2007; 92: 2506-2512
* Adjusted for age, gender, race, hypertension, diabetes and dyslipidaemia. Proportion of patients with hypertension, diabetes and dyslipidaemia significantly higher in HIV-positive vs HIV-negative cohort
n = 1,044,589
n = 3,851
# of MI 189 26,142E
vent
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HIV-infected patients have a higher incidence of myocardial infarction
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Brown TT & Qaqish RB. AIDS 2006; 20: 2165-2174
HIV+ patients have a higher prevalence of low bone mineral density
www.aids2012.org
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Triant VA et al. J Clin Endocrinol Metab 2008; 93: 3499–3504
Population-based study 8,525 HIV-infected patients2,208,792 non HIV-infected patients
HIV+
HIV-
p<0.0001
P<0.0001p<0.0001
p=0.001
Greater rate of fractures in HIV- infected patients vs un infected individuals
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Liver Disease Renal Disease
Goulet J. Clin Infect Dis 2007; 45: 1593-1601
Liver and kidney comorbidities more common in HIV+ patients
www.aids2012.org
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Heaton R et al. J Neurovirol 2011; 17: 3-16
Per
cent
impa
ired
Neurocognitive impairment remains highly prevalent despite of cART
Pre-cART
cART
HIV+
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Patel P et al. Ann Intern Med 2008; 148: 728-736
Cancer Type, Observed Rate per 100,000 Person-Years (95% CI)
ASD/HOPS(157,819
Person-Years)
SEER(334,802,121 Person-Years)
SRR* (95% CI)
Anal 51.4 (40.8-63.9) 1.5 (1.4-1.5) 42.9 (34.1-53.3)Vaginal 33.9 (18.0-57.9) 3.2 (3.2-3.3) 21.0 (11.2-35.9)Hodgkin’s lymphoma 51.4 (40.9-63.9) 3.3 (3.3-3.4) 14.7 (11.6-18.2)Liver 31.7 (23.5-41.8) 5.3 (5.2-5.4) 7.7 (5.7-10.1)Lung 88.8 (74.7-104.8) 67.5 (67.2-67.7) 3.3 (2.8-3.9)Melanoma 24.7 (17.6-33.8) 18.4 (18.3-18.6) 2.6 (1.9-3.6)Oropharyngeal 33.0 (24.6-43.3) 16.1 (16.0-16.2) 2.6 (1.9-3.4)Leukemia 15.2 (9.8-22.7) 12.2 (12.1-12.3) 2.5 (1.6-3.8)Colorectal 47.0 (36.9-59.0) 52.0 (51.7-52.2) 2.3 (1.8-2.9)Renal 14.0 (8.8-21.1) 13.0 (12.8-13.1) 1.8 (1.1-2.7)Prostate 32.7 (23.3-44.7) 173.5 (172.9-174.1) 0.6 (0.4-08)
ASD, Adult and Adolescent Spectrum of Disease Project; HOPS, HIV Outpatient Study; SEER, Surveillance, Epidemiology, and End Results, 1992–2003; *SRR, standardized rate ratio calculated as ASD/HOPS to SEER populations.
Non-AIDS–defining cancer rates higher in HIV+ patients vs general population
www.aids2012.org
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http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
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EACS guidelines
http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
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http://www.aahivm.org/hivandagingforumwww.aids2012.org
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Growing interest in learning about pathogenesis and care of comorbidities
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http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof
Most basic screening tools for NCDs are easily affordable
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Others may be not so easily affordable:DXA needed for measuring BMD
www.aids2012.org Washington D.C., USA, 22-27 July 2012
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http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
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http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
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% p
artic
ipan
ts
Comedications Comorbidities
N= 5761 2233 450 5761 2233 450
Hasse B et al. Clin Infect Dis 2011; 53: 1130-1139
The need of polypharmacy means higher risk for interactions and toxicities
Swiss HIV Cohort Study
www.aids2012.org
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Summary• The HIV infected population is ageing and NCDs are
becoming more prevalent as a cause of morbidity and mortality
• There is an increasing awareness for screening and management of NCDs in HIV+ patients and specific cost-effective guidelines have been issued
• Prevention and management for NCDs should be routinely included into the clinical care of HIV+ patients
• Issues of NCDs screening and management cost, overlapping toxicity of antiretrovirals, and risk of drug interactions will need to be continuously addressed
www.aids2012.org Washington D.C., USA, 22-27 July 2012
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Special thanks:• To my colleagues from the HIV Unit at Hospital Clínic,
Barcelona, and particularly to Jose Gatell
• Also to Pere Domingo, Omar Sued, Giovanni Guaraldi,
and Julian Falutz for their valuable input
• To Jordi Blanch, co-organiser of the annual HIV &
Neuropsychiatry Symposium in Barcelona
• and to all the contributors to the recent 2011 version of
European AIDS Clinical Society (EACS) guidelines
www.aids2012.org Washington D.C., USA, 22-27 July 2012