HIV and Aging: Living Long and Living Well

By 2015, more than 50% of the United States HIV population will be over 50. There are approximately 120,750 people now living with HIV/AIDS in NYC; 43% are over age 50, 75% are over age 40. Over 30% are co-infected with hepatitis.

What does the future hold for people with HIV and HIV/HCV as they get older?

These statistics and this question furnished the starting point for the New York Buyers’ Club March 28 event HIV and Aging: Living Long and Living Well, presented by Stephen Karpiak, PhD, of the AIDS Community Research Initiative of America (ACRIA).

Dr. Karpiak’s background uniquely positions him to paint the full picture behind the bare statistics, and to provide expert guidance through the complex healthcare challenges faced by the growing population of older people with HIV. After two decades as a researcher at Columbia University’s Medical School, Dr. Karpiak moved to Arizona, where he directed AIDS service organizations through the 1990s, including AIDS Project Arizona (which offered a supplements buyers’ club similar to NYBC’s). In 2002, back in NYC, he joined ACRIA as Assistant Director of Research, and was the lead investigator for the agency’s landmark 2006 study, Research on Older Adults with HIV. This report, the first in-depth look at the subject, surveyed 1,000 older HIV-positive New Yorkers on a host of issues, including health status, stigma, depression, social networks, spirituality, sexual behavior, and substance abuse.

Why are there more and more older people with HIV? The first and principal answer is very good news: HIV meds (HAART), introduced more than 20 years ago, have increased survival dramatically. Secondly, a smaller but still significant reason: older people are becoming infected with HIV, including through sexual transmission. (Older people do have sex, though sometimes healthcare providers don’t seem to acknowledge this reality.)

As Dr. Karpiak noted, HAART prevents the collapse of the immune system, and so it serves its main purpose, to preserve and extend life. And yet, as he reminded the audience, HIV infection initiates damaging inflammatory responses in the body that continue even when viral load is greatly suppressed. These inflammatory responses, together with side effects of the HIV meds, give rise to many health challenges as the years pass. In people with HIV on HAART, research over longer time periods has found higher than expected rates of cardiovascular disease, liver disease, kidney disease, bone loss (osteoporosis), some cancers, and neurological conditions like neuropathy.

That brings us to “multi-morbidity management”—a term we weren’t enthused about at first, since it sounded more like medical-speak than the plain talk our NYBC event had promised. But Dr. Karpiak gave us a simple definition: dealing with three or more chronic conditions at the same time (and HIV counts as one). He then made the case that this is a critical concept to grasp if older people with HIV are going to get optimal care. Multi-morbidity management, he explained, is a well-accepted healthcare concept in geriatric medicine, which recognizes that older people may have several conditions and will benefit from a holistic approach in order to best manage their health. Treating one condition at a time, without reference to other co-existing conditions, often doesn’t work, and sometimes leads to disastrously conflicting treatments.

And here’s where Dr. Karpiak warned about “polypharmacy”–another medical term worth knowing. “Polypharmacy” can be defined as using more than five drugs at a time. Frequently, it comes about when healthcare provider(s) add more and more pills to treat a number of conditions. But this approach can backfire, because, as a rule of thumb, for every medication added to a regimen, there’s a 10% increase in adverse reactions. That’s why adding more and more drugs to treat evolving conditions may be a poor approach to actually staying well.

In closing, Dr. Karpiak focused especially on a finding from ACRIA’s 2006 study: the most prevalent condition for older people with HIV, aside from HIV itself, was depression. Over two-thirds of those surveyed had moderate to severe depression. Yet while depression can have serious conse-quences–such as threatening adherence to HIV meds–it has remained greatly under-treated. It may seem an obvious truth, but as Dr. Karpiak underlined, psychosocial needs and how they’re met will play a big role in the health of people with HIV as they age. What social and community supports are available becomes a big medical question, and how healthcare providers and service organizations respond to it can make for longer, healthier lives for people with HIV.

And now we come back to NYBC’s contribution to the discussion on HIV and Aging. While NYBC doesn’t keep track of such information in a formal way, we do recognize that quite a few of our members have been using supplements since the days of our predecessor organization DAAIR–going back 20 years now. That’s a lot of accumulated knowledge about managing symptoms and side effects among people with HIV! To accompany the March 28 presentation, our Treatment Director George Carter drew up a pocket guide to complementary and alternative approaches: HIV and Aging – Managing and Navigating. Partly derived from his long experience, and partly drawn from a 2012 Canadian report, the guide ranges over those kinds of “co-morbidities” that Dr. Karpiak spoke of, including cardiovascular, liver, kidney, bone, and mental health conditions. Interventions or management strategies include supplements, but also diet and exercise recommendations, as well as psychosocial supports (counseling, support groups, meditation, and activism).

