Managing Multimorbidity and Polypharmacy in HIV: Insights From Michelle S. Cespedes, MD, MS

As HIV treatments evolve, so do the complexities of managing comorbidities and polypharmacy in people living with HIV. Michelle S. Cespedes, MD, MS, professor of medicine (infectious diseases) at the Icahn School of Medicine at Mount Sinai, New York City, New York, shares her insights on balancing effective HIV regimens with the risks of additional health concerns. She highlights the importance of patient education, the latest guideline changes influenced by the REPRIEVE study, and the critical role of doctor-patient engagement in optimizing care for long-term wellness.

Cespedes presented this study at IDWeek, the joint annual meeting of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists in Los Angeles from October 16 to 19, 2024.

ICT: How do multimorbidity and polypharmacy impact the treatment strategies for people with HIV, and what are the most common challenges you encounter when managing these complex cases?

Michelle S. Cespedes, MD, MS: Over decades of evolving treatments for HIV, we have learned that safe and effective regimens—that are simple to take and have few side effects—have the best patient outcomes and adherence. As the average age of people living with HIV continues to rise, comorbidities that require their own treatments increase the pill burden on patients. The most common challenges we encounter are minimizing the contribution of HIV treatments to additional health concerns (including weight gain, neuropsychiatric effects, and cardiovascular risk) and drug interactions with HIV medications. As HIV treatment evolves into more options with long-acting injectables that can last several months in the body after a single dose, it is important to review all medications to prevent interactions that can have long-term effects.

ICT: Can you explain how current guidelines and real-world data can be applied when making treatment decisions for HIV patients with multiple comorbidities?

MSC: People with HIV have been shown to have cardiovascular events at a younger age and even with lower traditional risk factors for having a heart attack. One of the most impactful recent studies in the HIV world is the REPRIEVE study, which demonstrated that the use of one of the cholesterol-lowering drugs in the statin drug class in people with HIV who had normal cholesterol levels and low risk of having a heart attack, actually decreased their risk of having a heart attack, stroke, or other cardiovascular event by 35 percent. The results of this extensive study have now changed the guidelines to recommend using a statin for people with HIV over the age of 40, regardless of the score the traditional risk assessment calculators would give them.

ICT: In your experience, what role does patient education and engagement play in managing the complexities of polypharmacy for people with HIV?

MSC: Patient engagement with their providers is essential to preventing missed opportunities to address the possibility of poor outcomes or drug interactions. For example, some common minerals, including calcium and magnesium, found in over-the-counter multivitamins can decrease with the drug levels of some HIV medications. Occasionally, another medical specialist that the patient sees may prescribe a medication—like a blood thinner, steroid, or even a blood pressure medication—that has a drug interaction with their HIV treatment. Ongoing conversations for education on new advancements and risks are critical for the doctor-patient relationship.

ICT: Could you share some insights from the real-world testimonials of people with HIV that highlight the most significant challenges they face in managing comorbidities along with their HIV treatment?

MSC: One of the highlights from the testimonials included a patient who didn’t realize that his HIV medication was contributing to his depression and poor sleep until he was switched to another regimen. It highlights the importance of discussing side effects, even if one doesn’t think there is an association.

ICT: What expert guidance do you offer when balancing the risks and benefits of treating comorbidities in HIV patients to ensure both short-term and long-term wellness?

MSC: The importance of having continued dialogue regarding possible side effects of medications and the options to avoid them entirely cannot be overstated. Reiterating that the goal of treatment is not only to maintain an adequate immune system to prevent opportunistic infections but also to sustain overall health and quality of life. Cardiovascular disease remains a major contributor to disease for people with HIV, so in addition to remaining adherent to their HIV regimen, patients are also encouraged to maintain an active lifestyle with a healthy diet and exercise, as well as avoiding the use of tobacco. Recent data on the benefit of statins for those with HIV over the age of 40 has now been incorporated into the guidelines as a recommended strategy to prevent cardiovascular events in this population.