HIV Infection in the Elderly

August 5, 2016

There is general consensus among public health authorities that the elderly are not being screened for HIV as frequently as are younger persons. But there is compelling reason to do so.

Recognizing, diagnosing, and managing HIV infection in the elderly can be challenging. In the United States, as is true for much of the world, people are living longer, are sexually active longer, and are at the same risk for acquiring HIV as their younger counterparts.

         In 2014 (the last year for which data are available), only about 10% of all HIV infections diagnosed that year occurred in persons 55 years or older (the CDC definition of elderly). In fact, there was about an 8% decrease in diagnosed HIV infections in that age group between 2010 and 2014. However, according to the CDC,1 in 2012, 25% of all persons living with HIV were aged 55 or older, and in 2013, 37% of all HIV-related deaths occurred in that age group. Both the CDC and the US Preventive Services Task Force (USPSTF) recommend that routine screening for HIV be performed through the age of 65; the USPSTF also recommends screening even older individuals who are at “increased risk” for HIV infection.

      There is general consensus among public health authorities that the elderly are not being screened for HIV as frequently as are younger persons. While older persons visit physicians more frequently than, say, adolescents, older persons are less likely to discuss their sexual practices and preferences or drug use, with physicians.1 In addition, physicians seem unlikely to ask the elderly in-depth questions about their sexual activity, including sexual activity during travel, sex outside of marriage, and contact with commercial sex workers. I provided HIV care for one 80+ year old women a number of years ago who told me that she had to ask her primary care provider three times to be tested for HIV, and that he kept “downplaying” her risk. In fact, at that time, I had a cohort of 10 HIV-infected women all over the age of 80, all of whom acquired HIV from heterosexual sex when they were in their late 60s or early 70s. All did relatively well for quite some time, even though, according to the CDC, only 73% of HIV-infected persons 65 years of age or older survive 12 months after their diagnosis (death from any cause), compared to 99% of HIV-infected persons aged 20 – 24.1

      The elderly do have more co-morbidities (eg, hypertension, kidney disease, hyperlipidemia, osteoporosis, diabetes) than do younger persons, making it a challenge to prioritize their health care concerns during a typical brief office visit. In addition, it can be difficult to differentiate between non-specific geriatric complaints and HIV-related signs and symptoms. Nevertheless, it is prudent to recognize that, for instance, fever and cough may represent infection with PCP, that fever and headache may represent cryptococcal meningitis, and that HIV-infection is one of the leading causes of thrombocytopenia, regardless of age.

In summary, I recommend the following be done for all patients over the age of 13:

 o Take a thorough sexual history at every, or every-other, visit, including asking questions related to sexual activity while on business trips.

 o Recognize that certain life events, such as the death of a spouse, may increase the likelihood of increased “risky” sexual activity.

 o Emphasize proactively the benefit of condom use to prevent sexually transmitted diseases, such as syphilis, gonorrhea, chlamydia (including LGV), and herpes.

               Above all, do all of the above in a non-judgmental fashion.

  Finally, for those elderly who are found to be HIV-infected, recognize that there are many real and potential drug-drug interactions between the available antiretroviral drugs and medications used to treat arrhythmias, hypertension, hyperlipidemia, HCV, and diabetes.

Disclosures: