At the International AIDS Society Conference in Sydney, Peter Staley interviews Professor Brian Gazzard, an expert on HIV and aging from Chelsea and Westminster Hospital in London. With a healthy dose of humor, Professor Gazzard counsels against overreacting to the additional risks of living with HIV while growing older. Below is the transcript.
This is Peter Staley with AIDSmeds.com and I’m here with Professor Brian Gazzard from Chelsea & Westminster Hospital in jolly old London, England, where I went to college as a young man. Welcome.
Welcome to you.
I heard a wonderful talk you gave this morning with a fair bit of wit, about HIV and aging. Although, given my age and my HIV status I found some of the information you shared to be a little scary. Give us an overview of the issue. One of the most shocking statistics you gave was that 1/3 of HIV positive adults are over 50.
Well that’s a good thing, isn’t it? Which is that they are now living a lot longer in the HIV context, obviously, over the years, many people will arrive at over 55 and that’s a good thing. The numbers becoming infected over the age of 50 are quite low, but you’ll be glad to hear that sex is still possible after 50. And so there are a number of people. And of course in some ways, that’s a vulnerable group, isn’t it? Women don’t need to have contraception, and so they may not be using barrier methods, people don’t feel themselves at risk and there’s certainly no sort of elderly gay men having sex with men type messages out there, are there actually? So HIV continues to become incident in older age. So that’s important. But that’s the good statistic, I thought.
Well the other one that kind of scared me though was the average age now of a 20 year old’s life span, for HIV, they might die at around 53 is the current stat?
I think that that is...those are cohort studies, so those are difficult to interpret. But it did strike me as pretty surprising, and that came out at CROI this year. So if you’re a 20-year-old now, your average life expectancy would be about 45 if you’re HIV-positive and would be 53 if you’re HIV negative. Now interestingly, that’s very different if you’re from Denmark. If you’re from Denmark and you’re HIV positive and you’re 20 your survival is nearly normal. So it probably relates to the poor access to healthcare, to the high number of intravenous drug users who obviously have a shortened survival, and many other factors that will shorten people’s survival. Although I think it is true that people don’t survive quite as long as they should.
So if I keep going to the doctor I can hope for getting past my 50s, which I’m fast approaching?
I don’t know if it has anything to do about going to your doctor. I think that the recipe for getting past 50 is to be happy.
Well, I’m trying to do that as well. A lot of the diseases you covered, almost all of them, the major groups: cardiovascular, cancers, and dementia as well. Alzheimer’s. All of these are showing higher rates in people with HIV than their negative…
You shouldn’t be too alarmed. What we’re really saying is that we all die of something. So we all die in the end of renal failure, or a stroke or a neoplasia. You die a bit earlier if you’re HIV positive. And what we want to to do is try and say “is that because the old drugs you were using won’t happen, now we’re not using the thymidine analogs. Could we find a better regimen where that won’t happen?” So the interest, in a way, is much more to say “are there better regimes that will prevent excess mortality from a large number of chronic diseases, none of which are very important in their own but add up to a shortened lifespan. My personal view is yes, that quite a lot of that is sort of imperfect HAART and as HAART gets better then some of those diseases of aging will go away. But it is one of the more interesting things I think at the moment about HIV. How you design studies and how you look at cohorts to directly try to and eliminate the people who still die. I think it’s amazing. For example, many people die of suicide who are HIV positive. Well that’s the sort of sense social isolation, etc. and our inability to welcome them into a community somehow. So I think there are a lot of lessons in there, there’s a very high rate of alcoholism in the elderly who are HIV positive in the States. A lot of social exclusion. So it’s an important issue as well as the diseases.
Let’s touch a bit on all three of these just shortly. Cardiovascular. A very interesting point you made is that most of the talk has been about “are the drugs hurting us?” But there’s definitely a school of thought that says that HIV might be the main culprit and the drugs are actually keeping it from being worse than it would be.
