Faced with an aging population with HIV, clinicians will need to help these older patients navigate a healthy route from antiretroviral therapy (ART) initiation through complex comorbidities to an increased focus on maintaining function toward the end of life, according to a new report.
The Lancet HIV Commission report on aging and HIV outlines a three-phase approach to managing affected patients:
- Establishing a therapeutic alliance with patients
- Maintaining health despite increasingly complex conditions
- Focusing on patients’ priorities for preserving cognitive and physical capacities
“Public health HIV prevention messages about safe sex, HIV screening, and early HIV diagnosis need to be better tailored to older people. People older than 50 years are 200-400% more likely to experience a delayed HIV diagnosis and treatment than people younger than 50 years, which can endanger their health, prolong the period in which their viral load is detectable, and expose other people to infection,” wrote a group led by Amy Justice, MD, of Yale University in New Haven, Connecticut.
Relative to younger people, older people are assumed to be at lower risk of HIV infection, which can lead to delayed diagnosis and treatment. That sets them back in their ability to have healthy aging, cautioned Justice during a presentation at the International AIDS Conference in Rio de Janeiro.
Aging with HIV also puts people at greater risk of conditions such as cardiovascular disease, liver disease, and some cancers — all at earlier ages than their counterparts without HIV.
In managing the health of older adults with HIV, clinicians must remember that physiological age versus chronological age for people with HIV can be very different, noted Justice. “ART has dramatically extended survival; it’s a miracle of modern medicine,” she said. “But most people living with HIV do not have a normal life expectancy.”
People aging with HIV are heterogeneous, added co-author Keri Althoff, PhD, of Johns Hopkins University in Baltimore.
“We have individuals who were infected many decades ago and have survived, we have individuals with perinatally acquired HIV and have survived many years, and we have younger individuals who are just initiating treatment,” she noted. “This is the time — this is the moment — to help start that aging trajectory.”
The full report was published simultaneously in the Lancet HIV.
Follow the Three-Phase Clinical Path
“In all phases, it’s important to support ART adherence, good mental health, a healthy lifestyle, and self-care,” said Brenda Crabtree, MD, of Salvador Zubiran National Institute of Medical Sciences and Nutrition in Mexico City, another contributor to the report.
The recommended first clinical phase is building a therapeutic relationship with older patients who are initiating ART. During this phase, tackling substance use, reduced self-care, and screening and treatment are critical, as is the initiation of a well-tolerated ART regimen, Crabtree noted.
“Older people might face synergistic stigma from ageing and HIV infection and therefore avoid HIV testing, even when they suspect that they have HIV. Health-care providers should ask older people about sexual health, consider HIV as a possible explanation for symptoms commonly associated with acute or chronic HIV infection, and ask about substance use,” the group wrote.
The second phase combines management of chronic HIV with the prevention, screening, and treatment of comorbid disease, explained coauthor Tristan Barber, MD, of University College London. Phase two’s goals include monitoring a patient’s physiological age, following primary care guidelines, and minimizing the harms of polypharmacy involving HIV drugs and those for aging’s comorbid conditions.
What physiological age is an older person with HIV? “I always say to students training in my clinic that we have to think not only about people’s birthday age, but also their HIV age,” Barber said. Being a 70-year-old who acquired HIV in 1990, for example, “you’re a very different 70-year-old to someone who acquired HIV in 2020,” he noted.
The inflection point between the second and third clinical phases comes with about 10 years of life remaining. Predicting that point can be challenging, Barber conceded.
With the transition, clinicians and patients move to the phase three goals of focusing on individual patient preferences for receiving care, conducting a comprehensive geriatric assessment, and planning for end of life.
Growing Needs for a Growing Population
The need for better healthy aging strategies in HIV will only grow in the next decades, according to the report.
Right now, the median age among the estimated 39 million people with HIV globally is 41 years, and 11.5 million of those people are older than age 50 years. By 2040, 20.2 million people older than 50 could have HIV, accounting for 51% of everyone with HIV and pushing the total population’s median age to 50 years. At that point, almost every one of those older people with HIV (96%) will likely be living in low- or middle-income countries, researchers projected.
In the U.S., HIV prevalence is on the rise in those older than 50. The estimated prevalence of diagnosed and undiagnosed HIV infections is highest in those age 55-64 years, at 728.1 cases per 100,000 population, topping the prevalence rate of those age 25-34 years, at 487.1 per 100,000.
The authors say they expect to see HIV incidence among older adults increase proportionately with prevalence if prevention, screening, and diagnostic programs aren’t targeted at that group.
