Older adults, regardless of HIV status, are often receiving multiple medications. How does polypharmacy affect the use of HAART? Are there any strategies that can be used to avoid complications?
Dr Karris: Polypharmacy in aging PLWH is an issue with growing awareness. As HIV providers move towards integrase strand transfer inhibitor-based regimens, drug interactions will become less of an issue. However, there are data that suggest polypharmacy negatively affects adherence to HAART and other important medications, such as insulin and antihypertensives.9 One strategy is to purposefully practice deprescription.
Dr Kaplan-Lewis: Polypharmacy has the potential to affect adherence with complex medication regimens, as well as increase the chance of drug-drug interactions. Medication reconciliation at every visit is essential. Patients should bring all their medications to each appointment for evaluation. In addition, medication assistance programs that include pharmacies that do medication delivery/blister packs and pill box assistance, as well as concerted efforts across specialties to minimize unnecessary medications, are all key to minimizing potential morbidity from polypharmacy.
It has been suggested that individuals with HIV may need earlier and/or more frequent monitoring for potential comorbidities compared with the general population. What type of monitoring should be undertaken?
Dr Karris: The area where the data are strongest is in osteoporotic disease, and guidelines recommend fracture risk assessment for all men and women starting at age 40 years and screening those ≥50 years.10 There is also evidence in atherosclerotic disease, where current screening algorithms appear to underestimate the burden of disease in aging PLWH, but more work is necessary to better understand how to appropriately risk stratify this population.
Dr Siegler: My experience has been that clinicians are vigilant about common comorbidities such as heart disease and diabetes. I welcome the growing interest in screening for osteoporosis and in trying to prevent antiretroviral-related bone loss with bisphosphonates. I would encourage clinicians to also screen for depression and for early signs of cognitive impairment, and to ask about patients if they have recently fallen. Often the walk from the waiting room to the examination room says more about the vulnerability of the patient than the cardiac exam.
What can clinicians do to improve the care of their older patients with HIV?
Dr Karris: HIV providers are often focused on the primacy of HIV, and thus may deprioritize other issues that are important and relevant to the successful aging of their older patients. Continuing to educate ourselves on the relevant issues that impact and are important to our aging PLWH remains part of our responsibility. When accessible, partnering with geriatricians for co-care and co-learning may help both specialist better care for aging PLWH. This is a growing model of care that has demonstrated success at Cornell with Dr Siegler and at UCSF with Dr Meredith Greene. We are hoping to emulate this model at University of California, San Diego, in the very near future.
Dr Kaplan-Lewis: Clinicians should focus on a patient-centered approach using a geriatric care model, engage family and community support, focus on maintaining function and preserving health, and perform frequent reassessments of medical, access, and social issues that affect patients’ life and care, as many of these variables are a moving target.
Dr Siegler: I’d recommend spending 1 office visit to do a geriatric assessment and find out what the patient’s functional and psychosocial needs are. If possible, find a local geriatrician who can see patients or offer training in functional assessments. Social workers should consult with their gerontologic colleagues to become familiar with the aging services network, as most people are eligible for services when they reach age 60 years.
Is there anything you want clinicians to know or keep in mind as they care for older patients with HIV, as well as younger patients with HIV as they age?
Dr Karris: Many clinicians believe the issues PLWH face as they age are similar to those of their HIV-uninfected peers. However, I (and others) would argue that aging PLWH live with a higher proportion of healthy disparities and co-occurring epidemics (eg, past trauma, history of substance abuse) that result in additional challenges to the aging experience. Thus, HIV clinicians should continue our role as advocates and educate ourselves on the growing needs of aging PLWH and support novel strategies directed at helping our patients successfully age, such as specialty HIV elder housing and other programs.
Dr Kaplan-Lewis: As with any patient, treat your aging patients with HIV as you would want your loved one treated. Advocate fiercely for your patients and be cognizant that comorbidities can present earlier and at greater frequency in this population.
Dr Siegler: The first step is asking patients if they’ve thought about aging and what kind of help they think they need. Although we often think of 50 years as the cut-off between older and younger people with HIV, the over 50 years group is extremely heterogeneous. Some have never thought about aging and want an opportunity to ask questions about it and get help in preparing for it. Others are frail and impaired and need geriatric services right away. Some need help with setting priorities and accessing palliative care.
- Centers for Disease Control and Prevention. HIV among people aged 50 and over. https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Updated June 9, 2017. Accessed August 19, 2017.
- Bradley H, Prejean J, Dawson L, et al. Health care coverage and viral suppression pre- and post-ACA implementation. Presented at: Conferences on Retroviruses and Opportunistic Infections (CROI) 2017. February 13-16, 2017; Seattle, WA. Abstract 1012.
- Karpiak S, Shippy RA, Cantor M, et al. Research on Older Adults With HIV. New York: AIDS Community Research Initiative of America, 2006. https://www.acria.org/roah. Published 2006. Accessed August 19, 2017.
- Lundgren JD, Babiker A, El-Sadr W, et al; Strategies for Management of Antiretroviral Therapy (SMART) Study Group. Inferior clinical outcome of the CD4+ cell count-guided antiretroviral treatment interruption strategy in the SMART study: role of CD4+ cell counts and HIV RNA levels during follow-up. J Infect Dis. 2008;197(8):1145-1155.
- Aberg JA, Gallant JE, Ghanem KG, et al; Infectious Diseases Society of America. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV medicine association of the Infectious Diseases Society of America. Clin Infect Dis. 2014;58(1):e1-e34.
- American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246.
- Greene M, Covinsky KE, Valcour V, et al. Geriatric syndromes in older HIV-infected adults. J AcquirImmune Defic Syndr. 2015;69(2):161-167.
- Singh HK, Del Carmen T, Freeman R, Glesby MJ, Eugenia LS. From one syndrome to many: incorporating geriatric consultation into HIV care. Clin Infect Dis. 2017;65(3):501-506
- Cantudo-Cuenca MR, Jiménez-Galán R, Almeida-Gonzalez CV, Morillo-Verdugo R. Concurrent use of comedications reduces adherence to antiretroviral therapy among HIV-infected patients. J Manag Care Spec Pharm. 2014;20(8):844-850.
- Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis. 2015;60(8):1242-1251.