NYBC has also updated several info sheets from its website and blog, offering these as a way to address some of the most common healthcare issues facing people with HIV as they get older: cardiovascular topics; :digestive health; NYBC’s MAC-Pack (a close equivalent to K-PAX®); key antioxidants NAC and ALA and their potential to counter inflammatory responses; and supplement alternatives to anti-anxiety prescription drugs. These info sheets, together with the HIV and Aging – Managing and Navigating pocket guide, are available on the NYBC website and blog.

We hope that our HIV and Aging: Living Long and Living Well event has been useful to all. Special thanks to our audience on March 28, many of whom brought excellent questions to the session. Now let’s continue the conversation…

To your health,

New York Buyers’ Club

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Supplements for Bone Health: A Special Note for People with HIV

Bone health has been a growing concern for people with HIV, since studies have indicated that HIVers experience higher than expected rates of osteopenia (bone mineral density lower than normal) and osteoporosis (bone mineral density very low, with heightened risk of fractures). A 2012 review from Johns Hopkins researchers, for example, concluded that the “increasing prevalence of osteoporosis in HIV-infected persons translates into a higher risk of fracture, likely leading to excess morbidity and mortality as the HIV-infected population ages.”

The Johns Hopkins study urged more attention to Vitamin D deficiency and supplementation as one way to counter these HIV-related bone issues. But we think it’s also worth looking at recent Canadian research, not focused especially on people with HIV, but with some striking findings about the value of multiple supplements to support healthy bone mineral density levels. The supplements investigated included vitamin D(3), vitamin K(2), strontium, magnesium and docosahexaenoic acid (DHA), all chosen because of previous evidence about their benefit to bone health. Following a year-long study of patients with varying levels of bone loss, the Canadian researchers determined that this supplement regimen was as effective as a class of drugs often prescribed for osteoporosis (bisphosphonates, such as Fosamax or Boniva). And, they found that the combination of supplements was even effective for people who had failed to benefit from the prescription osteoporosis drugs.

We hope to see further study of supplement combinations for bone loss in people with HIV. It’s an acknowledged problem as HIVers get older, and if there’s a potential way to lower this health risk over the long run, let’s take a serious look at it!

Note: NYBC stocks Jarrow’s Bone Up or Ultra Bone Up, plus Max DHA or EPA-DHA Balance, which provide most of the micronutrients in the Canadian study (missing is the Strontium, but NYBC hopes to have a recommendation for that in the near future).

Visit the NYBC website for more information:

http://www.newyorkbuyersclub.org/

References:

The Johns Hopkins study: Walker Harris V, Brown TT. Bone loss in the HIV-infected patient: evidence, clinical implications, and treatment strategies. J Infect Dis. 2012 Jun;205 Suppl 3:S391-8. doi: 10.1093/infdis/jis199.

The Canadian study: Genuis SJ, Bouchard TP. Combination of Micronutrients for Bone (COMB) Study: bone density after micronutrient intervention. J Environ Public Health. 2012;2012:354151. doi: 10.1155/2012/354151.

High Frequency of Vitamin D Deficiency in People with HIV

A number of reports in recent years have suggested an increased prevalence of osteopenia and osteoporosis (moderate and severe bone loss) in HIV-infected patients. In 2008, moreover, a study in the Journal of Clinical Endocrinology & Metabolism reported a higher rate of fractures in HIV-infected individuals compared with uninfected individuals. So there is reason for concern that osteoporosis and osteoporotic fractures will become major health problems for people with HIV as they age.

Here, we’re reporting on another study, released at the start of 2009, which fills in more pieces of information about bone health in people with HIV–and also provides guidance on supplementation strategies that could counteract bone loss and increased bone fracture rates associated with HIV. This research looked at fairly healthy (“ambulatory”) people with HIV visiting a Boston clinic in mid-winter and early spring months, and found a high frequency of vitamin D deficiency. Further tests linked this deficiency to a diminished ability to absorb and use calcium, the central ingredient in bone mass.

Based on their study, the investigators suggested that many people with HIV could benefit from daily vitamin D intake of at least 700-800 IU taken with 1200-1500mg of calcium, especially during the winter months, when the body does not have the opportunity to produce Vitamin D from exposure to sunlight.

Our conclusion: studies are now filling in the details that allow us to conclude that osteoporosis and osteoporosis-related fractures may become an increasingly important health concern for people with HIV as they age. However, there is also growing evidence that supplementing with Vitamin D and calcium can reduce this risk to bone health. It’s therefore important for people with HIV to check their multivitamin to see if they are getting appropriate levels of these two nutrients, or add a specific Vitamin D – Calcium supplement to their diet.

NOTE: NYBC stocks Vitamin D3 (the form most readily used by the body) and Calcium Blend (a food-based vegetarian supplement which includes Vitamin D3). Also available: Bone Up (Jarrow), a supplement containing calcium, Vitamin D and other components specifically for bone health.

Reference: M. Rodriguez, B. Daniels, S. Gunawardene, and G.K. Robbins. High Frequency of Vitamin D Deficiency in Ambulatory HIV-Positive Patients. AIDS RESEARCH AND HUMAN RETROVIRUSES, Vol 25, 1, 2009.

