AIDS Community Research Initiative of America (ACRIA) - Summer 2004
Jerome Ernst, MD

Aging affects us all - something that was unfortunately not true for most of the HIV-positive population until recently. But thanks to the wonders of modern science, many HIV-positive Americans are joining the march to older age together with millions of their fellow citizens. In the year 2000, 34 million people in the United States were older than 65 years; by 2025, this number will almost double. And, given effective antiretroviral therapy, HIV-positive people will face the same burdens of diseases of aging as everyone else, with the added problems of HIV/AIDS and the complications of drug-drug interactions - the effects of antiretroviral drugs on drugs used to treat diseases that affect the elderly and vice versa.

In the following paragraphs, a few ailments common in older people will be discussed. They include high blood pressure (hypertension), heart disease, high cholesterol and triglycerides (hyperlipidemia), colorectal cancer, prostate cancer, and osteoporosis (reduction in bone mass). A bit about each condition and how being HIV-positive affects its treatment will be presented. Of particular concern are the interactions between the drugs used to treat these ailments and the antiretrovirals used to treat HIV.

Blood pressure can be lowered in two ways - by living a more healthy life and with drugs. By a healthier life, I mean by losing weight if one is overweight, stopping smoking if one smokes, reducing one's alcohol consumption if one drinks, and moderate exercise. These changes are often enough to treat mild hypertension.

There are a large number of antihypertensive drug options for patients whose blood pressure does not respond to these interventions. Frequently, both a healthier way of life and antihypertensive drugs are needed.

Definitions of hypertension continue to change. For me, a person needs to be treated if their blood pressure is above 135/85 mm mercury. The first number is known as the systolic reading. It is the pressure measured in the arteries when the heart is contracting. The diastolic reading, or second number, is the pressure measured in the arteries when the heart is no longer in contraction. The contracting state is called systole and the relaxed state is called diastole. Thus, a blood pressure of 135/85 means that the systolic blood pressure is 135 and the diastolic is 85.

People with high blood pressure usually remain symptom free for years before they develop the complications of stroke, heart attack, heart failure and renal failure. The time course for developing these complications is sped up by abnormal levels of lipids, or fats, in the blood (dyslipidemia), cigarette smoking, diabetes mellitus, obesity, lack of exercise, high salt diet, and situational stress.

Weight Reduction
Clinical trials have shown that the more weight one loses, the greater the fall in blood pressure. Even a weight loss of several pounds may be enough to enable one to do without drugs or to reduce the amount of drugs needed to control blood pressure. If weight gain recurs, hypertension may return.

Exercise
Exercise also helps reduce high blood pressure. After exercise, blood pressure may fall as much as 6 to 7 mm Hg, independent of any weight changes. It has been shown that moderate-intensity exercise is as effective as higher-intensity exercise. A 20 to 30 minute daily walk may be just as effective at lowering one's blood pressure as an intensive workout.

Dietary Adjustment
A recently published clinical trial done in people with mild hypertension showed that increasing fruits and vegetables in one's diet resulted in a moderate reduction of blood pressure. The reduction in blood pressure was almost doubled if one also reduced their dietary fat intake. Some patients who were on a high fruit and vegetable and low fat diet had normal blood pressure after only eight weeks.

Sodium Restriction
Salt restriction has been shown to reduce the need for drug therapy in hypertension. This seems to occur with or without weight reduction. The problem most patients have is maintaining a low salt diet over time. I usually tell my patients to do the best they can but not get crazy over it.

Alcohol Restriction and Smoking Cessation
Reducing alcohol intake to less than two shots of liquor or 8 ounces of wine a day is effective in reducing blood pressure and may even help prevent the disease. And, while stopping smoking may not affect blood pressure levels, it does eliminate an additional risk factor for cardiovascular disease.

Stress Reduction/Relaxation Training
Stress reduction has not been shown conclusively to be effective in reducing blood pressure when used as the main treatment. Also, it has not been proven that a high-stress job by itself is enough to produce high blood pressure. Current thinking is that it is how one copes with stress that may cause hypertension rather than the stress itself.

