Intended for healthcare professionals

Clinical Review

HIV infection, antiretroviral treatment, ageing, and non-AIDS related morbidity

BMJ 2009; 338 doi: (Published 26 January 2009) Cite this as: BMJ 2009;338:a3172
  1. Steven G Deeks, professor of medicine1,
  2. Andrew N Phillips, professor of epidemiology2
  1. 1Positive Health Program, San Francisco General Hospital, University of California, San Francisco, CA 94131, USA
  2. 2HIV Epidemiology and Biostatistics Group, Department of Primary Care and Population Sciences, and Royal Free Centre for HIV Medicine, Royal Free and University College Medical School, University College London, London NW3 2PF
  1. Correspondence to: S G Deeks, 995 Potero Avenue, San Francisco, CA 94110, USA sdeeks{at}

    Summary points

    • Although mortality in people with HIV infection continues to decrease as treatment improves, it is still higher than in uninfected people

    • The risk of non-AIDS related morbidity and mortality—including cardiovascular disease, liver disease, and cancer—is higher in untreated HIV infection than in treated infection

    • The incidence of cancer, liver disease, and cardiovascular disease is higher in treated patients than in age matched HIV uninfected people

    • Lower CD4+ T cell counts on treatment are associated with increased risk of cancer, liver disease, and perhaps cardiovascular disease

    • Treatment improves immunological function, but persistent defects—many of which are seen in advanced ageing—remain

    • Inflammation often remains raised during long term antiretroviral treatment; the cause and clinical relevance of this persistent inflammation are unclear

    More than 25 antiretroviral drugs from six therapeutic classes are now available for the management of HIV infection (box 1). Most patients who take medication achieve durable and perhaps lifelong viral suppression, so the classic AIDS related conditions are becoming less common. However, treated patients do not have completely restored health. Compared with people without HIV infection, patients with the infection who are treated with antiretrovirals have increased risk for several “non-AIDS” complications, many of which are commonly associated with ageing (box 2). This risk is particularly evident in patients whose CD4+ T cell counts are below normal during long term treatment, but it is also seen to some extent in those with higher CD4+ T cell counts. As a consequence of the changing spectrum of HIV associated disease, the medical management of HIV infection is evolving—a lower proportion of time is now spent managing drug resistance and short term toxicities and a higher proportion is spent managing these premature age associated complications. This review discusses the evidence that the major complications of “treated” HIV disease—including cardiovascular disease, malignancy, renal disease, …

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