Preventative health for PLHIV: some key issues

Preventative health for PLHIV: some key issuesSean Slavin

Assistant Director

Context • ‘Prevention’: changes in meaning over time

o transmission preventiono HIV disease prevention

• More PLHIV, living longer, thus the median age of PLHIV rising.

• Observational studies increasingly emphasise risks of non-AIDS morbidity and mortality

Diagnoses of HIV infection and AIDS in Australia

Source: State and Territory health authorities

HIV viral load and CD4+cell count by year1

Source: Australian HIV Observational Database

1 Dashed lines indicate the years of retrospective data collection.

Clinical Infectious Diseases 2008 47(4):542–553

Age distribution of HIV positive MSM in Australia

Thanks John Murray – NCHECR / UNSWE

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Multiple co-morbidities: HIV versus controls

Guaraldi G et al. CROI 2010. Abstract 727

Comorbidities analysed: hypertension, Type 2 Diabetes Mellitus, Cardiovascular disease and osteoporosis Guaraldi G, CROI 2010 Abstract727

“Prevention” has a broader meaning among PLHIV

• Heart / vascular system, liver, kidneys, psycho-social, bones, brain

• Risk factors – being HIV+ - also lifestyle, family history, social context.

• Many of these are the same as for the general population, although they may work in slightly different ways

• What do we do?o A number of scientific questions need to be answered

through researcho Lifestyle change is probably a step in the right direction but

not a complete solution

Aetiology & Consequences

• HIV disease (various theories re. mechanisms)• Rx (still much to learn about long term effects)• Lifestyle risks (elevated among PLHIV)

• Specific co-morbidities esp. brain, bone, vascular, liver, kidney

&/or• A non-specific acceleration of senescence

Problems with prevention

• Treatment as preventiono Rx lowers VL and reduces transmission risk

• Public healtho Prioritises populations over individuals

• Need to emphasise health and human rights of individuals

o Individuals responsible for population health• Need a political agenda around social context that goes

beyond the homilies

CVD risks – what we can influence

A cautionary note

• Health reform is moving fast – increasing role for primary health care to reduce reliance on hospitals

• A place for community based health promotion

• Even good GPs time poor and often prefer a drug intervention and increasingly being asked to squeeze more into a 15min consult.

Conclusion: HIV+ health and the national prevention agenda

• There is some overlap• Lifestyle risks can and should be reduced but this

isn’t a silver bullet for non-AIDS morbidities• Remain cognisant of:

o social determinants – poverty, stigmao Confounding conditions – mental health esp.

• Health not universal good – social identity• Critical relationship with social contexts and

particular behaviours that includes things like pleasure, quality of life, social identity

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