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Aging/HIV Clinical Care & Research - New IDSA Guidelines
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IDSA GUIDELINES 2009 Primary Care Guidelines Update by HIV Medicine Association
Clinical Infectious Diseases Sept 1 2009
New IDSA HIV Guidelines Push 'Adherence to Care' - (08/17/09)
Bone Guidelines Excerpted From New IDSA Guidelines- pdf of full paper attached - (08/12/09)
These newly released guidelines discuss a number of clinical issues related to aging: metabolic monitoring including testosterone testing, bone evaluations/monitoring and some guidelines, screening for proteinuria, baseline urinalysis and calculated creatinine clearance, pregnancy discussions with patients, women's exams, use of condoms, body changes & cosmetic surgery. "data from recent studies suggest those living with HIV are at higher risk for developing common health problems, such as heart disease, diabetes, or cancer,"....."it's imperative that HIV care providers be aware of the primary care needs of their patients, and that includes routine screening for these kinds of conditions."...."It's not just about adherence to medication, it's also about adherence to care,"Judy Aberg said. list of HIV diagnostic tests has been expanded.
Recent studies have found very high rates of vitamin D deficiency in patients, ARTs associated with bone loss, report 60% osteopenia & 15% osteoporosis in patients at average ages in their mid 40s, which is not seen in the general population until the elderly years.
GENDER AND GONADAL FUNCTION DIFFERENCES IN THE PREVALENCE OF BONE ...and Low Vitamin D levels
Male hypogonadism was defined for total testosterone <300 ng/mL. Femalehypogonadism (menopausal) were defined for LH and FSH >20 ng/ml and 17 ...
www.natap.org/2009/CROI/croi_131.htm
Thyroid Dysfunction & Bone Disease in HCV & HIV
These include prolonged bed rest associated with chronic illness, smoking, severe weight loss, hyperthyroidism, hypogonadism, malabsorption, and medications ...
www.natap.org/2008/HIV/123008_04.htm
AGING RESEARCH: the NIH & NIAID has invited researchers to submit grant requests to conduct aging-related studies which includes immune activation, senesence, frailty, cognitive impairment/CSF/CNS disease, and bone disease. It is now 2 years after the NIH held an HIV/Aging Workshop. This is progress but it is slow. I am afraid it might be too late for older patients but I guess we will have to wait & see early results from research. I am concerned about mitiochondrial toxicity, which can be cause by both HIV and some ARTs, in contributing towards aging. A recent study published showed substituting nevirapine for nukes improved mtiochondrial damage and we know already that tenofovir and abacavir improves mitochondrial damage as well. There apears at this time to be inadequate markers for evaluation of kidney disease. Perhaps it is time to discuss is there a role for including new markers into government, academic and drug company clinical studies including bone biomarkers like vitamin D and bone dexas neurological/cognitive impairment evaluations, frailty markers, and activation & senesence biomarkers. I think we should be conducting separate studies in patients over 50 years of age utilizing these markers and evaluations.
NIH Workshop on HIV in Older Adults Oct 20 2007 - (08/18/09)
Physical examination. A complete physical examination should be performed at the initial encounter.
A comprehensive cardiopulmonary examination should be performed, including examination for evidence of peripheral vascular disease
It is important to perform a careful anogenital examination for evidence of rectal cancer, prostate cancer in men, and STDs, including condylomata and herpes simplex infection. Examination of HIV-infected women should include careful palpation of the breasts and apelvic examination. The pelvic examination should include visual inspection of the vulva and perineum for evidence of genital ulcers, warts, or other lesions.
The neurological examination should include a general assessment of cognitive function, as well as motor and sensory testing.
Serum Testosterone Level
Evidence Summary
Recommendation
Providers should consider obtaining morning serum total testosterone measurements in male patients who complain of fatigue, weight loss, loss of libido or erectile dysfunction, or depressive symptoms or who have evidence of reduced bone mineral density (C-III).
HIV-infected men, especially those with advanced disease, are at risk for hypogonadism. Whether antiretroviral therapy ameliorates or contributes to this condition is unclear. A total testosterone level that is below the lower limit of normal should be confirmed by repeat testing because of the variability of assays. Because testosterone circulates primarily while bound to plasma proteins, such as albumin and sex hormone-binding globulin, a determination of free testosterone with a reliable assay (such as equilibrium dialysis) may be needed if alterations in binding proteins are suspected. Alternatively, a free testosterone level can be estimated using a free androgen index (calculated as the total testosterone level divided by the sex hormone binding globulin level). Free testosterone assays available at most local laboratories that use analog methods have limited reliability.
Once the diagnosis of hypogonadism is established, further testing by measuring luteinizing hormone and follicular stimulating hormone should be considered to determine whether it is primary source (testicular failure) or central source (hypothalamic or pituitary dysfunction). If luteinizing hormone and/or follicular stimulating hormone levels are abnormal, further evaluation to establish the cause should be considered with specialty consultation as needed.
All HIV-infected women of childbearing age should be asked about their plans and desires regarding pregnancy upon initiation of care and routinely thereafter (A-III).
Women who do not wish to become pregnant should be advised to use effective contraception. Condom use should be recommended with each sexual act, which provides dual protection against pregnancy, STDs, and potential superinfection with HIV. However, condoms are associated with higher rates of failure than other contraceptive methods, and women should be counseled about the greater effectiveness of using a second method of protection as well.....HIV-serodiscordant couples who desire pregnancy should be counseled about ways to minimize risk of transmission to the uninfected partner while trying to conceive.
Patient self-report of body shape changes may be sufficient for clinical practice screening for body morphology changes. Anthropometry (measurements of skin-fold thickness and circumference of the waist and hip) does not differentiate subcutaneous from visceral fat and requires training to perform. Although dual-energy X-ray absorptiometry has been used in research studies to evaluate regional body composition, it cannot distinguish subcutaneous from visceral fat but can compare limb fat with truncal fat. Computed tomography scanning at L4/5 can be used to assess visceral fat and quantitate subcutaneous fat. The body mass index assesses lean body mass but cannot determine fat distribution. None of these tools is currently recommended for clinical practice.
Polylactic acid and calcium hydroxylapatite have been approved for treatment of facial lipoatrophy, but these interventions may provide only short-term benefit in some patients. Cosmetic surgery (eg, liposuction) may be warranted for disfiguring cases of lipohypertrophy. Modification of antiretroviral drug therapy (ie, substitution of another drug for stavudine or zidovudine in a patient with facial lipoatrophy) can partially reverse lipoatrophy.
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