CIHR HIV/AIDS Research Initiative: Summary Report on the Roundtable on Issues of Comorbidities in HIV/AIDSOttawa ON
September 21-22, 2010
Table of Contents
- Research Topics for a Funding Opportunity
- Funding, Partners, and Knowledge Translation
- Going Forward
Significant advances in treatment over the past 20 years have meant that, in developed countries, HIV is now largely experienced by those infected as a complex chronic disease. While people with HIV are living longer than before, the combined effects of the aging process and the physical and mental impacts of the disease and its treatment are increasing the occurrence of co-existing health conditions in members of this group.
People with HIV have higher rates of comorbidities — including cardiovascular, kidney and liver diseases, malignancies, and neurologic disorders — than their uninfected peers. They are also more likely to be co-infected with other sexually transmitted infections and with hepatitis B and C. Furthermore, in the United States — a country with an HIV epidemic similar to that in Canada — up to 50 percent of people with HIV have a mental illness such as depression, while 13 percent have both a mental illness and substance-use issues.
This situation is challenging for clinicians and community-based HIV support services and has serious implications for health care costs, as many of these conditions result in hospitalization and extended use of health care services. Health care providers managing people living with HIV must be knowledgeable not only about HIV care but also about the management of other comorbidities in the context of HIV. Given the lack of information available and challenges related to accessing and navigating the health care system, it is extremely difficult for people living with HIV/AIDS to have their multiple health concerns addressed effectively.
More research is required to understand comorbidities in people living with HIV, improve care and treatment, and develop interventions to reduce the risks and rates of comorbidities. Recognizing this, the Strategic Plan for the Canadian Institutes of Health Research (CIHR) HIV/AIDS Research Initiative identified "issues of co-infection and comorbidity" as a priority research theme, which has been the focus of strategic initiative development in 2010.
Roundtable Purpose and Objectives
To help support the development of a research agenda for this theme, the CIHR Institute of Infection and Immunity (CIHR-III), the lead Institute for the CIHR HIV/AIDS Research Initiative, hosted an invitational roundtable on Issues of Comorbidities in HIV/AIDS in Ottawa on September 21 and 22, 2010. Over 30 researchers, health service providers, and community stakeholders from across Canada and the United States took part in the event. The objectives of the roundtable were to:
- bring together a diverse group of researchers and other stakeholders to discuss the results of a national consultation and the current state of evidence related to HIV/AIDS and comorbidities;
- identify priority areas for cross-disciplinary research on comorbidities in HIV/AIDS;
- identify promising areas for the translation of knowledge and the development of policies and interventions related to comorbidities in HIV/AIDS;
- discuss the types of resources needed to advance research; and
- facilitate multi-disciplinary networking.
Recommendations were referred to the CIHR-III Scientific Director and the CIHR HIV/AIDS Research Advisory Committee (CHARAC) for decision making and the development of Funding Opportunities on research related to issues of comorbidities in HIV/AIDS.
Definition of Comorbidity
For the purposes of the roundtable discussion, a "comorbidity" was defined as any health condition that co-exists with HIV infection. This includes, but is not limited to, mental health issues and addictions, metabolic disorders, cancers, kidney disease, bone and blood disorders, neurological issues, and cardiovascular disease-as well as co-infections, such as tuberculosis and hepatitis C.
Prior to their discussions, roundtable participants highlighted what they saw as key issues related to research on comorbidities in HIV/AIDS. Three common points came out of these discussions:
- A national, collaborative, coordinated, cross-disciplinary approach that is integrated across professions and research themes and involves people living with HIV/AIDS and affected communities is required to address research needs in this area.
- Comorbidities are complex and must be considered in terms of multi-morbidity syndromes.
- Knowledge translation, exchange, and synthesis are vital to success.
In 2010, the Ontario HIV Treatment Network (OHTN) and the CIHR-III jointly sponsored the Overview of Systematic Reviews on issues of comorbidity in HIV/AIDS to improve understanding of the current state of knowledge and identify gaps in synthesized knowledge. The overview mapped and summarized all of the reviews according to specific HIV-related comorbidity domains (e.g., co-infections) and topics within those domains (e.g., hepatitis C).
The CIHR-III also conducted an independent national consultation to determine what stakeholders viewed as the key issues and priorities for research in HIV/AIDS comorbidities and what research funding programs would be of greatest benefit. The consultation included two components: an electronic survey to provide a breadth of perspectives from diverse stakeholders; and targeted key informant interviews to provide a more in?depth reflection of research issues in HIV/AIDS comorbidities.
Roundtable participants received copies of both the Overview of Systematic Reviews and the Stakeholder Consultation Report in advance of the meeting as background for discussions. In reviewing the documents, they noted a number of knowledge gaps, including a lack of nationally representative data on the population as a whole (e.g., age profile, prevalence of comorbidities, differing economic and social impacts), and little information on young people (including mothers and children), pregnancy, pain, smoking, amphetamine use, and syphilis as it relates to this subject area.
