Additional Observation May Be Required in Older Patients With HIV

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Cardiovascular disease is a common issue for older patients with HIV.
Cardiovascular disease is a common issue for older patients with HIV.

With the introduction of highly active antiretroviral therapy (HAART), survival following HIV diagnosis has risen dramatically, and HIV infection has evolved from an acute disease to a manageable chronic condition. Patients are also being diagnosed with HIV later in life and living longer with the condition, which presents new challenges.

According to Marco Ruiz, MD, MPH, of the department of medicine at Louisiana State University Health Sciences Center in New Orleans, medication interaction is of utmost concern as well as the functional limitations associated with both HIV and aging. 

Social isolation of aging HIV patients, use of other substances (such as alcohol and recreational drugs), multiple comorbidities, and HIV stigmatization are also among the many challenges to treating and managing the disease successfully.

HIV May Increase Aging Process

Elderly populations are already at risk for age-related illnesses, such as cardiovascular disease, diabetes, cancer, liver disease, and kidney disease. And according to Martin S. Hirsch, MD, professor of medicine at Harvard Medical School in Boston, it appears that those diseases occur earlier in HIV-positive individuals than in those who are HIV negative.

“Many studies have showed that aging and HIV both can cause accelerated ‘coronary aging.' On top of this association, some antiretroviral drugs can increase cholesterol and triglyceride levels, causing an increased risk for strokes, cardiovascular events, etc.,” said Ruiz. “Therefore, appropriate control of these circumstances appears to be a priority. Use of ‘cholesterol-friendly drugs,' [like] nucleoside reverse transcriptase inhibitors, or NRTIs, seems to be a good strategy, but the development of HIV-drug-resistant strains to this family of drugs is on the rise.”

Drug-Drug Interactions Possible in Older HIV Patients

Another challenge of treating HIV infection in the elderly is the possibility of drug interactions with medications for comorbid conditions. 

“If someone in their 60s or 70s is taking a lot of medications for heart disease and for diabetes or other conditions, some of these medications may interact with certain antiretroviral medications for HIV,” said Hirsch. “For example, some HIV protease inhibitors may alter the metabolism of concurrent medications, either raising or lowering their blood concentrations to dangerous levels. Physicians and patients must be aware of the potential for drug interactions and pay attention to what medications are being prescribed because of the risk of adverse drug reactions.”

Early Diagnosis and Therapy in Older Population More Important

Research efforts have also indicated that delaying ART treatment could increase the risk of mortality and disease progression, especially in older patients. One study evaluating the effect of delaying ART initiation from 500 cells/mm3 to 350 or 200 cells/mm3 found that waiting to start treatment increased 10-year mortality, with older patients at a higher risk of consequences tied to delaying ART initiation as compared to younger patients.1

In an editorial related to this multicenter study, Hirsch and a colleagues discussed how the benefit of starting antiretroviral therapy upon diagnosis may be greater in elderly HIV-infected individuals than in younger infected persons.2 

“If you are 70, starting antiretroviral therapy as soon as you are diagnosed may be more important than starting treatment immediately when you are in your 20s,” said Hirsch. “This indicates that earlier diagnosis and early therapy in the elderly population is very important. We need to target this elderly population more than we are right now.”

Hirsch noted that this recommendation needs to be considered in the context of two other studies published recently in the New England Journal of Medicine that showed that starting antiretroviral therapy as early as possible after HIV diagnosis is important.3,4 

“Both of these large randomized trials, called START and TEMPRANO, came up with same conclusion – that starting therapy early, before the immune system has deteriorated, is much better than waiting, whatever age the patient is. The take-home message was that physicians should start [treatment] as soon as an HIV diagnosis is made,” said Hirsch.

On July 28, 2015, the U.S. Department of Health and Human Services (HHS) panel on antiretroviral therapy issued a statement strengthening their initial recommendation to now advise giving ART to all HIV-positive patients, regardless of pretreatment CD4 count, which was based on data from the START and TEMPRANO studies.5  

“This was a somewhat controversial issue until these studies were published. Because of these new studies, the HHS panel on antiretroviral therapy has updated its guidelines to more definitively recommend therapy in all HIV-infected patients, and the need to identify and treat elderly patients with HIV infection becomes even more important,” said Hirsch.

Multidisciplinary Approach Needed With Older Patients

Although HIV was once an infectious disease best handled by infectious disease doctors, Hirsch notes that it is now clear that all health care providers who treat aging patients should be aware of the possibility of HIV infection in their patients. “HIV is no longer an infection solely of young people, a situation that has changed dramatically over the last 30 years,” said Hirsch.

Conclusion

Hirsch believes physicians need to talk with their patients and explain that just because they no longer need to worry about pregnancy, they still need to use condoms for protection against sexually transmitted infections. “In addition, because HIV appears to be more progressive and run a quicker course in older patients, starting antiretroviral therapy upon diagnosis is essential in the older population. Thus, education, testing, and early treatment are all important in the elderly population,” said Hirsch.

Medically reviewed by Pat F. Bass III, MD, MS, MPH

References:

1.     Edwards JK, et al. Clin Infect Dis. 2015; doi: 10.1093/cid/civ463.

2.     Walensky RP, et al. Clin Infect Dis. 2015. doi: 10.1093/cid/civ467

3.     The TEMPRANO ANRS 12136 Study Group. N Eng J Med. 2015. doi: 10.1056/NEJMoa1507198

4.     The INSIGHT START Study Group. N Engl J Med. 2015. doi: 10.1056/NEJMoa1506816.

5.     Statement by the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents Regarding Results from the START and TEMPRANO Trials. Aids Info. Available at: https://aidsinfo.nih.gov/news/1592/statement-from-adult-arv-guideline-panel---start-and-temprano-trials. Accessed: July 31, 2015.


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