Clinical care of HIV-patients: evaluating progress and future challenges

Abstract

Since the introduction of combination therapy in 1996, Human Immunodeficiency Virus (HIV) treatment has changed substantially. Over twenty new antiretroviral drugs have been licensed for the treatment of HIV-infection and HIV has been transformed into a long-term chronic infection for many patients. Yet it remains unclear how improved efficacy of new antiretrovirals reported in clinical trials has translated to population-level effectiveness in general clinical care. Nor is it clear how the increasingly chronic nature of HIV-infection, characterised by an ageing HIV-population increasingly suffering from age-related non-infectious co-morbidities and drug-drug interactions, will affect HIV care. Such an evaluation is important not just to measure progress, but also to address future challenges for clinical care in order to develop evidence-based changes to clinical guidelines and ensure continued high-quality care. By analysing a dataset that collects data from all HIV-infected patients in clinical care in the Netherlands it was shown that the use of combination antiretroviral therapy (cART) regimens in the Netherlands closely follows changes in guidelines, to the benefit of patients. While there was no significant improvement in mortality, newer drugs with better tolerability and simpler dosing resulted in improved immunological and virological recovery and reduced incidence of switching due to toxicity and virological failure. An individual-based model of the ageing HIV-population in the Netherlands was constructed and used to quantify and evaluate the future challenges posed by an ageing HIV-population. The model showed that the age-structure of HIV-patients in the Netherlands is rapidly shifting to older age. By 2030, almost three quarters of patients will be aged 50 or over. This will result in an increased burden of co-morbidity, polypharmacy and an increasing proportion of patients who will experience potential complications with their HIV-treatment. Cardiovascular disease (CVD) in particular will become a major burden of co-morbid disease. Integrating a smoking cessation programme or changing HIV-treatment guidelines to recommend prescribing a polypill for CVD to all HIV-patients aged 45 or 55 years and over could improve the burden of CVD, improve patient outcome and be cost saving in the long-term.