Meeting participants were asked to identify priority topic areas for research on comorbidities in HIV/AIDS using selection criteria developed by the roundtable working group and approved by the CIHR-III Scientific Director and the Chair of CHARAC. Topics considered most appropriate were those that:
- addressed important research issues, opportunities, and gaps that have been identified by stakeholders;
- had strong potential for significant impact on the health of Canadians living with HIV/AIDS;
- had strong potential for collaborations across sectors and disciplines; and
- facilitated research and/or knowledge translation activities not well suited for CIHR's open funding programs.
After much discussion, roundtable participants identified five priority topic areas for research on comorbidities in HIV/AIDS:
- Accelerated aging in HIV/AIDS
- Intersection of HIV/AIDS with mental health and brain-related conditions
- Interventions to improve quality of life, functional status, and symptom burden among people with HIV and multi-morbidities
- Comorbidities and comorbidity syndromes
- Assessment of the economic, social, physical, and mental health burden of HIV/AIDS-related comorbidities
A number of different viewpoints were expressed on the use and meaning of the term "comorbidities". Some participants perceived it as focusing more on biomedical issues than on social determinants, while others noted that it did not capture the complexities of interactions between multiple comorbid conditions. Clear consensus was not reached on whether "comorbidities", "multiple comorbidities", or "multi-morbidities" was the preferred term.
The need for national baseline information and ongoing surveillance on comorbidities in HIV/AIDS was recognized as critical to designing interventions and assessing their effectiveness. Participants noted that investigator-driven research funding should not be used for this purpose and suggested that organizations such as the Public Health Agency of Canada (PHAC) could take the lead on improving interprovincial linkages in the collection of surveillance data. They did, however, acknowledge that researchers should collaborate with PHAC to contribute to this work and ensure their data needs are met; and that efforts should be made to build on CIHR-funded infrastructure (e.g., networks, cohorts) that could be of value in this regard.
Areas in which Canada was already recognized as having a particular strength included ongoing research on neurocognition, metabolic and bone disorders, liver and cardiovascular diseases, malignancies, aging, and co-infections/sexually transmitted infections. Also noted as examples of what was working well were Canada's social-science approach to mental health issues, well-established cohort research infrastructure, efforts to link economic and health information, and availability of national-level health information.
Accelerated Aging in HIV/AIDS
There is evidence that aging may be accelerated in people living with HIV/AIDS, and that this group is at higher risk of chronic health conditions and frailty associated with this process. Both HIV and its treatment appear to be factors in this increased risk.
Research in this topic area would focus on the biological, clinical, and psychosocial aspects of aging that are altered by HIV and/or its treatment and the understanding, prevention, detection, and treatment of aging-related diseases and disabilities across the lifespan. Potential research questions could address the effects of HIV and its treatment on the aging process and age-related diseases, determinants and outcomes of frailty in HIV, and consequences for functional ability.
Key areas for potential gain in this area include improved understanding of the biological mechanisms of aging in HIV and the synthesis of guidelines for preventing disease and disability and maintaining quality of life.
Intersection of HIV/AIDS with Mental Health and Brain-Related Conditions
HIV has an adverse effect on neurocognitive function that is lessened but not eliminated by treatment. Mental health issues and substance misuse are common in people living with HIV/AIDS and can affect both adherence to treatment and progression of the disease. HIV diagnosis and the challenges of living with the virus may also have a negative impact on mental health and substance use.
Research in this topic area would focus on the impact of mental health, neurocognitive impairment, and drug and alcohol use and misuse on HIV progression, outcomes, care, and management at the individual and population levels-as well as the impact of HIV on mental health, neurocognition, and drug use. Biological and health disparities in specific populations would be an integral component of studies.
Potential research questions could address the linkages between mental health problems and adherence to HIV medications; depression in people with HIV; the interactions of HIV, aging, and neuocognitive issues; and reducing harms associated with substance misuse in HIV-infected populations. They could also focus on identifying effective models of care for addressing mental health issues and drug misuse in HIV-infected populations, improving understanding of HIV treatment across the blood-brain barrier, eliminating barriers to accessing HIV/AIDS and mental health services, and assessing the impact of mental health on secondary prevention.
Key areas for potential gain in this topic area include the application of existing knowledge about issues contributing to HIV infection — particularly in marginalized populations - to improve disease management at the health-care system level; and the increased engagement of researchers involved in mental health and brain-related conditions in HIV/AIDS research.
Interventions to Improve Quality of Life, Functional Status, and Symptom Burden among People with HIV and Multi-Morbidities
Health interventions take a clinical, program, or policy approach to the prevention or treatment of diseases and conditions - they refer to specific actions aimed at improving the physical or mental health of an individual or population.
Research in this topic area would focus on the study of logical groupings of multi-morbidities (e.g., conditions affecting the liver such as hepatitis B and C, alcohol, and fatty liver disease) and the development of multiple intervention approaches at the individual, community, and system levels to address them. It would also include controlled trials to evaluate the impact of these interventions.
