People aged ≥55 years account for more than a quarter of all Americans living with diagnosed or undiagnosed HIV infection.1 Whereas HIV was once a rapidly terminal disease, life expectancy now approaches that of the general population, a dramatic transformation that has been largely attributed to an increased understanding of the disease and the development of highly active antiretroviral therapy (HAART).
However, with increasing life expectancy have come unique care-related challenges as people living with HIV (PLWH) reach older ages, regardless of their age at diagnosis. Infectious Disease Advisor had the opportunity to discuss such challenges with 3 HIV experts, including Maile Ann Young Karris, MD, from the Division of Infectious Diseases, Department of Medicine, University of California, San Diego; Emma Kaplan-Lewis, MD, from the Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York City; and Eugenia L. Siegler, MD, Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York City. The interviews were conducted separately via email, and their responses compiled for this article.
Healthcare access has been reported to be a major hurdle for many older HIV-positive patients. What access issues do these individuals face, and can they be overcome?
Dr Karris: The Affordable Care Act has significantly improved healthcare access for many persons with HIV, except in areas where Medicaid expansion was not pursued.2 I don’t know of data suggesting the healthcare access issues differ by age in PLWH; however, some barriers to access may become more pronounced as people age. For example, transportation to appointments may be more difficult to arrange or afford in persons with fixed incomes, with a growing number of specialists caring for an increasing number of medical comorbidities.
In terms of care access issues, 1 concern aging PLWH have is wondering who will help care for them when they are not capable of fully caring for themselves.3 It has been hypothesized that finding compassionate professional nonfamilial caregivers may be difficult because of persistent HIV and lesbian, gay, bisexual, and transgender stigma.
Dr Kaplan-Lewis: Older PLWH face various care access issues, including limited mobility, which may make physically getting to the physician challenging. If they have a fixed income, there may be competing priorities and difficulty scheduling appointments. Care coordination services targeted to the needs of older individuals, home visiting programs, and transportation assistance are essential in overcoming some of these obstacles, but funding for such essential programs is often inadequate.
Dr Siegler: As people with HIV age, the cost of their medications for comorbidities may exceed the cost of their antiretrovirals. We must ensure access to medications to meet all their needs, along with nutrition, dental, mental health, and social services. Access to long-term care in all its forms will be a significant challenge. We need creative ways to enable aging PLWH to remain in the community, get the services they need, and have easily accessible opportunities to socialize without worrying about disclosure or stigma. Connection is such an important part of healthy aging. I would love to see demonstration projects that take models that have worked successfully for the elderly and adapt them for those aging with HIV. As 1 example, CMS could encourage creation of Program of All-Inclusive Care for the Elderly programs designed specifically for people with HIV.
Persons diagnosed in the late 1980s and 1990s were managed with more toxic medications, often at later disease stages. Are there any special concerns in this population vs those diagnosed more recently and treated with HAART?
Dr Karris: There is a belief that persons who “aged” with HIV (ie, the population you describe) are going to be different from persons who acquired HIV at an older age, and possibly from PLWH who will be aging in the new era of immediate/early HAART and less toxic HAART. However, it is still unclear how different these distinct populations truly are.
It has been demonstrated that ongoing HIV replication, even with preserved CD4 T cells, leads to increased inflammation that subsequently contributes to the development of diseases of aging, such as cardiovascular disease, renal disease, and so on.4 Therefore, there are concerns that persons who “aged” with HIV are going to be experiencing earlier and higher rates of these medical comorbidities than HIV-uninfected peers and, possibly, than the upcoming generation of PLWH.
Dr Kaplan-Lewis: The population with HIV diagnosed in the earlier years of the epidemic is only now reaching middle and older age; thus, there is a paucity of data regarding geriatric medicine in older persons with HIV. However, exposure to older regimens with adverse effect profiles that include mitochondrial toxicity and lipodystrophy have important metabolic implications as individuals age. Close attention on physical examination for evidence of lipoatrophy or lipohypertrophy and a detailed review of systems focused on possible long-term sequelae of mitochondrial toxicity, particularly neuropathy, are important. Routine lipid and glucose screening should be followed as recommended in the HIV primary care guidelines,5 with an understanding that insulin resistance can occur with greater frequency in individuals receiving certain ART regimens, particularly those that are protease inhibitor-based.
What comorbidities and complications should clinicians think about when caring for older HIV-positive patients?
Dr Karris: HIV providers are often trained in primary care, along with HIV, and thus are excellent at identifying and managing primary care issues of aging PLWH, including medical comorbidities and HIV-associated issues such as drug interactions, hypogonadism, and bone disease. However, geriatric syndromes, such as frailty, falls, polypharmacy (specifically with Beer’s criteria medications6), and social isolation may be unrecognized and underdiagnosed.7
Dr Kaplan-Lewis: The comorbidity profile is similar to that of the HIV-negative geriatric population, but cardiovascular disease, kidney disease, liver disease, neurocognitive decline, and malignancy, particularly lung, anal, cervical, and liver cancers, should receive additional focus.
Dr Siegler: Clinicians should be aware of aging-related syndromes as well as comorbidities. Especially concerning are gait disorders and frailty, along with cognitive impairment, both related to HIV and resulting from degenerative and vascular diseases. Many comorbidities are common as people with HIV age, but heart disease, osteoporosis, diabetes, hypertension, and emphysema exact a very great toll, as does cancer. We recently published a review that focused on the role of the geriatrician in helping clinicians evaluate patients with these comorbidity and aging-related syndromes.8