Improving the Care of Aging Adults Living With HIV
HIV is known to lead to many unique health concerns in older adults, with patients often exhibiting comorbidities and characteristics associated with older age much sooner than their age-matched HIV-n
The advent of highly active antiretroviral therapy in the mid-1990s has enabled people living with HIV to achieve a normal or close-to-normal life expectancy, the effect of which is now being realized. In 2014, approximately 45% of people living with HIV in the United States were aged ≥50 years, 27% were aged ≥55 years, and 6% were aged ≥65 years.1 Although new HIV diagnoses among people aged ≥50 years decreased by 10% from 2010 to 2014, this age group still accounted for 17% of new HIV diagnoses in 2015.1 Despite such data, HIV/AIDS in the United States is still thought of by many as a disease of young adults, and this is where the majority of screening and prevention efforts have continued. Subsequently, many older adults are not being diagnosed until later stages. In 2014, 40% of patients aged ≥55 years had advanced to AIDS by the time they received their HIV diagnosis.1
"Ageism perpetuates the invisibility of older adults, which renders current medical and social service systems unprepared to respond to the needs of people aging with HIV infection," said Mark Brennan-Ing, PhD, director for research and evaluation at ACRIA, a nonprofit and community-based AIDS service organization based in New York City, in an American Psychological Association press release.2
Whether patients age with HIV/AIDS or are first diagnosed at older age, HIV is now known to lead to many unique health concerns in older adults, with patients often exhibiting comorbidities and characteristics associated with older age much sooner than their age-matched HIV-negative counterparts.2,3
Infectious Disease Advisor had the opportunity to discuss age-related concerns in older patients living with HIV with 2 experts, Eugenia L. Siegler, MD, professor of clinical medicine and Mason Adams Professor of Geriatric Medicine at Weill Cornell Medical College, New York City, and Kristine M. Erlandson, MD, associate professor of medicine in infectious diseases and geriatric medicine at the University of Colorado Denver-Anschutz Medical Campus, Aurora.
Both physicians are involved in ongoing research that is helping to improve understanding of the effect of HIV on aging, and they shared their insights on how care in older adults with HIV can be improved to better address several major health concerns in this population, including cardiovascular disease, frailty, and polypharmacy. The interviews were conducted via email, and their responses were compiled for this article.
Infectious Disease Advisor: Can you tell us about any of the studies you have been or are currently involved in examining the effect of HIV among older adults?
Dr Siegler: We are collaborating with Mark Brennan-Ing, PhD, senior research scientist at the Brookdale Center for Healthy Aging at Hunter College, City University of New York, and ACRIA in their multisite survey, Research on Older Adults with HIV 2.0.4 This study, which is a follow-up to the groundbreaking 2005 to 2006 Research on Older Adults with HIV study,3 uses a survey to examine a broad range of psychosocial concerns in people >50 years with HIV.
At our site, the Center for Special Studies at Weill Cornell-New York Presbyterian Hospital, we are randomly selecting potential research participants, and we will be linking clinical information from the electronic medical record to the survey, enabling us to examine correlations between mental health concerns, such as depression, loneliness, stigma, and anxiety; socioeconomic concerns; and clinical data, such as HIV viral load, medications, and comorbidities.
The goal is to glean information that will help better inform the care and support services provided to older adults with HIV.
Dr Erlandson: We recently completed a clinical trial of high-intensity exercise vs more moderate-intensity exercise to measure the effect on physical function in older adults with and without HIV.5 We were interested in whether a higher intensity of exercise was needed for improvements in function, and whether a higher intensity of exercise would be associated with heightened inflammation. We presented our preliminary results on physical function at the Conference on Retroviruses and Opportunistic Infections 2018.6
We found that both moderate- and high-intensity exercise resulted in significant improvements in function among both people with and without HIV, and higher-intensity exercise led to greater improvements in strength, particularly in those living with HIV. The effect on inflammation will be presented this September at the 9th International Workshop on HIV and Aging 2018 in New York.
We also have an opportunity to measure the effect of statin therapy on muscle function as part of the large REPRIEVE Trial.7 We have previously shown that physical function impairments are associated with inflammation and fat within the muscle, and we hypothesize that statin therapy may have a protective effect on objectives measures of muscle function.8,9
The AIDS Clinical Trials Group HAILO (HIV Infection, Aging, and Immune Function Long-term Observational) A5322 Study, the Multicenter AIDs Cohort Study, and the Women's Interagency HIV Study are also tremendous resources for data on aging with HIV,10-12 and I have several ongoing analyses within these cohorts. Many of these participants have been engaged in research for decades.
I'm also fortunate to have the opportunity to co-chair the International Workshop on HIV and Aging in September 2018 in New York City. This annual workshop brings together international clinicians and researchers focused on improving the care of older adults living with HIV. Many new collaborations, research proposals, and clinical initiatives have been introduced through this workshop.
