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HIV+ Women & MSM: aging & other issues
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Download the PDF here
Download the PDF here
As part of a Series in the Lancet - 2 articles on MSM & women
February 18, 2021
HIV and women in the USA: what we know and where to go from here
Adaora A Adimora, Catalina Ramirez, Tonia Poteat, Nancie M Archin, Dawn Averitt, Judith D Auerbach, Allison L Agwu, Judith Currier, Monica Gandhi
Summary
New diagnoses of HIV infection have decreased among women in the USA overall, but marked racial and geographical disparities persist. The federal government has announced an initiative that aims to decrease the number of new infections in the nation by 90% within the next 10 years. With this in mind, we highlight important recent developments concerning HIV epidemiology, comorbidities, treatment, and prevention among women in the USA. We conclude that, to end the US HIV epidemic, substantially greater inclusion of US women in clinical research will be required, as will better prevention and treatment efforts, with universal access to health care and other supportive services that enable women to exercise agency in their own HIV prevention and care. Ending the epidemic will also require eliminating the race, class, and gender inequities, as well as the discrimination and structural violence, that have promoted and maintained the distribution of HIV in the USA, and that will, if unchecked, continue to fuel the epidemic in the future.
HIV and other health issues
People with HIV experience many comorbidities that reflect concomitant biological, psychological, and social structural factors in their lives. In the following sections, we highlight a few comorbidities with particular significance for women, especially older women.
Obesity
The prevalence of obesity and overweight has increased among all races and ethnicities in the USA. ART initiation is associated with weight gain, some of which has been regarded as a reflection of improved health.
From 1998 to 2008, mean body-mass index (BMI) was lower among people with HIV initiating ART in the USA and Canada than among individuals in the general population, but 3 years after starting ART, the mean BMI of people with HIV increased and became equal to (or exceeded, in the case of White women with HIV) the mean BMIs of their counterparts in the general population.
Studies of weight gain have focused concern on specific classes of antiretroviral drugs. Integrase inhibitors, especially dolutegravir, have been associated with weight gain among individuals who are initiating ART and among those changing type of ART whose plasma viral loads are suppressed.
Some studies have shown more pronounced weight gain among women and Black people with HIV than among the general population with HIV.
South African women who took tenofovir alafenamide and emtricitabine combined with dolutegravir showed even greater weight gain (10 kg) over the course of 96 weeks than those who took either tenofovir disoproxil fumarate and emtricitabine combined with dolutegravir (5 kg) or tenofovir disoproxil fumarate and emtricitabine combined with efavirenz (3 kg).
The mechanisms through which these antiretroviral agents result in weight gain remain unclear, but the implications of weight gain for common comorbidities, such as diabetes, hypertension, and cardiovascular disease, are concerning.
Mental health disorders and neurocognitive impairment
Psychiatric disorders are common among people with HIV in the USA. Among participants in the Medical Monitoring Project, a nationally representative sample of patients receiving care for HIV infection in the USA, the estimated prevalence of depression in the 2 weeks preceding the survey was 23%; 12% of survey respondents had major depression.
Depression, which is common among women in the general population, is even more prevalent among women with HIV. Among 1027 women with HIV in a large multisite cohort, the lifetime prevalence of depression was 32% and the 12-month prevalence was 20%, compared with a lifetime prevalence of 23% and 12-month prevalence of 10% among US women in general.
Depression is strongly associated with non-adherence to ART.
The effect of depression on neurocognition appears to differ by sex; depression is a stronger predictor of impaired executive function among women with HIV than among men with HIV. Moreover, the duration of depression predicts both virological failure and mortality among women.
HIV-associated neurocognitive impairment is most common among women with evidence of more advanced HIV disease, although the degree of impairment is usually small.
