The push was to get people onto HIV treatment earlier, but treating HIV was not enough. PLWHA were getting older and were developing conditions traditionally related to aging, such as cardiovascular disease, frailty, renal and hepatic failure, and non-AIDS-related cancers, decades before their HIV-negative counterparts. People with higher CD4 cell counts are more vulnerable to non-AIDS-related death, although mortality from those conditions has increased among all HIV-positive people.90,91
Although HAART as well as access to care and treatment had drastically reduced AIDS-related death rates in the United States, not everyone was reaping the benefits of HIV treatment. Death rates remained higher among injection drug users, and people with HIV were now surviving long enough to die from other comorbid, non-AIDS-related conditions, such as hepatitis C virus (HCV), diabetes, and pulmonary disease.92,93,94 “It’s like night and day. . . . In the 1980s, when we were seeing AIDS in hospital inpatient units, the time from diagnosis to death was 3 to 6 months; now it’s more than 25 years, an unbelievable increase in longevity. Now we need to consider all the chronic diseases that pop up longitudinally,” says Young.
In the early years of the epidemic, before HAART, it was not uncommon for patients to take a plethora of medications to treat their HIV—something that posed very real barriers to adherence.
Providers now need to focus on all-around primary health care in addition to management of HIV disease, particularly as the population of people who are aging with HIV has grown. In 2009, according to the CDC, 28 percent of people living with HIV were older than age 50.95 By 2015, one-half of the HIV-positive population in the United States will be older than 50 years of age.95,96 Older PLWHA are likely to suffer from other comorbidities; long-term toxicity from ART; and complications from HIV itself, including cognitive impairment, frailty, bone loss, renal, hepatic and cardiovascular disease, type 2 diabetes, high cholesterol, and hypertension.97,98
Polypharmacy (use of several prescription medications at the same time) is common among older PLWHA. One study found an increasing number of medications prescribed to PLWHA as they aged, from an average of more than 7 drugs for people in their 20s to more than 12 medications for people in their 50s and more than 14 drugs for people in their 60s.99 Many drug-drug interactions occur between antiretroviral agents and medications for common comorbid conditions (e.g., PIs and certain drugs used to lower cholesterol). A significant amount of research has been devoted to identifying and managing or avoiding drug-drug interactions. Providers have many resources available to guide successful comanagement of HIV and other conditions and to avoid drug-drug interactions. AETCs have produced a variety of materials, including charts, tables and posters, pocket guides, slide sets, and links to online databases.
HRSA’s Ryan White HIV/AIDS Program has evolved in response to a changing epidemic. A deadly disease has turned into a treatable condition. “If someone is going to die in 6 months, closure with family and friends matters most,” says Cheever, “but when they are going to live for at least 20 years, getting off heroin is important. There are very few medical interventions that have made as much difference as ART. It allows us to address multiple priorities and improve outcomes.”
The Ryan White HIV/AIDS Treatment Modernization Act of 2006 reflected this change. For the first time, 75 percent of funds had to be dedicated to 13 core medical services. Support services needed to be essential to delivery of HIV medical care. The focus included getting more people into care, as early as possible, and keeping them there. “Ryan White has quickly adapted to change. It’s more than prescribing a new drug, it’s a philosophical shift from deadly to chronic,” says Cheever. “We didn’t worry about people quitting smoking or getting a colonoscopy. Now we can.”
Getting Better All the Time
On October 12, 2009, a few days after it passed the Senate, the House of Representatives passed the Ryan White HIV/AIDS Treatment Extension Act of 2009 by a vote of 408 to 9, and President Obama signed it into law October 30, 2009.