COMMENTARY

HIV in Older Adults: A Quick Reference Guide for HIV Primary Care Clinicians

Joseph P. McGowan, MD

Disclosures

December 19, 2014

The HIV epidemic is aging across the globe. A recent report from UNAIDS indicates that there are 4.2 million people older than 50 years living with HIV worldwide, a doubling over the past 20 years.[1] Although only 17% of new HIV diagnoses in the United States in 2012 were among people older than 50 years, it is estimated that by the end of this decade, over one half of people living with HIV/AIDS will be over the age of 50.[2,3,4]

There are several factors behind this "graying" of the epidemic:

The effectiveness of combination antiretroviral therapy (ART) to persistently suppress HIV replication and allow immune reconstitution, leading to a dramatic decline in HIV mortality at younger ages;

Delayed diagnosis of HIV infection, owing to clinically latent infection; and

HIV acquisition over the age of 50.

The Quick Reference Guide for HIV Primary Care Clinicians for the Management of HIV in Older Adults, developed by the New York State Department of Health AIDS Institute, addresses these issues and others unique to providing care for older people living with HIV/AIDS.

At the individual level, older patients on ART face unique challenges that may affect treatment adherence, such as the following:

depression;

social isolation;

lack of a support network;

experience of stigma;

inadequate access to proper meals;

lack of mobility;

poor eyesight;

comorbid conditions;

diminished cognition;

drug interactions;

use of multiple concurrent medications for other chronic diseases; and

fear that ART use will disclose HIV diagnosis.

HIV-infected individuals older than 55 years have nearly four times more chronic comorbid conditions than those younger than 45 years, and these illnesses may present up to a decade earlier than in uninfected persons, raising the possibility of HIV-associated premature aging.[5] Common HIV- and ART-associated morbidities that overlap with and may be exacerbated by aging include cardiovascular disease, neurocognitive disease, bone mineral loss, frailty, decline in renal function, diabetes, lipodystrophy, and cancer.

Current models of HIV pathogenesis describe a continuous process, beginning long before the stage of AIDS is reached, that is driven by direct HIV effects (on the brain, kidney, and intestinal tract), coupled with immune activation-induced endothelial or other end-organ damage. Such processes as atherosclerosis are initiated, which then may be worsened by other risk factors (eg, intrinsic or drug-induced lipid abnormalities), even after HIV may be suppressed by ART.[6]

The accompanying guide provides information on incorporating screening for conditions of aging for which HIV-infected patients are at risk, such as osteoporosis and cardiovascular disease. Also outlined are some of the best practices in screening for cognitive dysfunction, substance use, and mental health disorders; identifying potential drug interactions between ART and the polypharmacy associated with management of multiple concurrent chronic medical illnesses; initiating ART; and managing the unique adherence challenges faced by many older persons.

Delayed diagnosis of HIV in older persons is common, owing to lack of recognition of risk. In addition, many symptoms of HIV disease, such as weight loss, thrush, and shingles, may be attributed to other causes in older persons, especially those with chronic illnesses. In New York City in 2013, the concomitant rate of AIDS at the time of HIV diagnosis was nearly double (33%) for persons older than 50 years than for younger individuals (17%).[7] Late diagnosis of HIV in older persons places them at higher risk of developing life-threatening opportunistic infections and presents a challenge to primary care providers to screen their older patients for HIV regardless of perceived risk behavior or symptoms.

Although approximately two thirds of AIDS cases in older persons are in men who have sex with men, a higher proportion of older persons with HIV infection report an "unknown" source of HIV acquisition than younger age groups, which may reflect unease among healthcare providers about discussing sexual practices and risk behaviors with their older patients. Rates of chlamydia and syphilis have increased each year since 2007 among adults older than 45 years.[8] Approximately 80% of individuals over age 50 years are sexually active, and 7% engage in behavior that may put them at risk for a sexually transmitted infection.[9] Erectile dysfunction coupled with condom-associated erectile problems may promote "condom fatigue." Changes to the vaginal mucosa (drying and atrophy) and higher vaginal pH may make older women more vulnerable to trauma and acquisition of infections during sex.

Older people are more likely than younger people to develop AIDS within 12 months after HIV infection. Older people with HIV greatly benefit from treatment with combination ART and often achieve higher rates of viral suppression than younger people living with HIV/AIDS, although CD4 cell recovery may be less complete.[10,11,12]

Aging may exacerbate the deleterious impact of HIV on the immune system, owing to complementary physiologic effects; these include the waning of immune surveillance, involution of the thymus, a decline in innate immunity, immune senescence manifested by increased rates of reactivation of latent infections (such as varicella zoster and tuberculosis), and increased susceptibility to pneumococcal disease. Therefore, pneumococcal vaccination and screening for latent tuberculosis infection should be included in the care of all older persons with HIV infection.

The advances in treatment of HIV have given us the tools to add years to the lives of people living with HIV/AIDS. Use of the information included in The Quick Reference Guide for HIV Primary Care Clinicians for the Management of HIV in Older Adults may help add life to their years.

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