That data’s very persuasive. So I think the most interesting thing about the SMART data, you remember the CPCRA study, of STIs really versus continuing drugs permanently. I mean, that data showed very clearly surprisingly that coming off therapy was very bad for you in terms of cardiovascular risk. The cardiovascular risk went up. And I mean I think there has been a view for ages that the actual underlying cause of atheroma is really not clear. That one of the things that precipitates heart disease is actually an infection. And that’s been around for a long time. And I think the SMART study gets quite a lot of credence to that, I think, within HIV. And as I was saying in the talk this morning, Sam Bozzette, who wrote a very good paper that was in the New England Journal, initially, about heart disease and looking at the VA studies. And showing an enormous reduction in heart disease with the advent of antiretroviral therapy. That was all ignored when the D:A:D study came along and showed that PIs produced increased heart disease risk. But I think Sam Bizetti was probably right. HIV treatment produces a fantastic reduction in risk of atheroma, but not quite back to normal as a residual risk, which is related to the drugs. And that’s an important issue. And I think that, I was again joking, I mean I was a heavy smoker until 6 months ago, and then stopped. And there’s nothing worse than a stopped smoker. As a result of me having stopped smoking we’ve now got a smoking cessation clinic in our unit. But I think that’s really important, actually. That there’s no good coming in and demanding to know what your cholesterol is every three months if you’re having five fags outside before you come in the door!
And for our American audience, fags are cigarettes.
Yes, I’m so sorry. Nobody would we be capable of having five fags outside our door.
Oh, don’t underestimate us. [laughs] The scariest stuff you talked about though, I thought, was the cancer. Basically, all the various forms of cancer, people with HIV over the age of 50 are getting them at higher rates than HIV negative people. And the theory here is that HIV might really be playing a role in causing these cancers.
Well, I think there are two theories, really. I think for some of them, HIV may actually be interfering with the cellular mechanisms and leading to cancer. But of course the HIV’s got to infect those cells first, so that won’t be all cancers. And I think the persuasive data that I was trying to present this morning is that it must be a loss of immune competence. So in other words, the same sort of cancers very common in transplantation, wherever you lose your immune system. And I think it’s going to be a very strong argument centered around when treatment should start, very very strongly associated with having a low CD4 count. So triple the rate of cancers if your CD4 count was at 50 when you started therapy. Much more slight risk only if your CD4 was over 300 when you started. So I think you’re back to what is the current most important thing about HIV in the developed world I think, which is more widespread testing. How do you get people into the clinic, well, not necessarily the clinic, but how do you get their HIV status now, how do you normalize the process of getting a test. Because then you get treatment when you need it, rather than when your CD4 count is 50 and your cancer risk will be increased.
Finally, dementia. Everybody I know who is HIV positive and myself included who’s at my age or higher, we all think that our memory is going much faster than our HIV negative friends. And you’ve said this is anecdotally what a lot of doctors are hearing too. That low-grade dementia is presenting itself as memory loss.
I don’t believe it really. Well, not that I don’t believe it scientifically, well I don’t know whether I should say that on tape, but obviously all the neurologists who are interested in HIV disease have really got nothing to do, have they really? Age dementia is a thing of the past, which is a good thing for all of us. So they now say, “oh, there’s a very subtle…you can’t detect it, Brian, but it’s there.” I must say, I mean I’ve been doing this job for 30 odd years, I still don’t see anybody who’s really dementing. They may have, and I think that’s fair, very subtle changes. Does it really matter if you can’t do your 2 times table 500 times as long as it doesn’t get worse. And I think that that’s really unknown at the moment. I think it’s very hypothetical. That as we get older, we will all dement.
What about the relationship with Alzheimer’s?
Well that’s all theoretical rather than practical. So there’s no good evidence that Alzheimer’s is common. What there is evidence of us that there’s sort of amyloid deposition, which is the pathology of Alzheimer’s, is quite common in HIV dementia. So it would be logical to suppose that the two might go together. But there’s no data that they do. And in a way, we all need to make living wills, don’t we? I mean HIV started living wills. And I’m very proud of living wills, and I think we all sort of “I don’t want to go alone, when I’m demented.” So, fortunately there’s no euthanasia issue... all you have to do is stop taking the pills. I think it’s a much easier process. The world isn’t going to be full of demented gay men wandering the streets of Sydney.
Well, there’s a fair amount of it going on in New York already. [laughs] But this has been a hopeful conversation in the end. It’s about living happy, and I’m glad you made that point. Thank you for joining us.
Good to talk to you.