Dr Allison Agwu on the Health Effects of In Utero vs Later HIV Acquisition

Many young people develop resistance to antiretroviral treatment or they experience lipoatrophy; many also have metabolic complications or inflammation via immune activation, noted Allison Agwu, MD, ScM, FAAP, FIDSA, Johns Hopkins University School of Medicine.

Many young people develop resistance to antiretroviral treatment (ART) drugs, or they experience lipoatrophy or lipodystrophy; many also have metabolic complications related to ART or inflammation via immune activation, noted Allison Agwu, MD, ScM, FAAP, FIDSA, professor of pediatrics and internal medicine, Division of Infectious Diseases; program director, Pediatric Adolescent Young Adult HIV/AIDS Program; and medical director, Accessing Care Early Clinic at the Johns Hopkins University School of Medicine.


How do the health consequences of persons born with HIV differ vs those who acquire the virus later?

I think in terms of adults born with HIV compared to those who may have acquired it later on, if we look at adults of the same age—I mentioned those born with HIV are in their 30s and 40s—and you look at someone who acquired HIV and are now adults—they acquired maybe in their late teens, etc—they have maybe 10 years of HIV experience, while one born with HIV has 30 to 40 years of experience, right? That's antiretroviralexperience, and we know that treatment for HIV was first nothing, than monotherapy, dual therapy, right, and then going on until we got to highly active antiretroviral therapy [ART]. We knew one wasn't enough.

Many of these young people develop resistance, so they are more likely to have cumulative resistance. There is resistance that has developed to multiple agents; many have multidrug resistance. So they may have limited treatment options in terms of the individuality, they may have the impact of having lifelong ART in their system. So many of them bear the scars of that: lipoatrophy, lipodystrophy. Many of them have metabolic complications related to that that have been as a result, compared to the younger people who are the ones who acquired in adolescence or adulthood, where they're less likely to have seen all those agents, less likely to see monotherapy, less likely to have drug resistance

There’s certainly the impact of the virus itself in terms of inflammation, and so then you have those who have that inflammation, which continues whether or not you're on treatment and are suppressed. We know now that that inflammation, the immune activation, continues in your system. What those 30, 40 years of that compared to 10 years or less mean, and what does it mean when you have that inflammation and that viral replication while you're developing in utero or over time? Which gives us a suggestion that if we're seeing comorbidities in older adults who have been on HIV treatment or have had HIV for a long time, what should we be seeing and what should we be worried about in those people who have had lifelong HIV antiretroviral treatment?

Your ability to think critically, etc, that may be impacted, which then affects education, financial, etc. So the ripple effects related to that. Then you have depression, ADHD [attention-deficit/hyperactivity disorder], other things that we know are associated with HIV itself; antiretroviral treatment, suboptimal; and then the life impacts of all that on yourself as a person living with HIV or family, etc, around you. So I think in the talk, you saw there was literally every aspect and saying, “Well, how does this impact these individuals?” And then in the second decade of life, third decade, as life evolves, and the things that happen regularly in life, and then HIV that impacts over time. Some we know, and some we don't know yet, because they’re still playing out, and how do we definitely need to think about it in order to intervene earlier when possible?