HIV and AIDS are becoming more common among people over 50, for many reasons. Providing adequate treatment can be a challenge. New guidelines are here to help.
In May 2012, the American Geriatrics Society (AGS), the American Academy of HIV Medicine, and the Acquired Immunodeficiency Syndrome Community Research Initiative of America released the first guidelines regarding the management of older patients with HIV.2 This is an important development, because the prevalence of new HIV infections and AIDS in individuals over age 50 are both increasing and under-recognized.
When the HIV/AIDS epidemic first began in the early 1980s, its victims were typically young-in their 20s or 30s, or, in the case of children born to HIV-positive women, even younger. With no effective treatment, they also died young.
The advent of antiretroviral therapy (ART), however, means that people with the virus are living longer-a lot longer. They are aging with the disease just as people age with diabetes, hypertension, and other chronic conditions.
In 2005, 15% of people living with HIV/AIDS were age 50 or older (see graph). Today, that has risen to about a third of those in the US with HIV/AIDS, and the percentage will continue to increase over the coming decades.1 By 2015, most people living with HIV/AIDS in the United States will be 50 or older.2
In addition, increasing numbers of older individuals are becoming infected.1
Estimated Numbers of HIV/AIDS Cases by Age-2005Source: Centers for Disease Control and Prevention
One reason for primary infection in older individuals is that, contrary to popular perception, older people are still sexually active. One survey found that 73% of those ages 57 to 64, 53% of those ages 65-74, and 26% of those ages 75-85 had sex during the past year.3 They also use drugs, with HIV infection from drug injection responsible for more than 16% of HIV infections among individuals 50 and older.4 Older adults who smoke crack are also likely to engage in risky sexual behavior when using drugs.5
The increasing numbers of HIV-infected individuals over 50 years of age prompted the Health and Human Services’ Panel on Antiretroviral Guidelines for Adults and Adolescents to add a section on HIV and the Older Patient to its most recent guideline update, issued in late March.1 The panel highlighted several challenges related to HIV prevention and treatment in this population:
• Age-related physical changes, such as vaginal dryness in post-menopausal women, can increase the risk of HIV transmission because vaginal walls are more likely to tear, providing easier access to the virus. Other increased risks for transmission occur as older men use erectile dysfunction drugs such as sildenafil (Viagra) and have sex more often. In addition, older people are less likely to use condoms because birth control is no longer an issue. One study found that nearly 60% of older single women who had been sexually active in the past decade had not used a condom during intercourse.6 Yet another study found that just 13% of older women thought condoms could effectively prevent infection.7• Screening for the HIV virus in this population is very low because clinicians and patients themselves perceive their risk as low.
• Older people transition from HIV diagnosis to AIDS far faster than younger individuals. In one study, half of those older than 60 developed AIDS within 1 year of HIV diagnosis compared to 16% of those younger than 25.8• Aging-related comorbid conditions, such as hyperlipidemia, diabetes, and hypertension, can complicate AIDS management. Conversely, HIV infection and ART themselves carry an increased risk of age-related conditions such as cardiovascular disease.
• Few clinical trials on ART have included participants ages 60 to 80. This is a problem since older adults often metabolize drugs differently than younger individuals, and often have comorbid renal or hepatic deficiencies.1 In addition, older people tend to take several medications simultaneously. It’s unclear how polypharmacy will affect ART efficacy.
• Although virologic response to ART appears to be similar in older patients and their younger counterparts, there is sometimes a “less robust” CD4 T-cell recovery after starting therapy, possibly because of immunologic weaknesses.1• Viral infection may intensify the development and severity of common comorbidities in the elderly. For instance, HIV infection in the brain can exacerbate neurocognitive impairment. Comorbidities can further stress the immune system and add to the disease burden of the viral infection.1
The recommendations in the guidelines from the AGS and other groups parallel those from the Panel on Antiretroviral Guidelines for Adults and Adolescents.2 Specifically:
• Perform routine, opt-out HIV screening in all adults, regardless of age or individual factors, in order to identify HIV-infected older patients. Repeat HIV screening at least annually in patients known to be at risk. All HIV-infected individuals should also be screened for hepatitis A, B, and C viruses when they start care.
• Initiate ART in patients 50 and older who have a CD4 count less than 500 cells/mL, an AIDS-defining illness, HIV-associated nephropathy, or chronic hepatitis B infection
• Consider ART in patients 50 and older who have a CD4 count greater than 500 cells/mL
• If possible, avoid an initial ritonavir-boosted protease inhibitor-based regimen in patients with diabetes or hyperinsulinemia
• Routinely monitor CD4 cell counts and HIV RNA levels in all patients 50 and older as recommended for the general population with HIV
Other considerations that are particularly important in older HIV-infected individuals include:
• Monitoring adverse ART-related events that affect the renal, cardiovascular, metabolic, and skeletal systems1• Addressing issues of polypharmacy by encouraging patients to use a single pharmacy or a pharmacy chain with an integrated computer network. Ideally, have patients receive their medications from an HIV specialty pharmacy.2 • Monitoring other medications that older patients are taking for any potential drug-drug interactions. For instance, certain statins should not be used in conjunction with certain ART medications.1
Treatment adherence, always a problem in any patient with a chronic condition, is just as important in older, HIV-infected patients. Studies are mixed on whether older patients are more or less likely to be adherent with their medication. However, in addition to the traditional reasons for nonadherence (medication burden, cost or availability barriers, limited health literacy, etc.), neurocognitive deficits in the elderly may make adherence more challenging.2
The majority of primary care clinicians’ patients are 50 or older. Thus, PCPs are uniquely situated to provide preventive counseling, screening, and appropriate treatment to older patients regarding HIV infection.
Remember: Just because people are old doesn’t mean they can’t engage in risky behavior. Also remember that as younger patients with HIV continue living with the virus for 10, 20, 30 or more years, they will soon become (or already are) those older patients in your practice. Therefore, it is important that you understand the unique approaches their disease requires.
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents; March 29, 2012.
2. Summary Report from the Human Immunodeficiency Virus and Aging Consensus Project: Treatment Strategies for Clinicians Managing Older Individuals with the Human Immunodeficiency Virus. J Am Geriatr Soc. 2012;Epub ahead of print.
3. Lindau ST, Schumm LP, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med. 2007;357(8):762-774.
4. Centers for Disease Control and Prevention. Persons Aged 50 and Older: Prevention Challenges. 2007; http://www.cdc.gov/hiv/topics/over50/challenges.htm. Accessed May 15, 2012.
5. Kwiatkowski CF, Booth RE. HIV risk behaviors among older American drug users. J Acquir Immune Defic Syndr. 2003;33 Suppl 2:S131-137.
6. Lindau ST, Leitsch SA, Lundberg KL, et al. Older women's attitudes, behavior, and communication about sex and HIV: a community-based study. J Womens Health (Larchmt). 2006;15(6):747-753.
7. Henderson SJ, Bernstein LB, George DM, et al. Older women and HIV: how much do they know and where are they getting their information? J Am Geriatr Soc. 2004;52(9):1549-1553.
8. Thompson MA, Mugavero MJ, Amico KR, et al. Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations From an International Association of Physicians in AIDS Care Panel. Ann Intern Med. 2012; Published online.