Co-morbidities, Overview

Prevention & Management of Co-morbidities in PLWH

 

Successful management of PLWH goes beyond provision of effective ART, with increasing focus attributed to the appropriate management of co-morbidities in order to ensure the best outcomes for PLWH. Recognised co-morbidities that disproportionately affect PLWH include mental health issues (particularly depression and anxiety disorders), cardiovascular, pulmonary, hepatic, metabolic, neoplastic, renal, bone, central nervous system disorders as well as sexual dysfunction (including age-related changes such as menopause). Collectively, these conditions can significantly impact the physical and mental health of PLWH as they grow older. Recognising that older persons comprise a significant proportion of many populations living with HIV, the current version of the Guidelines suggests HIV-specific age cutoffs for screening for many of these co-morbidities as well as greater focus on prevalent conditions such as weight gain and obesity and age-related conditions such as frailty.

Potential contributors to co-morbidity pathogenesis include a higher prevalence of recognised risk factors, potential toxicities from ART exposure, and HIV infection (or co-infections with CMV and HCV) contributing to immune dysfunction/dysregulation, chronic immune activation and inflammation. Taking this into consideration, particular focus should be paid to cessation of smoking, which contributes to many of the co-morbidities described.

The COVID-19 pandemic has brought many challenges to the care of PLWH, including interruption or significant changes to routine healthcare provision. In this setting, it is of particular importance that healthcare professionals other than HIV specialists, who are involved in the care of PLWH and who are not familiar with the use of ART, should consult their HIV specialist colleagues before introducing or modifying any treatments for co-morbidities. As intervals between visits to HIV clinics are increasingly extended, or even interrupted, PLWH may need more frequent review by their primary care doctor and we would encourage establishment of formal shared-care arrangements to optimise management of co-morbidities and prevent unwanted drug-drug interactions.

Many HIV doctors are not specialists in managing co-morbidities and, although general guidance on management of common co-morbidities is included in these Guidelines, HIV doctors should seek expert advice where appropriate in the prevention and management of such conditions. Situations where consultation is generally recommended are indicated within this document.

In particular, as individuals with treated HIV age, some may experience multiple co-morbidities occurring together, which may contribute to frailty and disability. Such circumstances may require a comprehensive “geriatric-type” multidimensional, multidisciplinary assessment aimed at appropriately capturing the composite of medical, psychosocial and functional capabilities and limitations of older PLWH. A suggested approach for the management of older PLWH are included in this version of the Guidelines.

Depending on future clinical research findings, and the constantly evolving challenges presented by the COVID-19 pandemic these recommendations will be regularly updated as required, http://www.eacsociety.org and in the EACS Guidelines App.

The current recommendations highlight co-morbidities that are seen frequently in the routine care of PLWH and those for which specific issues should be considered.