About one-quarter of the estimated 1.2 million people living with HIV infection in the U.S. are 55 or older, according to the Centers for Disease Control and Prevention. But while people with HIV are living longer and healthier lives thanks to improvements in the effectiveness of antiretroviral therapy, the complications associated with long-term HIV infection remain unknown.
In observance of National HIV/AIDS and Aging Awareness Day on September 18, amfAR spoke to Dr. Kenneth Mayer, a professor of medicine at Harvard Medical School, co-chair and medical research director at The Fenway Institute, and a member of amfAR’s Program Advisory Council.
amfAR: While a growing number of new infections are among people over age 50, the overwhelming majority of people in that age group with HIV are long-term survivors. What are the key issues facing this group?
Dr. Mayer: Many of the people who have been living with HIV for 20 or 30 years either started treatment relatively late because the guidelines back then suggested delaying treatment until immune decline was evident, and/or they started treatment with medicines that had more toxicities. So we don’t know what the long-term effects of the earlier treatment paradigm are. Also, because we have limited experience with people living with HIV for more than three decades, we don’t know what the effect is of even the subtle immune deficiency that somebody might have who begins treatment early.
There are several prospective studies that suggest that people living with HIV for long periods of time may be at increased risk for atherosclerosis, and various cancers, particularly those that are partially mediated by other viruses such as Epstein-Barr or human papillomavirus. But the big question is to what extent those factors, those risks, are due to HIV itself versus the effects of some of the medications, or the aging process interacting with both of those factors, as well as lifestyle issues.
Dr. Kenneth MayeramfAR: Where is the research lacking when it comes to older Americans living with HIV? What don’t we know? And what do we need to do to find out?
Dr. Mayer: The real operative question is what can we do to best promote the health of people living with HIV for long periods of time? So that question has several sub-questions. What’s the best treatment regimen for a person to be on? Will we see less morbidity as we use the integrase strand transfer inhibitors (a class of antiretroviral drugs)? And then the other is, to what extent are lifestyle factors either primarily responsible for and/or exacerbating the accelerated aging that we see in some people living with HIV. And there is certainly some suggestion that some of the things that people have control over (not smoking, being vaccinated against Hepatitis B, and early treatment for Hepatitis C) may have an impact on their lifespan.
amfAR: You have been taking care of people living with HIV since the beginning of the epidemic. Where have you seen the most dramatic improvements or changes in terms of treatment, prevention, and care?
Dr. Mayer: In terms of treatment, I think the proof that HAART (highly active antiretroviral therapy) worked in 1995−96 was a revolution. Because prior to that, you used to put someone on a regimen that had lots of side effects and they might get an improvement for months and then they would start getting sick again and then we would hope that we could find something else to keep them going. The viral load tests were also a major step because prior to that it was really sort of shooting from the hip in terms of determining whether you thought something was working or not. T helper (CD4) counts did not change in response to treatment in a precise way. Clinicians might not know that a treatment was failing until someone got really sick. With viral load tests, clinicians could change regimens before people started getting sick again.
The second wave of the revolution in treatment was between five and 10 years later, as some of the generic manufacturers started co-formulating the medicines and then the originator pharma companies started realizing maybe we should be making these medicines easier for people to take. So we now have five starting regimens that are one pill once a day. The biggest revolution in prevention has been PrEP (pre-exposure prophylaxis). Certainly we know that if individuals take it, if they are adherent, they can protect themselves against HIV.
amfAR: How optimistic are you that we will find a cure in the next five to ten years?
Dr. Mayer: It could be five years or it could be 50 years. There are glimmers. So far we only know of one person who has been cured (the Berlin patient) and the way he was cured is very unique and would be very expensive and have high a level of risk, so it wouldn’t be something you could replicate. But it shows that it is possible.
amfAR: Do you think we are closer to a vaccine?
Dr. Mayer: It’s like the tortoise and the hare. It’s always dangerous to predict because neither a cure nor an effective vaccine is immediately within our grasp, but lots of exciting work in both areas is underway. I think the question speaks to the need to keep doing this kind of research. And the important thing is, we don’t want to subject anybody to be participant in biomedical research if we don’t think that the intervention may be successful, but it’s also important to learn from “failures.” Clinical research is an iterative process, and it’s a humbling process to do the work. What’s gratifying is that we do at least have reasonable treatment and prevention options now, which was not the case when the epidemic first emerged.