MIAMI—Thirty years ago, veterans with human immunodeficiency virus and their physicians focused on survival. Now, they face the same challenges associated with aging as other veterans. That change is driving new research and new care structures at the VA.
Prostate cancer, for instance, has become a significant issue for many of the more than 27,000 veterans with HIV who receive care through the VA. It now ranks as the second most common malignancy among older veterans with HIV. Only lung cancer occurs more often.
“Our population with HIV infection is aging (the median age is above 55 years, with the oldest 90 years old),” said Gordon Dickinson, MD, staff physician at the Division of Infectious Diseases at the Miami VAMC and a contributing author of a study on HIV infection and prostate cancer in veterans presented at IDWeek 2018. “Prostate cancer is not surprising” in this age group, Dickinson added.
Perhaps more surprising to those not directly involved in the care of veterans with HIV is how well they respond to treatment. Dickinson and his colleagues found that HIV did not appear to affect the prognosis of veterans with prostate cancer. Ironically, it might actually help them a bit.
With aggressive screening of prostate-specific antigens and the regular visits with providers that form the foundation of HIV care at the VA, “we may have picked up several [cases of prostate cancer] early,” Dickinson told U.S. Medicine. “There is literature to suggest the diagnosis is made at a slightly younger age if the patient has HIV.”
The Miami VA researchers conducted a retrospective review of patients with HIV who received care at the Miami VAMC between 2007 and 2016. Of the 1752 total, 45 veterans had a diagnosis of prostate cancer. The average age at which the Miami veterans with HIV were diagnosed with prostate cancer was 62.09 years. That was about four years younger than the mean age of diagnosis for all men in the U.S., based on statistics from the American Cancer Society.
Almost three-quarters of those with prostate cancer were African-American, and more than half reported alcohol consumption (53.3%) and smoking (51.1%), while 31.1% used drugs.
The majority of patients had well-controlled HIV. Nine out of 10 (88.89%) patients took antiretroviral therapy, and 90% of them had an undetectable viral load. The mean CD4 count was 576.84 cells/uL. The normal range for CD4 cells is 500 to 1,500 cells/uL.
“The PSA rather than digital rectal exam was important in diagnosing prostate cancer” in veterans with HIV, Dickinson noted.
Just 13.3% of those with prostate cancer had nodules or masses detectable by digital rectal exam at diagnosis. The other 86.7% of patients were referred for a needle biopsy based on elevated PSA levels and were identified at a very early stage (clinical stage T1c N0 M0). The mean PSA for men diagnosed with prostate cancer was 13.96. Sixty percent had enlarged prostates.
Treatment included surgical prostatectomy (37.8%), radiation therapy with or without androgen deprivation therapy (62.2%) and androgen deprivation monotherapy or active surveillance (6.7% combined).
Dickinson said his experience has been that veterans with HIV respond well to treatment, and the study bore that out. After a mean follow-up of 42.3 months, the researchers found that only one patient had died of metastatic prostate cancer. Four patients had died of other malignancies, one each for Hodgkin lymphoma, pancreatic cancer, renal cancer and hepatocellular carcinoma.
“The takeaway is that, in an aging HIV population, prostate cancer is common and that the tumor seems to respond to treatment in much the same fashion as it does among the HIV-free population,” Dickinson said.
Who Manages Comorbidities?
Dickinson noted that the same factors that are driving greater diagnosis of prostate cancer in veterans with HIV also are transforming their care at the VA.
“Doctors with a special interest in HIV management are often infectious disease specialists without special skills related to diabetes, renal disease, heart disease and the problems of aging such as dementia, frailty, etc.,” he said. Yet, increasingly, those comorbidities are the primary health challenges for older HIV patients.
While no one questions that HIV specialists are best suited to manage antiretroviral therapy and opportunistic infections, there is active debate about who should provide care for the comorbidities HIV patients develop as they age. One approach consolidates care in HIV clinics, while another manages comorbidities for HIV patients the same way as for other patients—in primary care clinics.
In the Miami HIV clinic, infectious disease specialists who focus on HIV “converted from being the primary care providers for our veterans with HIV, to being the specialty physicians, while the primary care is managed by a PACT” or patient-aligned care team, Dickinson noted.
The majority of VAMCs have pursued a consolidated care approach, according to a VA Health Services Research & Development study led by Barbara G. Bokhour, PhD, of the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, Massachusetts.2
That study found “substantial variation in viral, hypertension, and diabetes control across VA HIV clinics but these are not highly correlated at the clinic level.” Overall, “VA performance is very high for quality measures of HIV care,” while comorbidity care varied substantially.
To assess which structure provided better care for patients with common comorbidities, HSR&D researchers looked at one of the most frequent issues faced by older veterans—hypertension. They found that patients who received care within an HIV clinic were 31% more likely to achieve hypertension control than those whose health issues were co-managed between a PACT and an HIV clinic. 3
The investigators noted that shared care models tended to be adopted by smaller HIV clinics with fewer internal resources and suggested that consolidated care and shared care models may have different impacts on treatment outcomes for other chronic comorbidities such as hyperlipidemia, diabetes and osteoporosis.
1. Baez Presser J. Dickinson GM, Gonzoles-Zamora J. Clinical Characteristics and Treatment Patterns of Prostate Cancer in HIV-Infected Veterans over a 10-Year Period. IDWeek 2018. Poster Abstract Session: HIV: Malignancy. October 6, 2018.
2. Bokhour BG. IIR 12-385: Integrating HIV Care in the VA: Extending PACT Principles to Specialty Care.
3. Appenheimer AB, Bokhour B, McInnes DK, et al. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open Forum Infect Dis. 2017;4(1):ofx005. Published 2017 Feb 3.