Journal Article

Optimal ARTs for HIV and Older Adults

THE BOTTOM LINE:

In this 2020 publication the authors identify certain current general antiretroviral therapy (ART) recommendations for use specifically in older adults with HIV. Included are multiple data driven recommendations that can, if used, result in reduced ART toxicities that are associated with elevated frequencies of various diseases and conditions in HIV + older adults.  Emphasis is placed on reducing potential bone, renal, neurocognitive and neuropsychiatric toxicities and cardiovascular risk. In addition, the article focuses on concerns that certain ART medications are associated with significant weight gain. More research is needed to clarify the level of risk associated with the increases in weight.  

ABSTRACT

Purpose of review: The age of people with HIV) continues to rise, and yet older people have tended to be under- represented or excluded from premarketing studies of antiretroviral therapy (ART). In this review, we highlight special considerations for the use of ART in older people with HIV, with a focus on toxicities associated with specific antiretroviral agents or drug classes as well as key research questions moving forward. 

Recent findings: Like all people with HIV, older people with HIV should be started on ART as soon as possible, regardless of CD4 count, and with a regimen that includes an integrase strand transfer inhibitor (INSTI) and two nucleoside reverse transcriptase inhibitors. Important toxicities to consider when choosing an ART regimen include bone and renal effects related to tenofovir, weight gain related to INSTIs and tenofovir alafenamide, neurocognitive and neuropsychiatric toxicities related to efavirenz, and increased cardiovascular risk associated with abacavir and boosted protease inhibitors. With the ongoing importance of INSTIs as a component of preferred ART regimens, further characterization of INSTI-related weight gain is a critical current research priority in understanding ART toxicity. 

Summary: There are multiple potential toxicities of ART to consider when selecting a regimen for older people. Specific agents or drug classes have been implicated in adverse bone or renal effects, weight gain, neuropsychiatric and neurocognitive effects, and cardiovascular risk.

 

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