Infectious Disease Advisor: Risk for cardiovascular disease is increased among older patients with HIV vs their age-matched HIV-negative counterparts. How can screening for and management of cardiovascular disease be improved in older patients with HIV?
Dr Siegler: The first step is just to begin a discussion about lifestyle risk factors. Smoking cessation is critically important, yet difficult to accomplish. But it's always worth discussing. Exercise and healthy weight are also essential. Clinicians should use 1 of the risk assessment tools such as the D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) or ACC/AHA ASCVD (American College of Cardiology/American Heart Association arteriosclerotic cardiovascular disease) risk calculator and ensure their patients are receiving an AIDS-related virus-compatible statin if their risk indicates it.
There is growing interest in computed tomography coronary angiography, as often anatomic evidence of plaque is more compelling than theoretical risk. A good review on screening and risk assessment for coronary artery disease was published last year in HIV Medicine.13
Dr Erlandson: Oftentimes our clinic visits are filled with such a multitude of other problems that cardiovascular risk assessment, particularly in patients who are asymptomatic, may become a lower priority. Ideally, we should emphasize the importance of healthy lifestyle behaviors much earlier in life, including smoking cessation, avoidance of other substances, regular exercise, a healthy diet, adequate sleep, and treatment of depression or other mood disorders. For the evaluation of cardiac risk, many of the electronic medical records now have simple "dot phrases" that input relevant data from the medical record and quickly calculate the cardiac risk. With this risk calculation, we can then prioritize blood pressure control and smoking cessation and decide whether to initiate a statin.
Demonstrating the effect of smoking cessation or adequate blood pressure control on the risk for a cardiac event can be particularly informative for patients, particularly if they are reluctant to start an additional medication. Early initiation of and excellent adherence to antiretroviral therapy are also key factors.
Infectious Disease Advisor: Frailty is a major concern in older patients with HIV. Does it differ from frailty observed in the general older adult population? Are there any steps that can be taken to protect these patients from frailty?
Dr Siegler: Frailty likely appears earlier in HIV-infected people than it does in their uninfected counterparts, and it is a predictor of morbidity and mortality. The AgehIV Cohort Study group from the Netherlands just presented their findings at AIDS 2018, suggesting that comorbidity burden, waist-to-hip ratio, and depression increased the risk for frailty.14
Although frailty can be measured in different ways, by definition, it is a marker of vulnerability, and it is difficult to reverse once it has been established. Keeping socially engaged and physically active may help forestall frailty even in the setting of other chronic problems.
Dr Erlandson: This is a question that I don't know we can completely answer yet. Frailty was first characterized in a much older cohort, and we are still trying to understand whether frailty among either younger or older patients with HIV is the same as frailty among older patients without HIV. We do know that frailty seems to occur at least as often, if not more often, among people with HIV, and that frailty is associated with poor outcomes, including increased mortality.15
Exercise is the main intervention that is effective in reducing frailty among older adults without HIV. In our exercise study, we saw that an exercise intervention resulted in improvements in many of the components of frailty, including gait speed and strength.6 Routine physical activity before the onset of frailty and prescribed exercise among frail persons are the most effective interventions that we know of at this point. Frailty is also strongly associated with social and cognitive factors; therefore, maximizing social supports and slowing cognitive decline may also play an important role in limiting progression of frailty.
Infectious Disease Advisor: Cognitive impairment is another well-established concern in older adults with HIV, and it appears to affect these patients much earlier than the general population. Are there things clinicians can recommend to help patients protect their cognitive health?
Dr Siegler: All the things we do to promote cardiovascular health can promote cerebrovascular health as well. In addition, avoiding recreational drug use, discontinuing any unnecessary prescription medications, connecting socially, and keeping viral load suppressed may also help.
Dr Erlandson: Although data are just emerging in HIV, exercise and routine physical activity, in addition to a healthy weight, are associated with improved cognition among older adults with HIV. In addition to Dr Siegler's suggestions, brain-stimulating activities, such as reading and puzzles, may preserve cognitive function with aging. Mood disorders can often overlap with cognitive impairment, particularly among older adults; therefore, identification and management of these disorders may improve cognition.
Infectious Disease Advisor: With increasing age often comes more comorbidities and polypharmacy, placing patients at increased risk for a variety of complications. What can clinicians do to reduce these risks?
Dr Siegler: This is a huge challenge. When a person has multiple comorbidities, how do you decide which medications are necessary and which ones aren't? Often algorithms or practice guidelines were developed for comorbidities in isolation and aren't additive. It may help to step back and get an overall sense of a patient's prognosis and whether tight control of chronic diseases will affect their lifespan or quality of life. The primary care provider has this important overall perspective that the subspecialist often lacks. Patients will likely have opinions about which medications they value and which ones they feel aren't helping them. You may not agree with them, but it's always worth hearing their perspective and starting a negotiation.