Moreover, impairment persists despite plasma viral suppression. Compared with men with HIV, women with HIV in the USA might be more susceptible to HIV-associated neurocognitive impairment because of the higher prevalence of factors that adversely affect the brain and cognitive reserve, such as low education, substance use, and depression. However, women with HIV have higher odds of impairment than their male counterparts, even after adjustment for age, race, and education. The pathophysiology of neurocognitive damage is unclear but might be associated with the previously mentioned sociodemographic factors, adverse cognitive effects of commonly used non-antiretroviral medications, and persistence of HIV-infected cells in cerebrospinal fluid.
Cardiovascular disease
Cardiovascular disease has emerged as a comorbidity of major concern for older women with HIV. Among the 2187 women in the Veterans Cohort Study, the risk of cardiovascular disease (ie, acute myocardial infarction, unstable angina, ischaemic stroke, and heart failure) in women with HIV was almost 3 times higher than in HIV-seronegative women (hazard ratio 2⋅8).
Women with HIV also have increased risk of ischaemic stroke (hazard ratio 1⋅89), even after adjustment for demographic factors, traditional stroke risk factors, and sex-specific risk factors, such as menopause status and oestrogen use.
HIV infection is associated with an increased risk of incident heart failure among women, and women with HIV in a US health-care system-based cohort had increased rates of hospitalisation for heart failure and all-cause cardiovascular mortality. The pathophysiology that drives this increased risk has not been completely elucidated, but might relate, in part, to increased immune activation due to HIV. Cardiac imaging has shown that women with HIV were more likely to have myocardial fibrosis, decreased diastolic function, and elevated markers of immune activation with resultant inflammation. The relative risk of both myocardial infarction and stroke is greater among women with HIV than among men with HIV—an observation that some people have attributed to sex-based differences in immune mechanisms, given that women generally mount stronger immune responses than men. As in other morbidities, gender inequities in care have been reported: compared with men with HIV in the Data Collection on Adverse Events of Anti-HIV Drugs cohort (a combination of cohorts in Australia, Europe, and the USA), women were less likely to receive most interventions to prevent and treat cardiovascular disease (eg, lipid-lowering drugs, angiotensin-converting enzyme inhibitors, and invasive cardiovascular procedures), even after adjusting for cardiovascular risk.
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The persistent and evolving HIV epidemic in American men who have sex with men
Kenneth H Mayer, LaRon Nelson, Lisa Hightow-Weidman, Matthew J Mimiaga, Leandro Mena, Sari Reisner, Demetre Daskalakis, Steven A Safren, Chris Beyrer, Patrick S Sullivan
Summary
Men who have sex with men (MSM) in the USA were the first population to be identified with AIDS and continue to be at very high risk of HIV acquisition. We did a systematic literature search to identify the factors that explain the reasons for the ongoing epidemic in this population, using a social-ecological perspective. Common features of the HIV epidemic in American MSM include role versatility and biological, individual, and social and structural factors. The high-prevalence networks of some racial and ethnic minority men are further concentrated because of assortative mixing, adverse life experiences (including high rates of incarceration), and avoidant behaviour because of negative interactions with the health-care system. Young MSM have additional risks for HIV because their impulse control is less developed and they are less familiar with serostatus and other risk mitigation discussions. They might benefit from prevention efforts that use digital technologies, which they often use to meet partners and obtain health-related information. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities. Transgender MSM are an understudied population, but emerging data suggest that some are at great risk of HIV and require specifically tailored information on HIV prevention. In the current era of pre-exposure prophylaxis and the undetectable equals untransmittable campaign, training of health-care providers to create culturally competent programmes for all MSM is crucial, since the use of antiretrovirals is foundational to optimising HIV care and prevention. Effective control of the HIV epidemic among all American MSM will require scaling up programmes that address their common vulnerabilities, but are sufficiently nuanced to address the specific sociocultural, structural, and behavioural issues of diverse subgroups.
