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CME/CE credit available May 13, 2020 – May 13, 2021. Estimated time to complete all chapters: 14 hours. Jointly provided by the Annenberg Center for Health Sciences at Eisenhower and American Academy of HIV Medicine, in collaboration with Postgraduate Institute for Medicine.
The American Academy of HIV Medicine (AAHIVM), the American Geriatrics Society (AGS) and the AIDS Community Research Initiative of America (ACRIA) released the first clinical treatment strategies for managing older HIV patients: The HIV and Aging Consensus Project: Recommended Treatment Strategies for Clinicians Managing Older Patients with HIV in the fall of 2011.
Among those with HIV infection receiving ART (Antiretroviral Therapy), the proportion achieving viral suppression is growing, aging, and experiencing a widening spectrum of “non-AIDS” diseases. Concurrently, AIDS-defining conditions are less common.
We recommend routine, opt-out screening for HIV infection in all adults, including those over the age of 65. As described below, HIV screening based on identification of risk factors alone is not effective, especially since older adults may be more likely than the general population to have unrecognized risks, and are therefore more likely to present late in the course of infection with HIV/AIDS.
Multiple cohort studies involving untreated HIV-infected persons have established that older persons have a more rapid progression to AIDS and shortened survival when compared with younger persons. For HIV-infected persons older than 50, limited data exist from randomized, controlled antiretroviral therapy clinical trials, as most randomized therapy trials have excluded persons older than 50 or 60.
Consensus is widespread for the use of most vaccines in persons living with HIV (PLWH). These recommendations are nicely summarized in an Infectious Diseases Society of America Guideline for Vaccination of the Immunocompromised Host and are also available from the Centers for Disease Control and Prevention (CDC).
Cardiovascular disease (CVD) is the leading cause of death in the United States and world-wide. Since the main predictor of heart disease is age, and since PLWH are living longer and growing older as a result of effective antiretroviral therapy (ART), the prevalence of CVD will increase.
According to the Global Initiative for Chronic Obstructive Lung Diseases (GOLD), COPD is “characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposures to noxious particles or gases.”(GOLD 2020) COPD is common in PLWH, diagnosed in approximately 15-20%.
Cigarette smoking is known to be a significant cause of morbidity and mortality in the HIV-uninfected population, and is one of the leading causes of cardiovascular disease in Western cultures. While about 15% of the general population in the U.S. smokes, between 39% and 59% of HIV-infected people smoke.
Antiretroviral therapy (ART) has led to improved survival and reduced disease progression in PLWH.1 According to CDC estimates, 47% of PLWH in the United States are 50 years or greater and 16% are 65 years or greater.
Hypertension (HTN) remains one of the more common chronic diseases in the general population, affecting nearly 75 million adults in the United States. Recent studies have attempted to address the potential relationship between HIV infection, antiretroviral therapy (ART), and HTN.
In the ART era, non-AIDS defining illnesses (NADI), which includes non-AIDS Defining cancers (NADCs), are the leading cause of morbidity and mortality.
The rate of HBV and HCV among PLWH in the United States and other Western countries is as much as tenfold higher than the rate among HIV-uninfected individuals.
The incidence of type 2 diabetes mellitus is reported to be as much as four times higher in patients living with HIV compared to uninfected patients and increases with increasing age. The incidence of the metabolic syndrome is also higher.
The prevalence of disease and comorbidities increases with advancing age, and along with this process come additional medications to treat comorbidities. Increasing number of medications increases the risk of adverse drug events and drug-drug interactions.
Osteoporotic bone disease affects persons with HIV infection disproportionately when compared with others of similar age. Bone density is lower, and the fracture rate as much as 60% higher, in HIV-infected individuals.
For those at high risk, sexual behavior has more often been defined through the narrow prism of HIV prevention. But, sexual health is broadly defined as more than just the absence of dysfunction or disease. Sexual health is a significant element contributing to the quality of life of every person including older adults living with HIV.
To reduce HIV infections in the US, the CDC is pursuing High-Impact Prevention (HIP) approaches. These methods include combined biological and behavioral interventions that are evidence-based, cost-effective, and often tailored for specific populations and geographic contexts. Key to achieving the greatest impact on the reduction of new HIV infections is the promotion of two highly-effective biomedical interventions: Treatment as Prevention (TasP) and the uptake of pre-exposure prophylaxis (PrEP) among at-risk individuals.
Chronic infection burdens repair and immune functions that are already slowing as a result of aging. Particularly important is the age-related shift in glutathione status, leaving a more pro-oxidant state in cells. The slower protein assembly of aging plays out as impaired muscle, organ, and bone repair. Impaired protein assembly yields “immune senescence”—an inability to activate naïve T cells and generate memory T cells. Immune cell activity is sensitive to nutrition deficits; HIV infection alters gut cell structure, impeding all nutrient absorption, even in the HAART era.
An estimated 47% of persons living with HIV (PLWH) in the United States are over 50 years of age, with 15-25% of new infections diagnosed after the age of 50. (CDC 2016; Martin 2008; Nguyen and Holodniy 2008). Since 2008, the CDC has designated as “older” PLWH > 50 years old as a statistical definition, as HIV may accelerate the aging process due to the increased medical comorbidities and decreases in physical and mental functional capacity (Kirk & Goetz, 2009; Watkins 2012).
In contrast to other comorbid disorders in PLWH such as HIV associated neurocognitive disorders (HAND), depressive disorders, and substance use disorders, anxiety disorders have been less examined despite their high prevalence in HIV as compared to HIV-uninfected counterparts. Anxiety disorders may be present prior to an HIV diagnosis or may present as a consequence of an HIV diagnosis.
Psychiatric disorders that are typically excluded in the literature on older persons living with HIV (PLWH) are alcohol and substance use disorders, although this is slowly changing. Psychoactive substance use has been reported by 45.1% of younger PLWH and by 29.7% of older PLWH.
HIV-1-associated peripheral neuropathy is currently one of the most common neuro-AIDS conditions, with about 30-67% of HIV patients experiencing this condition.
HIV-associated neurocognitive disorder (HAND) remains a frequent problem despite effective antiretroviral therapy. Up to 50% of HIV patients will exhibit HAND upon neuropsychological (NP) testing; however, only about a quarter of these patients will endorse everyday symptoms and less than half of those are estimated to have HIV-associated dementia (HAD).