Transcript Powerpoint

NCD Complications
in HIV Patients
Esteban Martinez
Hospital Clínic
University of Barcelona
Barcelona
SPAIN
[email protected]
www.aids2012.org
Washington D.C., USA, 22-27 July 2012
HIV infection has changed from a fatal
disease into a chronic condition
80
3000
ACTIVE PATIENTS
2500
70
60
2000
50
Deaths
1500
40
30
1000
20
New patients
10
Number of patients
Mortality per 100 patient-years
This means long-term exposure to ART
and higher risk for non-HIV-related conditions
500
0
0
84
86
88
90
92
94
96
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98
00
02
Data from Hospital Clinic, Barcelona
Mortality in HIV-infected adults is still
higher than that in general population
Mortality per 100 person-years
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
• 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)
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Martinez et al. HIV Medicine 2007; 8: 251-258
AIDS-related deaths have decreased, but
non-AIDS-related ones have increased
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
Ruppik M, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 789.
Non-AIDS-related NCDs in
HIV+patients are higher with older age
Swiss HIV Cohort Study
www.aids2012.org
Hasse B et al. Clin Infect Dis 2011; 53: 1130-1139
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.
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).
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Guaraldi G et al. Clin Infect Dis 2011; 53: 1120-1126
HIV-infected patients have a higher
incidence of myocardial infarction
A
B
n = 3,851
RR 1.75
p <0.0001*
10
n = 1,044,589
8
6
4
2
0
HIV+
# of MI
189
HIV-
100
Events Per 1000 PYs
Events Per 1000 PYs
12
80
60
40
20
0
18-34 35-44 45-54 55-64 65-74
Age Group (Years)
26,142
* 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
Triant V et al. J Clin Endocrinol Metab 2007; 92: 2506-2512
HIV+ patients have a higher prevalence
of low bone mineral density
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Brown TT & Qaqish RB. AIDS 2006; 20: 2165-2174
Greater rate of fractures in HIV- infected
patients vs un infected individuals
Population-based study
8,525 HIV-infected patients
2,208,792 non HIV-infected patients
3.5
p<0.0001
HIV+
Fracture prevalence/100 persons
3
HIV-
2.5
2
p<0.0001
P<0.0001
1.5
p=0.001
1
0.5
0
All
Vertebral
Hip
Wrist
Triant VA et al. J Clin Endocrinol Metab 2008; 93: 3499–3504
Liver and kidney comorbidities more
common in HIV+ patients
Liver Disease
Renal Disease
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Goulet J. Clin Infect Dis 2007; 45: 1593-1601
Neurocognitive impairment remains highly
prevalent despite of cART
Percent impaired
Pre-cART
cART
HIV+
Heaton R et al. J Neurovirol 2011; 17: 3-16
Non-AIDS–defining cancer rates higher
in HIV+ patients vs general population
Cancer Type, Observed
Rate per 100,000
Person-Years (95% CI)
Anal
Vaginal
Hodgkin’s lymphoma
Liver
Lung
Melanoma
Oropharyngeal
Leukemia
Colorectal
Renal
Prostate
ASD/HOPS
(157,819
Person-Years)
51.4 (40.8-63.9)
33.9 (18.0-57.9)
51.4 (40.9-63.9)
31.7 (23.5-41.8)
88.8 (74.7-104.8)
24.7 (17.6-33.8)
33.0 (24.6-43.3)
15.2 (9.8-22.7)
47.0 (36.9-59.0)
14.0 (8.8-21.1)
32.7 (23.3-44.7)
SEER
(334,802,121
Person-Years)
1.5 (1.4-1.5)
3.2 (3.2-3.3)
3.3 (3.3-3.4)
5.3 (5.2-5.4)
67.5 (67.2-67.7)
18.4 (18.3-18.6)
16.1 (16.0-16.2)
12.2 (12.1-12.3)
52.0 (51.7-52.2)
13.0 (12.8-13.1)
173.5 (172.9-174.1)
SRR* (95% CI)
42.9 (34.1-53.3)
21.0 (11.2-35.9)
14.7 (11.6-18.2)
7.7 (5.7-10.1)
3.3 (2.8-3.9)
2.6 (1.9-3.6)
2.6 (1.9-3.4)
2.5 (1.6-3.8)
2.3 (1.8-2.9)
1.8 (1.1-2.7)
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.
www.aids2012.org
Patel P et al. Ann Intern Med 2008; 148: 728-736
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
www.aids2012.org
http://www.aahivm.org/hivandagingforum
Growing interest in learning about
pathogenesis and care of comorbidities
Most basic screening tools for NCDs
are easily affordable
http://hp2010.nhlbihin.net/atpIII/calculator.asp?usertype=prof
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
The need of polypharmacy means higher
risk for interactions and toxicities
Swiss HIV Cohort Study
Comorbidities
% participants
Comedications
N=
5761
2233
450
5761
www.aids2012.org
2233
450
Hasse B et al. Clin Infect Dis 2011; 53: 1130-1139
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 costeffective 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