Older MSM living with or without HIV have experienced the brunt of the HIV epidemic. Older MSM remain at risk of HIV and are the largest population of US residents with chronic HIV, requiring culturally responsive programmes that address longer-term comorbidities.....Older MSM have grown up in a world that has experienced gay liberation and the development of highly active ART and PrEP, but remains replete with other emerging challenges. Ageing with HIV infection presents other special challenges for MSM and other people with HIV, since chronic HIV increases the risks of cardiovascular and pulmonary disease, bone loss, and certain cancers, which also tend to be more prevalent in older individuals, independent of HIV serostatus. Older patients and their health-care providers need to carefully monitor interactions between the medications used to treat HIV and those used to treat common age-related conditions such as hypertension, diabetes, high cholesterol, and obesity. Older MSM might encounter some unique challenges not experienced by demographically similar heterosexual people with HIV. They might face social isolation due to illness or loss of family and friends similar to other ageing adults, but not have optimal support systems. Unlike younger MSM, older MSM did not grow up in an era when marriage equality was sanctioned, so they might be less likely to live in long-term, stable partnerships and have children. Some older MSM might have experienced ostracism from their birth families because of their sexual orientation, further exacerbating their isolation as they age. In a society that values certain norms of physical beauty highly, ageing MSM might find meeting new partners difficult. The resultant loneliness could lead to depression and self-medication with substances, and complicate maintenance of optimal health, which is less likely to happen when sufficient social supports are present.
Comorbidities and resilience of older MSM
In 2016, nearly half of people with HIV in the USA were aged at least 50 years, two-thirds of whom were MSM. Although new HIV diagnoses are declining among older people, approximately one in six HIV diagnoses in 2017 were among people older than 55 years.
Older Americans are more likely to present with late-stage HIV infection than younger people at the time of diagnosis, leading to worse clinical outcomes. Among people aged 55 years or older who received an HIV diagnosis in 2015, 50% had been living with HIV for 4⋅5 years before they were diagnosed, representing the longest delay in diagnosis for any age group. Delays in diagnoses could be caused by older people not considering themselves at risk of HIV infection, and physicians incorrectly presuming that older MSM are not sexually active or misdiagnosing HIV-related symptoms as manifestations of illnesses related to ageing.
Although older people with HIV tend to visit their health-care providers more frequently, they are less likely than younger people to discuss their sexual or drug use behaviours with health-care providers. Clinicians are also less likely to ask older patients about these issues, creating a so-called conspiracy of silence that delays HIV diagnoses and creates missed opportunities for discussions about PrEP and other prevention modalities for at-risk, uninfected older MSM.
Ageing with HIV infection presents other special challenges for MSM and other people with HIV, since chronic HIV increases the risks of cardiovascular and pulmonary disease, bone loss, and certain cancers, which also tend to be more prevalent in older individuals, independent of HIV serostatus. Older patients and their health-care providers need to carefully monitor interactions between the medications used to treat HIV and those used to treat common age-related conditions such as hypertension, diabetes, high cholesterol, and obesity. Older MSM might encounter some unique challenges not experienced by demographically similar heterosexual people with HIV. They might face social isolation due to illness or loss of family and friends similar to other ageing adults, but not have optimal support systems. Unlike younger MSM, older MSM did not grow up in an era when marriage equality was sanctioned, so they might be less likely to live in long-term, stable partnerships and have children. Some older MSM might have experienced ostracism from their birth families because of their sexual orientation, further exacerbating their isolation as they age. In a society that values certain norms of physical beauty highly, ageing MSM might find meeting new partners difficult. The resultant loneliness could lead to depression and self-medication with substances, and complicate maintenance of optimal health, which is less likely to happen when sufficient social supports are present.
Ageing with HIV should not be seen as a decifit-based experience for MSM. As LGBT people and people with HIV are living longer, an increasing array of organisations, such as Seniors Aging in a Gay Environment and the LGBT Aging Project, have been developed to provide supportive services and activities that can help prevent social isolation and adverse health consequences for ageing MSM and other sexual and gender minority individuals. Older MSM living with or without HIV have experienced the brunt of the HIV epidemic, and their responses, ranging from the creation of the globally influential AIDS Coalition to Unleash Power activist group to the development of many local services, provide lessons and cautionary tales for future generations of MSM. Older MSM have grown up in a world that has experienced gay liberation and the development of highly active ART and PrEP, but remains replete with other emerging challenges.
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