Metabolic Complications Linked With HIV, Impact on Patient Outcomes

In part one of this podcast series, Daniel Lee, MD, clinical director, Pacific AIDS Education Training Center HIV Learning Network, and director, Owen Lipid/Lipodystrophy Clinic, University of California–San Diego, offers insight into the medical complications associated with HIV, as well as their impact on patient outcomes.

Listen to part two.

Read the full transcript:

Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today, we are joined by Dr Daniel Lee, clinical director of the Pacific AIDS Education & Training Center HIV Learning Network, and director of the Owen Lipid/Lipodystrophy Clinic at the University of California–San Diego. He discusses the medical complications associated with HIV as well as their impact on patient outcomes. Dr Lee?

Hi, I'm Daniel Lee. I'm a clinical professor of medicine at UC San Diego Health. I work as a primary care HIV physician at the Owen Clinic, which is our HIV clinic at UCSD Medical Center.

My area of specialty, I'm an internist by trade but specialized in HIV care. My research is focused on the clinical management of metabolic complications in HIV. I started a subspecialty lipid/lipodystrophy clinic about 20 years ago to address these particular issues.

What are the complications associated with HIV, and what would you say their prevalence in these issues?

There are a ton of complications that can be associated with HIV. The ones that I'm most focused on are many of these metabolic complications associated with HIV.

The common ones that we see often have to do with things like lipid abnormalities, such as elevated triglycerides and cholesterol levels, glucose abnormalities, such as insulin resistance and diabetes, fat abnormalities such as lipodystrophy and HIV-associated weight gain, which is a hot topic right now, and also muscle abnormalities such as HIV-associated wasting.

The prevalence of these vary from patient to patient and obviously depends on which ones they perhaps get. However, as people are living longer with HIV and are getting older, we definitely are seeing much more of the lipid, glucose, and fat abnormalities.

Luckily, we don't see as much of the HIV-associated wasting as we did back in the early days, and a lot of that is really because of our improved antiretroviral therapy, but it still exists. We still see HIV wasting every now and then.

Unfortunately, with the COVID-19 pandemic, people are also exercising less and stress-eating a lot more, which leads to an increased prevalence of weight gain, high blood pressure, lipid abnormalities, as well as glucose abnormalities.

What is the impact of these complications on patient outcomes, generally speaking?

The impact of these comorbidities on patient outcomes can certainly affect the quality of life of our patients. For instance, HIV wasting and body fat changes, which we call lipodystrophy, can be quite disfiguring and reduce quality of life by affecting body image and self-esteem, and lead to increase depression and anxiety.

Other comorbidities, such as the lipid and glucose abnormalities, can increase cardiovascular and cerebrovascular risk. We have to be vigilant to screen our patients for heart attacks and strokes.

In addition, there is a concern about persistent inflammation associated with HIV, as well as a potential accelerated aging process that may exist in people with HIV. As I said, as people are living longer with HIV and are getting older, we are starting to see many more of these comorbidities at much younger ages.

Lastly, the effect of the increased prevalence of these comorbidities often result in polypharmacy, which is defined as taking five or more medications. In addition, this also increases the risk of drug interactions and potential side effects. It can be quite complicated.

What are some challenges specific to treating each of these complications?

For the treatment of lipid and glucose abnormalities, as well as weight gain, we oftentimes treat these very similarly in the HIV and the non-HIV population. However, the main challenge that I see in assisting people with HIV is in making changes in terms of their diet, as well as trying to increase exercise, especially during the COVID-19 pandemic.

In general, this is always difficult. Whether someone is HIV positive or not, or even as a health care provider, too, it's not always easiest to make these changes.

I also find that it is sometimes difficult to start new medications to treat the various comorbidities due to the fear of potential new side effects, as well as the issue of adding another medication to an already complicated regimen. This is a challenge that is very common to see in our patient population.

For the treatment of lipodystrophy or HIV wasting, another issue is that we often struggle with trying to obtain various treatments, such as growth hormone products, which are used to treat those problems. Unfortunately, it often requires prior authorization through the insurance due to the cost of these medications.

As a health care provider, having to deal with prior authorization processes is just another challenge to the growing list of the challenges that we have.

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