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New HHS ART Guidelines discuss & Provide Guidance: Immunologc Aging, Bone Screening, Frailty, Cognitive Evaluations, Polypharmacy, DDIs in Older PWH
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Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/special-populations-hiv-and-older
Here are excerpts from HHS ART Guidelines discussing older PWH and the aging problem, and mental health & cognitive impairment (monitor & evaluate), depesssion (screening recommended), heart disease (statin use recommended), bone mineral disease (DXA screening), and frailty (monitor & screen), and monitoring for social isolation and polypharmacy, and menopause. And discussed interventions and ways to address these conditions. Other Guidelines recommend these as well. Still, these are only recommendations and many clinicians and clinic administrations still persist in not implementing these. These must be mandated by federal and state leaders. Indeed, not only are 50% of PWH in the USA over 50 as of several years ago but it's expected that 75% will be over 50 and 50% over 60 by 2030. And a high and increasing of older PWH will have multi comorbidities. This is the majority of PWH and our care infrastructure and the RW care system must adapt to this reality. The RW care system is antiquated and was designed 25 years ago, but now we have a new reality and it must be updated and reconfigured to meet this majority population now. The need is existential. Jules Levin, NATAP
See Statin Therapy in People With HIV for recommendations from the Panel on Antiretroviral Guidelines for Adults and Adolescents (the Panel) on statin therapy as primary prevention of ASCVD among people with HIV.
HIV experts, primary care providers, and other specialists should work together to optimize the medical care of older people with HIV .....additional medical and social services may be required to effectively manage both HIV and comorbid conditions.
these guidelines provides guidance on selecting an ARV regimen based on a person's characteristics and specific clinical conditions (e.g., kidney disease, elevated risk for cardiovascular disease [CVD], osteoporosis)..... in older people, special attention should be paid to the greater potential for adverse effects of ART on renal, liver, cardiovascular, central nervous system, metabolic, and bone health (see Table 20).
Non-AIDS comorbid conditions constitute an increasing proportion of morbidity and mortality among people with HIV.3,111 Heart disease and cancer are the leading causes of death in older people with HIV in the United States. Similarly, other non-AIDS events, such as cognitive impairment and liver disease, have also emerged as major causes of morbidity and mortality in people with HIV receiving effective ART.
The frailty phenotype-defined clinically as a decrease in muscle mass, weight, physical strength, energy, and physical activity-represents an important example of an age-related syndrome that occurs with greater frequency and at earlier ages among people with HIV and is associated with a broad spectrum of adverse effects and disease risk. However, pharmacologic and non-pharmacologic interventions addressing frailty among people with HIV have been proposed and have the potential to significantly impact their quality of life and survival.
Age-related decline in neurocognitive function is faster in people with HIV compared to those without.....screening for neurocognitive impairment is important. Screening for depression and management of mental health issues are important when caring for older people with HIV.
Beyond screening and referral to specialists in neurology, neuropsychology, or geriatrics, an approach to cognitive impairment in aging people with HIV should involve assessing and correcting reversible and treatable factors that contribute to cognitive symptoms, as well as directly addressing modifiable risk factors.
Expert guidance now recommends bone density monitoring in men aged ≥50 years and postmenopausal cisgender women and suggests switching from TDF or boosted PIs to other ARVs (such as TAF or INSTIs, respectively) in older people at high risk for fragility fractures.
Given the high prevalence and faster progression of chronic kidney disease (CKD) in aging people with HIV-likely from a combination of HIV, ART, and non-HIV risk factors-development of CKD must be closely monitored in an older person on ART
Among people with HIV aged ≥65 years, it is predicted that the prevalence of comorbidities and polypharmacy rose with increasing age and duration of HIV infection. In the Swiss HIV Cohort Study, the prevalence of polypharmacy and inappropriate prescribing in people aged ≥75 was 66% and 67%, respectively. ......polypharmacy, including the use of drugs that affect neurocognitive function, can contribute to serious adverse outcomes, such as serious falls and fractures, delirium, hospitalization (including intensive care unit admissions), and death.
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