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NCD Complications
in HIV Patients
Esteban MartinezHospital Clínic
University of BarcelonaBarcelona
SPAIN
esteban@fundsoriano.es
Washington D.C., USA, 22-27 July 2012www.aids2012.org
0
10
20
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40
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60
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80
84 86 88 90 92 94 96 98 00 020
500
1000
1500
2000
2500
3000
ACTIVE PATIENTS
New patients
Deaths
Data from Hospital Clinic, Barcelona
This means long-term exposure to ARTand higher risk for non-HIV-related conditions
Mo
rtal
ity
per
100
pat
ien
t-ye
ars
Nu
mb
er of p
atients
HIV infection has changed from a fatal disease into a chronic condition
www.aids2012.org
Martinez et al. HIV Medicine 2007; 8: 251-258
Mo
rtal
ity
per
100
per
son
-yea
rs
• 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
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
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
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
ARR 1.75
p <0.0001*
0
2
4
6
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10
12
HIV+ HIV-
Eve
nts
Per
100
0 P
Ys
B
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100
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
s P
er 1
000
PY
s
HIV-infected patients have a higher incidence of myocardial infarction
Brown TT & Qaqish RB. AIDS 2006; 20: 2165-2174
HIV+ patients have a higher prevalence of low bone mineral density
www.aids2012.org
0
0.5
1
1.5
2
2.5
3
3.5
All Vertebral Hip Wrist
Fra
ctur
e p
reva
lenc
e/10
0 pe
rson
s
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
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
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+
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
http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
EACS guidelines
http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
http://www.aahivm.org/hivandagingforumwww.aids2012.org
Growing interest in learning about pathogenesis and care of comorbidities
http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof
Most basic screening tools for NCDs are easily affordable
Others may be not so easily affordable:DXA needed for measuring BMD
www.aids2012.org Washington D.C., USA, 22-27 July 2012
http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
http://www.europeanaidsclinicalsociety.org/guidelinespdf/2_Non_Infectious_Co_Morbidities_in_HIV.pdf
% 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
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
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
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