Módulo 2 – Curso pós-graduado – VIH e Envelhecimento

Non-AIDS Defining Cancers Among HIV Infected People

The epidemiology of non-AIDS defining cancers among HIV infected patients

Autor: Prof. Doutor Julian Falutz, MD, FRCP (McGill University Hospital Center, Montreal, Canada)

HIV survival and comorbidities: current status

Survival of patients infected with human immunodeficiency virus (HIV) has improved significantly since 25-30 years ago. Since the introduction of antiretroviral treatment (ART), a significant decline in mortality has been observed. Life expectancy has improved to the point where, on average, an individual diagnosed with HIV infection at around the age 20, with CD4+cell count > 500 cells/mm3and undetectable viral load can expect to live another 50 years1. Although some differences seem to exist between transmission groups (with injection drug users presenting a lower life expectancy), nowadays it is observed a nearly normal life expectancy in people living with HIV1,2.

From a clinical perspective, as mortality related to acquired immunodeficiency syndrome (AIDS) has decreased significantly, mortality due to non-AIDS related causes has increased. The D:A:D study showed that approximately 30% of the specific causes of death were related to typical AIDS complications, but the remaining causes were mostly due to non-AIDS malignancies (15%), liver related (13%), cardiovascular related (11%), and about 30% due to several other causes. Considering only the non-AIDS related mortality, non-AIDS defining cancers (NADC) were the most frequent (21%) cause of mortality3.

Guaraldi et al.4 showed that the number of comorbidities, namely, hypertension, diabetes mellitus, cardiovascular disease or osteoporosis, is always higher in HIV-infected individuals compared to seronegative subjects. Common non-AIDS comorbidities are the same as those occurring in older general population but are occurring at a younger age among HIV-infected subjects.

At the same time, aging-related comorbidities are increasing as the HIV population is aging. It is now estimated that, in most industrialized countries, 30% of all individuals with HIV are older than 50 years5. Although clinical problems associated with age are usually more relevant and common when people get under mid and late 80’s, in the HIV setting these problems seem to occur earlier. Hence, the age of 50 years is assumed as a cut-off from an epidemiological perspective, when considering older HIV patients6. Older HIV patients are more likely to have lower nadir CD4+ count and a lower plateau CD4+count (<500 cells/mm3) on stable antiretroviral drugs (ARV). Several reasons may contribute to this reduced immune response, either delayed diagnosis, delayed onset of treatment, polypharmacy or immunosenescence. Lower nadir and plateau CD4+ less than 500 cells/mm3 increases the risk of having non-AIDS events, including: non-AIDS malignancies, renal and liver disease7, bone demineralization8, myocardial infarctions9, and neurocognitive dysfunction10.

Hence, ART does not fully restore immune health, and effective immunovirologic control is inadequate to eliminate all the HIV effects in the majority of patients. Understanding of the long-term consequences of treated HIV infection is still evolving. From an aging perspective, it is not clear if these changing HIV comorbidity profile reflects a state of accelerated or accentuated aging. Accelerated aging in HIV patients suggests that the common aging phenotype occurs at a younger age. The problem is that there is no consensus in the geriatric literature about the definition of biological phenotype of aging. On the other hand, accentuated aging refers to HIV as being an additional co-factor for the development of other chronic conditions, which increases the prevalence of multimorbidity11, 12.

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