COMMENTARY

Growing Old With HIV: Beyond Just Surviving

Eugenia L. Siegler, MD

Disclosures

September 17, 2020

We have a remarkable success story in HIV: The population of people with HIV is aging, largely because of effective antiretroviral therapy.

The most recent HIV Surveillance Report estimated that about a third of the population with HIV in the United States is older than 55. Globally, in 2017, approximately 5.7 million people with HIV were older than 50.

Nonetheless, this success presents new challenges in the medical management of chronic health conditions. Older people with HIV may have advanced or premature aging and a higher risk for comorbidities than people who do not have HIV; they are also at higher risk for depression, frailty, polypharmacy, and other age-related conditions. Women may be especially vulnerable.

A Broader Perspective in HIV Care

For many clinicians, the focus of HIV care is viral suppression, but as patients with HIV age, a broader perspective is essential. Managing multiple comorbidities, recognizing and intervening to prevent problems with gait or incontinence, arranging for social supports to mitigate loneliness and isolation, and identifying and helping patients plan for deteriorating cognition are all complex care needs. A geriatric-focused approach to care, with an emphasis on maximizing function, is an effective way to manage the multiplicity of problems that older people with HIV may face and promotes a goal shared by all: healthy aging.

Two challenges in offering recommendations for the care of older people with HIV are the heterogeneity of the population and current dearth of data to support evidence-based recommendations. Although the US Department of Health and Human Services HIV treatment guidelines view all people with HIV who are older than 50 as "older," the needs of patients in their 70s may differ markedly from those of patients in their 50s. The physical and mental health concerns of a long-term survivor will probably not be the same as someone newly diagnosed with HIV. The medical care of women, men, and transgender individuals will all differ.

The New York State Department of Health (NYSDOH) AIDS Institute recently published new guidance for clinicians who care for older people with HIV. It presents an aging-related approach to care, provides resources for healthcare professionals and their patients, and offers advice for implementing care for older patients into HIV clinical practice.

Getting Started, Suggested Best Practices

Initiate a conversation about aging with each of your older patients to help them articulate concerns and priorities. Is the patient in good health and interested in aging well and understanding how HIV affects the way their body ages? Or, does the patient have concerns about chronic illness and function? This conversation can also provide an opportunity to address or readdress advance directives and consider palliative approaches to care.

Use a geriatric-focused framework for addressing concerns. For example, the Geriatric 5Ms — Mind, Mobility, Medications, Multimorbidity, and Matters Most — provides a context for evaluating and addressing the most common concerns of older people. This type of approach can help determine which problems are most important to address and which medications might be eliminated if polypharmacy is a concern.

Learn about basic screening tools for geriatric syndromes, such as fall risk or cognitive decline. Alternatively, generalized screening tools such as the Medicare Annual Wellness Visit can be adapted for use even with patients who are not yet 65 years old.

Become familiar with the Aging Network, which can link patients to community-based organizations that serve older people. Clinical staff can help determine locally available services by using search tools such as the Eldercare Locator.

Integrating Geriatric Approaches to HIV Care Settings

By definition, geriatric HIV care is a combination of two fields that until recently had few patients in common, even though they share practice concepts such as multidisciplinary teamwork and chronic illness management. Individual clinicians can adopt geriatric tools and think about promoting a more systematic integration of mental health, social service, and geriatric medical approaches into HIV care settings so all patients can benefit.

Clinical sites can begin by assessing staff interest and skills in caring for older people with HIV. Which staff members are interested in performing screening assessments? Are there local specialists, such as pharmacists or geriatricians, who would like to collaborate? High-quality care necessitates coordination with programs that reach beyond the clinic. How can staff learn how to access services available through an Area Agency on Aging?

Decide whether your site will offer general screening for age-related issues or focus only on a few specific problems, such as gait impairment and hearing loss. Engaging older patients in program planning can ensure that resources will be devoted to the issues they find most pressing. Develop a complete plan for each aging-related issue. Begin by identifying the population to be screened, choosing validated assessment tools that can be implemented with relative ease.

Protocols for referrals should also be developed.

The World Health Organization's Integrated Care for Older People handbook offers ideas for these types of protocols. To be effective and beneficial, screenings must be followed by referrals to the appropriate services. The NYSDOH AIDS Institute guidance provides links to an array of assessment tools and other resources to help with planning.

That so many of our patients are long-term survivors does not mean that mere survival should be the ultimate goal. Patients who are aging offer us the exciting opportunity to help them maximize function and enjoy an optimal quality of life while doing what was once thought impossible — growing old while living with HIV.

Eugenia L. Siegler, MD, is the Mason Adams Professor of Geriatric Medicine at Weill Cornell Medical College. She is dedicated to promoting comprehensive, compassionate care of older people, and spends most of her time caring for patients and teaching geriatric medicine.

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