Vitamin D3 makes a guest appearance on Martha Stewart (with help from Dr Andrew Weill)

Hope we won’t be regarded as too frivolous if we admit that yesterday evening we turned to our TIVO and took in the day’s Martha Stewart Show, which featured nutrition and integrative medicine guru Dr Andrew Weill. What struck us most about Dr. Weill’s segment was his answer to a question from a female audience member on strategies for preventing osteoporosis. Dr. Weill’s answer: women should start supplementing with calcium and Vitamin D3 by the time they leave adolescence. The benefits to bone health of calcium plus D3, and–just as significantly–new findings on Vitamin D3’s role in reducing cancer rates, are now so well documented that this supplement regimen has become a “no-brainer” even for younger women.

It was nice to see a current view on D3 presented so clearly to a mass audience. (Although we have put some effort into finding and interpreting the latest news on this very interesting vitamin, we are quite aware that this Blog does not reach a public of millions!)  But we also reflected, once more, that the new evidence about Vitamin D3 also ought to be of special interest to people with HIV.  As highlighted in the media earlier this month, many people with HIV who are entering middle age are facing health issues such as osteoporosis and cancers that are more usually associated with later life. And while there has not been so much research specifically on HIV and D3, the science may already be compelling enough to make this supplement a priority in regimens.  After all, we are talking about a very low-cost supplement with negligible risks of side effect. If the results of such supplementation are reduced osteoporosis and reduced cancer risk in people with HIV as they grow older, then it might just be time to take a cue from Martha Stewart and her guest Dr Weill…

Osteoporosis in People with HIV – Info Sheet from aidsmap.com

As a number of recent news reports have highlighted, osteoporosis can be a health concern for people with HIV, so we’d like to draw your attention to the information sheet presented on the website aidsmap.com, which is sponsored by the leading HIV health information nonprofit in Britain.
Below are some excerpts from the online information sheet:

—–
Why does osteoporosis occur in people with HIV?
Osteoporosis is caused by a lack of bone calcium and protein, but the reasons for its appearance in relatively young, HIV-positive people, is still unexplained.
The high prevalence of osteopenia in HIV-positive people relative to HIV-negative people suggests that HIV itself contributes to thinning bones in this population (Knobel 2001; McGown 2001; Negredo 2001). However, it is not yet clear whether other factors contribute to thinning bones in HIV-positive people. There is growing evidence that protease inhibitors are not associated with osteoporosis but other antiretrovirals may contribute to this condition.

Link to protease inhibitors and metabolic disorders?
Several studies have found that protease inhibitor (PI) treatment has been associated with a significantly greater incidence of osteoporosis.
For example, one study found that 21% of a group of 64 men receiving PIs, compared with 6% of an age-matched HIV-negative control group, had severe osteoporosis. There was no significant relationship between osteoporosis and fat redistribution (Tebas 2000). Fifty percent of the PI group had some evidence of reduced bone mass, compared to 29% of the control group. Although some researchers have speculated that reduced level of the male sex hormone testosterone might be linked to reduced bone mass, no link was found in this study.
Treatment of osteoporosis

In a recent presentation, one of the leading researchers on osteoporosis in HIV suggested that the only interventions currently supported by evidence are to ensure an adequate calcium intake (approximately 1500mg per day), and to ensure a vitamin D intake of between 400 and 1000IU per day.

You can read the complete aidsmap.com information sheet on osteoporosis in people with HIV at:

http://www.aidsmap.com/cms1032619.asp

Reading the New York Times article “AIDS Patients Face Downside of Living Longer”

This was the title of a New York Times article by Jane Gross published on January 6, 2008.  Focusing on several case studies, the piece highlighted “a constellation of ailments showing up prematurely or in disproportionate numbers among the first wave of AIDS survivors to reach late middle age.”

There’s no doubt that the article is timely: the number of people 50 and older living with HIV has increased 77 percent from 2001 to 2005, according to the federal Centers for Disease Control, and they now are a quarter of all cases in the United States (about 116,000). And, it’s certainly true, as the piece suggests, “the graying of the AIDS epidemic has increased interest in the connection between AIDS and cardiovascular disease, certain cancers, diabetes, osteoporosis, and depression.”

The New York Buyers’ Club (like its predecessor DAAIR) has always been engaged in looking ahead in order to size up and respond to the special health issues faced by people with HIV, whether those issues derive from the virus itself, or from medication side-effects. So if you’d like to know more about how our membership has used dietary supplements over the longer haul to maintain and improve their health, and to counter symptoms and medication side-effects, please do continue to consult this blog, as well as our website, found at www.newyorkbuyersclub.org. Also–if you’d like to be included the mailing and/or email list for our quarterly publication THE SUPPLEMENT, just drop a line to contact@newyorkbuyersclub.org. NYBC doesn’t claim to have all the answers to the health concerns of people with HIV, but you might be surprised at how many useful recommendations and suggestions (based on much reviewing of the science and many years of accumulated experience) our nonprofit information exchange has to offer.