Drug Therapy
Different physicians use different drugs, usually choosing the one that best suits the particular patient and with which the prescribing physician is most familiar. In general, most physicians start with a diuretic, then add either a beta blocker, ace inhibitor, or calcium channel blocker. Further changes depend on the patient's response.

Lipids are fatty substances in the blood. The one most everyone knows is cholesterol. There is the good cholesterol, called HDL (high density lipoprotein), and the bad cholesterol, called LDL (low density lipoprotein). Total cholesterol is the sum of these two components plus a few others that are present in much smaller amounts. HDL helps remove cholesterol from the body, while LDL helps deposit it in the walls of blood vessels where it can cause heart disease and strokes. A study published in the April 8, 2004 issue of The New England Journal of Medicine showed that the lower one's LDL, the lower the risk of further heart disease in people who already have heart disease. Up until this study, health guidelines called for lowering LDL in the blood to 100 mg/dL in people with risk factors for heart disease. Now, most physicians are trying to get their patients to go even lower. One result is that more people will need to be placed on statin drug therapy, which, together with a low fat diet, is the most effective way today to reduce LDL levels (see chart below for cholesterol ranges).

In this procedure, the doctor is looking for polyps (small benign growths that have the potential to turn cancerous), which can be removed through the colonoscope with special instruments. Since cancers of the colon can come from these polyps, removing them before this happens prevents the disease. The rate of major complications from this procedure, such as bleeding or perforating the colon, is less than 1%, and fewer than one out of a thousand people who have a colonoscopy die from complications.

The most common test for screening for prostate cancer is the rectal exam. Although it is an inexpensive test, it is not all that sensitive. This test picks up only about two thirds of cancers in men who don't have any symptoms.

The PSA (prostate-specific antigen) test is a blood test that was first used to monitor the spread of prostate cancer and is now being used as a screening test. PSA is a protein made by the prostate and is found normally in the blood. The amount of this protein in the blood increases in men who have prostate cancer. The PSA test is more sensitive than the rectal exam but often detects cancers that will not spread. Recent reports show that some men have cancer with low levels of PSA in their blood and other men with high levels do not have cancer. Illnesses such as prostatic inflammation or enlargement can cause elevated levels. Once someone is found to have an elevated PSA level, a needle biopsy of the prostate gland is usually done and, if cancer is found, an operation may be suggested. Whether or not surgery is recommended depends on many factors including the patient's age and the appearance of the cancer cells under the microscope.

Patients should not undergo PSA testing lightly. Because a high PSA level often leads to biopsies and surgery which may not always be necessary and can cause serious complications, it is important that all of this be explained to the patient before they have the test, in fuller detail than space allows here. Sort of like the informed consent one gets before having an HIV test. The complications of surgery include impotence and urinary incontinence - and, although not everyone gets these complications, not everyone with prostate cancer needs surgery. The subject is a complicated one, much more knowledge needs to be gathered, and patients should be well informed before they embark on screening tests for prostate cancer. Some physicians recommend that only high-risk patients undergo such screening.

Bone density has been reported to be lower in both HIV-positive men and women when compared to the HIV-negative population. However, the differences shown have not been significant and may not be related to age. It has been shown to occur regardless of whether or not patients are on antiretroviral therapy. A recent study from Spain suggests that the longer one is HIV-positive, the greater the loss of bone density. The significance and validity of this study will become apparent as the HIV population over 50 increases and more studies are done.

What's next?
This article is not meant to be and is by no means exhaustive in its discussion of diseases and conditions that affect the HIV-positive population over 50. What should be clear, however, is that the diseases of aging will become more prevalent in the HIV-positive population as it itself ages. It does not seem that being HIV-positive protects anyone from these illnesses. Whether these diseases will be less or more prevalent and how, if at all, their characteristics will differ from their manifestations in the HIV-negative population remains to be seen. The interactions between drugs used by someone with HIV and those used to treat the diseases of aging need further exploring. And, of course, the added costs of these medications will continue to be a problem for most Americans.

Jerome Ernst, MD is ACRIA's Medical Director and sees both HIV-positive and negative patients in his medical practice.

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