Co-morbidities, Overview

Prevention & Management of Co-morbidities

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 cardiovascular, pulmonary, hepatic, metabolic, neoplastic, renal, bone, central nervous system disorders as well as sexual dysfunction. Many of these conditions significantly impact populations 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 cut-offs for screening for many of these co-morbidities as well as the introduction of a new section offering guidance on screening for frailty in older PLWH.

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.

Health care 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, 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.

Conversely, many HIV doctors are not specialists in managing co-morbidities and should seek expert advice where appropriate in the prevention and management of such conditions. Situations where consultation is generally recommended are indicated elsewhere in this document.

In particular, as individuals with treated HIV age, some individuals may experience multiple co-morbidities, 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 elderly PLWH. Suggesting for this approach are included in this version of the Guidelines. One area that requires further exploration is how co-morbidities impact on overall quality of life and an appropriate approach to mitigate this. This issue will be a focus of the Guidelines panel going forward.

Depending on future clinical research findings, these recommendations will be regularly updated as required.

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.