Treating the older adult with HIV
Caring for the older adult with HIV
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In 1981, physicians in Los Angeles and New York City began reporting unusual occurrences of rare diseases, such as Pneumocystis jiroveckii pneumonia (formerly Pneumocystis carinii pneumonia) and a rare skin disorder called "Karposi sarcoma," in homosexual male patients.
On further study, these patients were found to have a severe depletion of CD4 T cells, resulting in an immune system deficiency. In 1983, the deadly retrovirus HIV was identified. Since then, researchers and health-care providers have been in a race to identify the transmission, prevention, and treatment of HIV.
Fast forward to 2014, when thanks to the era of highly active antiretroviral therapy (HAART), HIV has become a chronic disease for many patients. More people in the United States are living with HIV than ever before. With new effective therapies, many HIV patients are living better and longer lives with chronic disease—into their 50s and beyond.
At the same time, the number of HIV diagnoses in people aged 50 years and older is rising, creating a new subset of patients with unique risks and challenges for primary care providers.
The vast majority of studies on symptom management and disease sequelae done over the past 25 years have involved younger adults, literally excluding older patients with their unique comorbidities. This article was written to aid primary health-care providers in distinguishing the differences in prevention and treatment challenges for the older adult HIV patient. Pender's Health Care Promotion Model will be utilized to help the provider develop and implement care proactively and purposefully.1
Challenges in prevention and diagnosis
Generally speaking, 50-year-old people do not fall into the category of "older adults." In the HIV-infected population, however, the definition of older adult requires some adjustment. Until recently, the CDC did not keep data on HIV patients older than 50 years. To this day, United Nations surveillance data are kept only until age 49 years.2
A 2008 report from the CDC showed HIV infection and acquisition rates trending upward in people older than 50 years, whereas in the past, HIV was thought of as a disease of "young adults" aged 18 to 30 years.3 In 2005, persons in the United States aged 50 years and older represented 15% of new HIV diagnoses, 24% of the population living with HIV/AIDS, and 35% of all deaths from AIDS.3 With these rates rising steadily since 1990, the prediction is that half of all people living in the United States with HIV will be aged 50 years or older by the year 2015.4 These trends make clear the importance of discussing with patients the topic of HIV and aging.
Many of the same HIV risk factors exist in both younger and older adults. IV drug use and failure to practice safer sex are common transmission methods in both groups. However, older adults are less likely to perceive themselves as being at risk. Older women may not insist on condom use once they are past childbearing years.
For their part, health-care providers may not appreciate the older adult's risk of contracting HIV and, like older patients themselves, may not perceive these patients as being at high risk. This leads to a lack of education on safety and prevention and a delayed diagnosis in this subset of patients. Additionally, the symptoms that may lead to an HIV diagnosis in a younger adult, such as fatigue, weight loss and mental confusion, could be attributed to the normal aging process in the older adult.
The possibility of a missed diagnosis is ever-present in the older population, delaying the antiretroviral therapy that could improve the patient's health and longevity. Health-care providers need to routinely screen patients and assess their risk factors thoroughly. Using a "don't ask, don't tell" philosophy while taking a sexual history can delay diagnosis and treatment of patients at risk for HIV.
Screening the older patient
The CDC's current recommendation includes routine HIV screening for all Americans from adolescence through age 64 years, including pregnant women. Any patients older than 64 years who are believed to be at high risk for HIV exposure, including those who are IV drug users (IVDUs) and those who engage in unprotected sex when the serostatus of their partner is unknown, should be counseled about HIV testing.
The goals of these recommendations are not only to identify new infections, but to take away the stigma and fear of HIV testing in the United States and to encourage more patient-caregiver conversation about high-risk behaviors and prevention methods.3 In 2009, a statement released by the American College of Physicians suggested that the age range for screening be increased to 75 years because of the growing number of infections in this older age group.5
The need for education must be reinforced among health-care professionals to avoid missed opportunities for discussion and risk factor reduction with older patients. Clinicians need to question their older patients about their risk behaviors and discuss with them the risks of HIV and sexually transmitted infections.
Many states now offer an "opt-out" testing script that clinicians can use when recommending HIV testing for patients, such as pregnant women; yearly HIV testing for high-risk populations, such as IVDUs or those practicing unsafe sex; or diagnostic testing for a patient with clinical symptoms.6
Patients must understand that they have the choice to decide whether or not they want to be tested for HIV and that health-care treatment cannot be denied if they decide not to be tested. (See "Obtaining consent for HIV testing.")
Comorbidities of the older patient with HIV
Comorbid conditions are more likely to occur in older patients with HIV than in younger patients. Common comorbidities include hypertension, chronic obstructive pulmonary disease, diabetes mellitus, arthritis, dermatologic manifestations, hepatitis C, coronary artery disease, renal disease and lipid disorders.7,8 Studies show an increase in neurologic conditions in older HIV patients, such as cognitive dysfunction/dementia and Parkinson disease, both of which involve basal ganglia and dopamine pathways.7
Older patients are more likely to use alcohol and experience depression and drug abuse or dependence.9 Osteopenia and osteoporosis are becoming more common in both older men and women with HIV because infection with HIV is thought to cause increased osteoclast activity.10
Some studies suggest that HIV in older persons may cause a higher risk of cardiovascular disease. Antiretroviral therapy is known to increase risk of metabolic abnormalities, such as increased lipid levels, but whether antiretroviral agents are solely responsible for the increase in CVD has yet to be determined.11
Liver disease occurs in older HIV patients at higher rates as a result of hepatitis B and C, alcohol use, diabetes and toxicities associated with lipid-lowering drugs. Drug-related toxicity in this older group may result from age-associated alterations in albumin levels and from changes in the cytochrome P-450 enzyme, which aids in metabolizing two of the main classes of antiretrovirals. Thus, older patients may have significantly higher drug levels than younger patients and drug toxicities due to decreased elimination. Renal function also decreases with age, leading to additional reductions in drug elimination.
Given the multitude of health problems affecting older patients, polypharmacy and the potential for drug interactions are a consideration.11 Clinicians managing the care of HIV patients must be aware of the interactions between antiretroviral agents and other commonly used drugs.
Allopurinol, erectile dysfunction drugs, benzodiazepines and proton pump inhibitors are just a few examples of the medications requiring special attention in patients on antiretroviral therapy.7 Clearly, antiretroviral therapy for HIV needs to be closely monitored and adjusted for hepatic and renal functioning.
The immunosuppression resulting from HIV infection will lead to increased susceptibility to malignancy, and rates of cancer in HIV patients are expected to soar over the next 10 years. Cancer screening guidelines will have to be adjusted for this high-risk population.7,8,12
Among the HIV-related malignancies diagnosed more frequently in older patients are non-Hodgkin lymphoma, Karposi sarcoma, cervical cancer, rectal cancer, lung cancer, and hepatocellular carcinoma related to the presence of human papillomavirus or hepatitis B and C coinfection.
As the population of older patients with HIV continues to grow, clinicians must continue to provide routine preventive measures, such as colorectal screenings, Pap smears, and mammography, as well as immunizations and vaccinations. The guidelines for these preventive measures are likely to change over the next 10 years as more studies and trials include the older subset of the HIV population.