Aging With HIV: Expert Insights on Complications and Challenges
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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
from Jules: this is a very good discussion and brief addressing key issues in aging & HIV facing patients, clinicians and the HIV & RWCA care system; our care infrastructure & federal and state officials and advocates have very much neglected this most important issue fir HIV+ who are aging. The epidemiology of HIV has changed, now 80% in the USA are over 40-45 yrs old, 50% are over 50, and 25% over 60-65, soon 60% will be over 60. Comedications costs, and multi-comorbidity is COMMON amongst older HIV+ who are prematurely aging with disability, gait problems, cognitive impairment fractures, heart disease, cancers, and kidney disease.
"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......Advocate fiercely for your patients and be cognizant that comorbidities can present earlier and at greater frequency in this population.....spending 1 office visit to do a geriatric assessment....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......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.......treat your aging patients with HIV as you would want your loved one treated.....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.....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."
Aging With HIV: Expert Insights on Complications and Challenges
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. [from Jules: HIV stigma itself is bad regardless of sexual status, and on top of that aging 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. [from Jules: or non existent]
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
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.
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. Greene M, Covinsky KE, Valcour V, et al. Geriatric syndromes in older HIV-infected adults. J AcquirImmune Defic Syndr. 2015;69(2):161-167.
8. 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
9. Cantudo-Cuenca MR, Jimenez-Galan 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.
10. 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.