Potential research questions around this topic could focus on identifying or developing specialized or generalized "best models" of interprofessional collaborative care, interventions that maximize access to care by vulnerable populations (e.g., rural, Aboriginal, immigrant), and interventions for improving quality of life, functional status, and symptom burden in people living with HIV and multi-morbidities.
Key areas for potential gain in this topic area include the use of innovative technologies (e.g., telehealth, webinars) to create a template for providing care to a widely diverse population and the development of an integrated and coordinated approach to care that is focused on multi-morbidities.
Comorbidities and Comorbidity Syndromes
Both individual comorbidities and comorbidity syndromes (i.e., the presence of a collection of related morbidities, also known as multi-morbidities) have a significant impact on the health and well-being of people living with HIV. Comorbidity syndromes are not well defined or understood in the context of HIV, however, there is evidence that underlying mechanisms, such as chronic inflammation and virus replication, may be driving their occurrence in people living with HIV. Individual comorbidities and syndromes may also be affected by both behavioural and social factors, such as housing, addictions, and social supports.
Research in this topic area would include novel studies to investigate the pathogenesis, diagnosis, prevention, and treatment of HIV-associated comorbidities -in particular, studies focused on HIV comorbidities that cluster into syndromes (i.e., multi-morbidities) or single comorbidities that have a dramatic interaction with HIV.
Research questions could focus on the potential biological mechanisms underlying comorbidity syndromes and on how risk factors, outcomes, and therapies related to comorbidities-such as non-viral, non alcoholic liver disease (NASH), co-infections (e.g., viral hepatitis and STIs), neurocognitive dysfunction, bone disease, metabolic disorders, cardiovascular disease, and other multiple health conditions-are affected by HIV/AIDS. They could also examine novel therapeutic strategies and interventions.
A key area of potential gain in this topic area is to fill existing gaps in knowledge about neurocognitive dysfunction and NASH and their interaction with HIV/AIDS.
Assessment of the Economic, Social, Physical, and Mental Health Burden of HIV/AIDS-related Comorbidities
HIV and related comorbidities affect a wide range of outcomes including mortality, physical and mental health, ability to engage fully in life (e.g., employment, social activities, physical activities), and the economic well-being of both affected individuals and society as a whole. There is insufficient understanding of the national prevalence, severity, and impact of comorbid conditions in people living with HIV in Canada and how these factors differ among sub-populations.
Research in this topic area would focus on the quantification of the health, social, and economic consequences of comorbidities within the larger impact of HIV/AIDS. Findings would be used to develop and assess policy and program interventions to improve prevention and quality of life and to reduce economic impact. It would include consequences on affected individuals, specific at-risk populations, and society as a whole-both collectively and by specific comorbidity conditions.
Potential research questions could look at the direct treatment cost and health impact of various comorbidities and their sum, the economic and other costs of disability and loss of functionality at both the individual and population levels, the percentage of the total burden of HIV/AIDS that is specifically attributable to comorbidities, and how and why specific at-risk populations are affected differently by comorbidities and how disparities can be reversed.
A key area for potential gain in this area is the assessment of the impact of comorbidities on the total burden of HIV/AIDS to inform interventions that will improve prevention and quality of life for people living with HIV/AIDS and reduce economic costs. The development of enhanced surveillance in parallel with such efforts is also critical.
Participants agreed that a broad mix of funding tools and a staggered approach should be applied to research related to comorbidities in HIV/AIDS. These tools could include planning, catalyst, knowledge synthesis, team, emerging team, operating, and Partnerships for Health Systems Improvement grants, as well as new investigator and other salary awards.
The importance of including a wide range of partners in initiatives from the outset was also stressed-with a particular focus on research and knowledge translation (KT) being carried out in accordance with the "GIPA" principle (i.e., greater involvement of people living with HIV/AIDS). Potential partners include CIHR Institutes, government (e.g., PHAC, provincial ministries of health), groups/organizations involved in surveillance, non-government organizations (e.g., charities, HIV/AIDS associations), industry (e.g., pharmaceutical companies), existing research cohorts, and community stakeholders.
The importance of multi-disciplinary approaches to understanding and addressing comorbidities was strongly noted (e.g., involvement of physicians, rehabilitation experts, nurses, epidemiologists, decision- and policy-makers, psychologists, social workers, economists, biostatisticians, demographers, mathematical modelers, health planners). Emphasis was also placed on integrating KT into all stages of the granting process, stimulating the formation of connections and collaborations among partners, and providing training and/or practice guidelines on KT delivery.
The recommendations from the roundtable serve as a solid basis for developing a research agenda to address the complex issues of comorbidities in people living with HIV/AIDS. Building on the roundtable recommendations, CIHR-III is designing a comprehensive initiative that will enable comorbidities to be addressed through a range of research and knowledge translation approaches and will foster the further development of research communities and partnerships. New funding opportunities under the CIHR HIV/AIDS comorbidity initiative will be launched in 2011.
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