For healthcare practitioners working in the field of HIV, the past three decades have been a rollercoaster, says Dr. Julio Montaner, head of UBC’s Division of AIDS and director of the BC Centre for Excellence in HIV/AIDS (BC-CfE). Once a death sentence, HIV is now regarded as a chronic, manageable condition. So much so that on Dec. 1, World AIDS Day, the B.C.-CfE will unveil Healthy Aging With HIV, an initiative to better understand how to maximize the longevity of people living with HIV.
What is the life expectancy for someone who is diagnosed as HIV-positive today?
Over the last decade and a half, life expectancy has increased every three to four years. In the last 12 years we’ve gone from 30 years of additional life expectancy to 40 years, to 50 years. A 20-year-old diagnosed today with recently acquired HIV infection, who immediately starts antiretroviral therapy, will see a life expectancy of another 50 years of near-normal quality.
A natural result of the success of the highly active antiretroviral therapy strategy is that people infected with HIV are aging. It used to be that our patients were young, because the epidemic suddenly affected a number of people in the prime of their sexual life. Now that group is aging. As of this year, it’s estimated that 50 per cent of people with HIV in Canada are over the age of 50.
Do people living with HIV have additional health concerns as they age?
We have seen a dramatic decrease in people progressing to AIDS and dying from AIDS-related conditions. But on the other hand, we have seen an increase in non-AIDS-related illness and mortality: mainly liver disease, often due to hepatitis C infection, cardiac disease, renal disease, chronic obstructive pulmonary disease and arthrosclerosis. There is some indication that HIV itself may affect biological aging. As we all age, the protective ends of our chromosomes—telomeres—shorten. Our team has found early or premature emphysema among HIV-infected people is strongly associated with early shortening of telomeres.
Another factor may be the medications that we use to treat HIV. While modern regimens are quite safe, earlier treatments did have significant potential for the development of diabetes, renal dysfunction and osteoporosis. Exposure to those early life-saving drugs may have promoted accelerated aging that we unfortunately may not be able to turn around.
It’s also important to note that often the same underlying risk factors that facilitate the acquisition of HIV go hand-in-hand with risk factors for other conditions. For example, injection drug users have higher risk of Hepatitis C and people who have multiple sex partners are more likely to use recreational drugs, alcohol and to smoke. Thus, lifestyle modification plays an important role in the management of HIV infection today.
Is society ready to support them?
I think I need to be clear that the stigma, discrimination and the issues associated with an HIV diagnosis have improved over the last three decades, but they are still present. That’s illustrated by what happened to Charlie Sheen. For a number of years he was trying to conceal his HIV diagnosis and paid tons of money to do so, because he feared that if his HIV diagnosis was revealed it would totally change his ability to work and relate to others.
Think about a loved one with HIV going into a seniors’ home. I think it’s going to take some effort to ensure that society embraces seniors with HIV just as they embrace seniors with hypertension. And frankly, it’s a lot easier to look after somebody with HIV who has been undetectable for 30, 40 years than it is to take care of somebody with Alzheimer’s. Of course, there will be people with HIV who also have Alzheimer’s. HIV adds a level of complexity, but it’s totally doable. I think that the bigger issue is how we address stigma and discrimination in the context of HIV.
Do people living with HIV face greater socioeconomic challenges as they age?
I remember vividly in 1996, with the breakthrough of HAART (highly active antiretroviral therapy) treatment, that when we began telling people, “You’re not going to die from AIDS,” oftentimes the news was received with mixed emotions. It was: “You told me I was going to die! What do you mean? I have no future, nowhere to go, I stopped paying taxes, I stopped contributing to my pension.” People from those early days had to readjust and go back into the workforce and it became very complicated.
But in the last decade, we quite readily tell people, “You have HIV, it’s no different than hypertension, diabetes or asthma. We’re going to manage this with you. You’re going to be fine, your children are going to be fine, you’re going to have a virtually normal life. Go to school, get qualified, work, contribute to your pension, pay your taxes.” Today, we view it as a chronic manageable condition.