Dr Erlandson: I think that we need to place a greater emphasis on prevention at an earlier age. Reducing unhealthy behaviors in midlife can prevent some of these comorbidities and the associated polypharmacy at a later age. This may include a greater emphasis on smoking cessation, improved nutrition, and routine physical activity/exercise. Among older patients with polypharmacy, clinicians should regularly review medications with patients, including the long-term risks and benefits.
Infectious Disease Advisor: Any tips on how physicians can improve the overall care of their older patients with HIV?
Dr Siegler: Take a functional and holistic approach: What medications and therapies will help patients live their lives as healthily and meaningfully as possible? Promote an overall quality of life while also beginning the conversation about advance care planning. Find ways for patients to link to community resources. They are eligible for senior programs at age 60 years, and although they may not think such resources are appropriate (many people, irrespective of HIV status, deprive themselves of opportunities because they don't want to be with "old people"), community supports offer great opportunities for socialization, especially around meals, field trips, and exercise.
For those patients who are chronically ill and frail, it is worth discussing end-of-life care. At the AIDS 2018 meeting, I heard several people asking for more palliative care services, expressing concerns about a painful, prolonged end of life, and they wanted reassurance that they will be comfortable and treated with respect.
Dr Erlandson: The most important first step we can do to improve the care of our older patients living with HIV is to first understand their goals and priorities. Once we have a good understanding of what our patients want, we can help them work to achieve these goals, whether it be to maintain independent living, to not suffer, or to live as long as possible. Documenting goals, establishing advanced care directives and medical decision-makers, and deciding when screening and preventive measures are appropriate are important steps in the care of older adults that may be overlooked when addressing the myriad comorbidities and other more acute health issues.
- Centers for Disease Control and Prevention. HIV among people aged 50 and over. https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Accessed.
- American Psychological Association. Older adults with HIV: an overlooked population? http://www.apa.org/news/press/releases/2017/08/older-adults-hiv.aspx. Released August 4, 2017. Accessed July 31, 2018.
- Karpiak SE, Shippy RA, Cantor MH. Research on Older Adults with HIV. New York: AIDS Community Research Initiative of America, 2006.
- ACRIA. San Francisco Bay Area Programs. https://www.acria.org/san-francisco/. Accessed July 30, 2018.
- ClinicalTrials.gov. Exercise for healthy aging: the impact of HIV and aging on physical function and the somatopause. NCT02404792. https://clinicaltrials.gov/ct2/show/NCT02404792. Accessed July 30, 2018.
- Erlandson KM, MaWhinney S, Wilson MP, et al. Effects of HIV status on functional benefits of exercise in older sedentary adults. Presented at: Conference on Retroviruses and Opportunistic Infections 2018; March 4-7, 2018; Boston, MA. Abstract 755.
- REPRIEVE. Randomized Trial to Prevent Vascular Events in HIV. http://www.reprievetrial.org/. Accessed August 1, 2018.
- Erlandson KM, Allshouse AA, Jankowski CM, et al. Association of functional impairment with inflammation and immune activation in HIV type 1-infected adults receiving effective antiretroviral therapy. J Infect Dis. 2013;208(2):249-259.
- Erlandson KM, Allshouse AA, Jankowski CM, et al. Functional impairment is associated with low bone and muscle mass among persons aging with HIV-infection. J Acquir Immune Defic Syndr. 2013;63(2):209-215.
- AIDS Clinical Trials Group. ACTG Network Trial Update: HAILO A5322 - long-term follow-up of older HIV-infected adults: addressing aging, HIV infection & inflammation. https://actgnetwork.org/newsletter/april2015/hailo-a5322. Accessed July 30, 2018.
- Multicenter AIDS Cohort Study. The Multicenter AIDS Cohort Study (MACS) is a 30-year study of the HIV-1 infection in gay and bisexual men. http://aidscohortstudy.org/. Accessed July 30, 2018.
- Women's Interagency HIV Study. The Women's Interagency HIV Study (WIHS) is the largest ongoing prospective cohort study of HIV among women in the U.S. https://statepi.jhsph.edu/wihs/wordpress/. Accessed July 30, 2018.
- Nadel J, Holloway CJ. Screening and risk assessment for coronary artery disease in HIV infection: an unmet need. HIV Med. 2017;18(4):292-299.
- Verheij E, Kirk GD, Wit FW, et al. Increased risk of both mortality and incident comorbidity among frail HIV-positive and HIV-negative participants in the AGEhIV Cohort Study, and increased risk of frailty progression in those with HIV. Presented at: AIDS 2018: 22nd International AIDS Conference; July 23-27, 2018; Amsterdam, Netherlands. Abstract THAB0105.
- Kelly S, Wu K, Tassiopoulos K, et al. Functional status associated with cardiovascular disease and diabetes in HIV+ adults. Presented at: Conference on Retroviruses and Opportunistic Infections 2018; March 4-7, 2018; Boston, MA. Abstract 676.