SHM research focus: ‘Future challenges for clinical care of an ageing population infected with HIV: a modelling study'

Mikaela Smit.jpgStichting HIV Monitoring recently contributed data to a study published in the prestigious journal, Lancet Infectious Diseases. The paper, entitled 'Future challenges for clinical care of an ageing population infected with HIV: a modelling study', looked at how the profile of patients in the Netherlands infected with HIV is changing, in terms of disease burden and polypharmacy. We talked to the first author of the paper, Mikaela Smit, about the importance of her findings and what the implications will be for guidelines and monitoring.

Could you tell us a little about yourself?

I started off as a biologist and then did a Master’s and a PhD in epidemiology. I worked very closely with the Athena cohort during my PhD, which I did with both SHM and Imperial College London. We looked into the progress in HIV treatment since the introduction of antiretroviral therapy in 1996, but also the future challenges in HIV care, identifying ageing as being one of the major challenges to come. So, in terms of research, my focus is mostly on ageing, comorbidities and related problems in HIV care.

Could you briefly summarise the main findings of your paper?

The main point of the paper is that the HIV population in the Netherlands is ageing, partly due to good treatment. As a consequence, we are going to see quite a large increase in the burden of non-infectious age-related comorbidity. This, in turn, will complicate clinical care. Not only will these patients be more unwell, they will also be taking more medication. This extra medication may result in all kinds of issues with the HIV medication they are taking. So, the progress that has been achieved to date with new more tolerable antiretroviral medication, improved quality of life and life expectancy might be hampered in the future by the fact that these patients are going to become more complicated to manage clinically. The message is that we need to prepare for this in terms of guidelines, screening, and monitoring to ensure quality of care.

What is new about your study?

Previously, other groups have developed models to project demography of HIV-infected people in different settings, such as Southern Africa and Australia, but no one has taken a cross-disease approach, looking at non-communicable diseases and HIV and at the implications of these combinations in terms of both polypharmacy and HIV treatment. We are the first to make projections into the future across a number of different key comorbidities.  

Your study was carried out using data from a Dutch cohort study. What are the implications of your findings for the medical care of HIV-infected individuals elsewhere in the world, such as Africa?

The African epidemic is quite different. Whereas, in the Netherlands, the epidemic is mostly MSM-driven with fewer women, the epidemic in Africa involves far more women and children. In addition, we are also seeing a younger generation of HIV patients in Africa.  However, we do expect the same age-related problems to arise  given the tremendous response to the HIV epidemic in terms of treatment coverage, although there will be a time lapse. Furthermore, we will also see more women affected, although we don’t yet understand exactly what impact this will have. Finally, in Africa we are dealing with a different setting, where healthcare in many regions often remains focussed on episodic care of infectious diseases, acute symptomatic care and maternal health, and not is necessarily prepared to deal with long-term chronic disease management.

Can you tell us what you are working on at the moment and what your plans are for future research?

My main project at the moment is to look at this issue in Africa. We’re working on a healthcare model where we simulate both the HIV epidemic and co-infections and comorbidities to get an idea of the patient profiles that will arise. The idea is to see if we can use HIV as an entry point to treat not only HIV, but also other diseases. There are considerable cost benefits to be gained through this vertical approach. It’s a big project, but I am very excited about it.

Do you plan to come back to the present model?

Yes, we’ve been approached by various groups who want to make similar projections in other European countries. In the Netherlands, we are also working with the SHM, the Amsterdam Institute for Global Health and Development, and the AGEhIV Cohort Study to modify and expand this present model to better capture the future burden of cardiovascular disease amongst HIV-infected people.  In particular, we hope to understand more specifically how the cardiovascular disease burden is going to change and to evaluate the impact of various primary interventions and HIV-specific interventions.  The aim is to see whether and how HIV guidelines could be further strengthened and improved. I particularly enjoy this collaboration since so much care goes into SHM’s data and they offers so much potential – as a modeller, I find SHM’s data a joy to work with.

» Click here to read the abstract