Living With HIV -- and Everything Else
Many studies have shown a reduction of bone mineral density (BMD) in people with HIV. This can result from continuous use of HIV meds in addition to HIV itself, plus other risk factors such as older age, smoking, alcohol use, steroids, low vitamin D levels, low estrogen in women, and low testosterone in men. Low BMD may be linked to an increased risk of bone fractures. While some studies found no difference between HIV meds, other studies have shown some HIV meds can cause BMD loss. Researchers don't fully understand why. Of the meds that contributed to the loss of BMD, the greatest loss occurred during the first two years of treatment. After this period of time there may be a partial to full rebound in BMD. Treatment for individuals should be based on their risk factors.
Most people will benefit from calcium supplements. The type of calcium supplement, however, depends on the medications they are taking. Weight-bearing exercise has also been effective in preventing BMD loss. Most younger people with low BMD will not require treatment, and the need for bone-protective therapy should be guided by the risk of developing a bone fracture. Vitamin D levels should be measured in people with an increased risk of fractures, and vitamin D supplements should be taken by those with low vitamin D.
Vitamin D replacement has become an important topic in the past few years, since studies have shown a direct relationship between HIV and vitamin D deficiency. Vitamin D is essential for bone health, calcium balance, and immune function. It is found in fish, milk, and cereal, but most of the vitamin D we have comes from sunlight. Deficiency can occur due to disease (in particular HIV and kidney disease), HIV meds, poor diet, or a lack of sun exposure. Screening for vitamin D has become a routine part of HIV practice. Supplements can be prescribed, or over-the-counter products can be used. The strength and frequency of vitamin D supplementation will vary depending on the level of deficiency present.
People with HIV have an increased risk of heart disease and stroke. This is especially true if they also have other conditions like high blood pressure or diabetes. And the risk increases even more in individuals who smoke, are not physically active, are overweight, or male. Some studies have shown a 20% increase of death due to cardiovascular disease in people with HIV.
Treatments vary -- ideally, lifestyle changes such as healthy diet, quitting smoking, and starting an exercise program should be a first approach. These alone can significantly help in reducing the risk of heart disease or stroke. They may even reduce the amount of meds needed to treat other medical conditions. In certain cases, a mix of lifestyle changes and meds may still be needed. Certain meds can increase cholesterol, so switching to another medication may help.
People with HIV require six to 25 times the recommended daily allowance of certain vitamins and minerals. Thus a multivitamin is often required, either over the counter or by prescription. It's important to check with a health care provider before starting any supplements.
High Blood Pressure
The normal thickening of fibers in the blood vessels that occurs with aging may lead to higher systolic blood pressure (the top number). The target is to have the top number about 130 and the bottom about 70. The level should not be too low in older adults, however, since that can lead to other complications. Although high blood pressure in people with HIV is most likely due to other factors that can be modified -- such as obesity, high salt intake, and physical inactivity -- medication is recommended for persistent high blood pressure in order to reduce the risk of heart disease. It should be possible to find a regimen that is easy to take with other medications, since these drugs are often taken once a day.
The frequency of diabetes has been reported to be about four times higher in people with HIV. It is usually Type 2, which is associated with aging and obesity, but it can be made worse by certain HIV medications, such as protease inhibitors. Screening for diabetes through blood tests should be done regularly. It is now possible to have this done reliably without fasting through a test called "glycosolated hemoglobin". If diabetes is diagnosed, many times high blood sugar can be controlled with weight reduction and dietary changes, or modification of HIV medications. But if necessary, there are a variety of treatments for diabetes that can be used successfully. The target glycosolated hemoglobin level should be set higher in older persons to avoid the possibility of complications from the blood sugar getting too low.
As we age, our kidneys usually continue to clear waste products from the body effectively. But high blood pressure, diabetes, streptococcus infection, or other factors can cause kidney damage. HIV has been associated with a specific type of kidney disorder called HIV nephropathy, which is more common in African-Americans.
People with HIV should have creatinine, glomerular filtration rate, kidney function, and urinary protein checked annually. If kidney function is compromised, it may be necessary to adjust drug dosages to avoid an overdose. Sometimes the kidneys can be so damaged that they begin to fail, requiring dialysis (regular cleansing of body wastes with a machine). A kidney transplant can be done as a last resort, and has been successfully done in persons with HIV.
Comorbidities in Older Adults
On World AIDS Day 2011, the American Academy of HIV Medicine, the American Geriatrics Society, and ACRIA released a report entitled The HIV and Aging Consensus Project: Recommended Treatment Strategies for Clinicians Managing Older Patients with HIV. It presents the findings of an expert panel of leaders in HIV care and research as well as clinical and research experts in geriatrics.
Having several illnesses at the same time usually occurs only among people in their late 70s and older. But it is now happening in people with HIV who are younger than 65 (on average, 55 years old). We can only speculate that HIV itself, HIV treatment, the aging process, or behaviors that are seen commonly in those with HIV may contribute to the problem.
If providers use disease-specific guidelines for people with multiple conditions, the treatment plan can become quite complex and involve a large number of medications with a demanding dosing pattern. Issues of adherence and drug interactions become serious concerns. Add mental health conditions, cognitive impairment, substance use, and limited health literacy, and consistently following such a complex regimen becomes a challenge.
Treating HIV will bring up different concerns for different people. This is why good communication with a health care provider is so important. With proper counseling, education, lifestyle changes, or supplements, many of these concerns are manageable and the overall quality of life can be improved.
Michael Modzelewski is a pharmacist with MOMS Pharmacy of NYC. Richard Havlik is a medical epidemiologist, formerly with the National Institute on Aging.
This article was provided by ACRIA and GMHC. It is a part of the publication Achieve. Visit ACRIA's website and GMHC's website to find out more about their activities, publications and services.
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