Africa: Getting Old on ARVs

Data about the affects of ARVs on ageing are still scarce. (Photo: Eva-Lotta Jansson / IRIN)

"Eish, with ARVs, you get fat and you get old," a patient at Johannesburg Hospital recently told her doctor, referring to antiretrovirals.

A few years ago, when people infected with H.I.V. in the developing world were wasting away and dying in devastating numbers, her complaint would have been cause for celebration. But as more and more H.I.V.-positive Africans extend their life expectancy with ARVs, their waistlines and risks of contracting serious non-AIDS related illnesses, such as diabetes and heart disease, are expanding accordingly.

The fourth most common cause of death in H.I.V.-positive South Africans is now hypertension; diabetes comes in sixth.

Data from the developing world on ageing with H.I.V. are still scarce, but in the developed world only 8 percent of H.I.V.-positive people on ARVs die of AIDS-related illnesses.

"H.I.V. might become the ultimate lifestyle disease," Dr. Francois Venter, director of the Southern African H.I.V. Clinicians Society, told fellow clinicians at a monthly meeting in Johannesburg on Thursday.

As H.I.V. becomes an increasingly manageable chronic disease, Venter attempted to answer the question of how to help people living with the virus enjoy a relatively healthy old age.

H.I.V.-positive people may be at greater risk of certain illnesses associated with old age, and there is some evidence to suggest they may contract them sooner, but Venter was upbeat about their chances of preserving a good quality of life into old age, providing they exercised, watched their diets, and avoided stress.

"The same advice we give to H.I.V.-negative people is important for positive people," said Venter. "There's only one additional step—viral suppression [with ARV medication]."

Venter advised his fellow clinicians to pay particular attention to risk factors like obesity, smoking, and depression in their H.I.V.-positive patients, and to consider the "context for care": the extent to which factors like poverty or mental health might affect the wellbeing of their patients.

He dismissed "conventional thinking" that side effects resulting from antiretroviral therapy (ART) would eventually drive mortality in people living with H.I.V., but another clinician in the audience commented that "the jury is still out" on what the long-term impact of ART might be on their health.

According to a January 2008 report in The New York Times, many long-term survivors of H.I.V. in the United States are now experiencing severe health problems that experts attribute partly to the highly toxic first generation of ARV drugs that became available in the 1990's.

A study from Denmark has estimated that currently available ARV drugs, which are much less toxic and cause fewer side effects, can add 39 years to the life of a 25 year old. But no such studies have been done in Africa, where environmental factors like poverty and the high prevalence of dangerous opportunistic infections, including tuberculosis, could shorten an H.I.V. positive person's lifespan in spite of ARVs.

Africans also tend to start ARV treatment much later than their European and American counterparts—the average CD4 cell count (which measures the strength of the immune system) for South Africans starting ART is between 80 and 100—a factor that has been linked to a greater risk of contracting AIDS-related illnesses in the short term as well as non-AIDS-related illnesses in the long term.

Reaching a very low CD4 count can cause permanent damage to the immune system and some internal organs, making patients particularly susceptible to liver disease, kidney failure, and certain cancers. Treatment guidelines in most countries, although not in South Africa, now recommend starting patients on ART when their CD4 count drops below 350.

In South Africa, as in the rest of sub-Saharan Africa, by far the greatest risk factor for people living with H.I.V. is not being able to get ARVs. Venter noted that less than half of South Africans in need of ARV treatment were receiving it. Partly this is due to low rates of H.I.V. testing, but large numbers of patients still die while waiting to begin treatment. © IRIN

From Integrated Regional Information Networks.