Clinicians urged to manage HIV-infected elders differently from younger people

By Marilynn Larkin

NEW YORK (Reuters Health) - Differences in immune response to antiretroviral therapy, multimorbidity and antiretroviral toxicities are among the factors that differentiate older adults with HIV from their younger counterparts, and should influence care plans, researchers suggest.

"Each older adult with HIV is a unique and complex individual, and disease-centric guidelines should not be applied the same way in every individual," write Dr. Jonathan Appelbaum of Florida State University College of Medicine in Tallahassee and Dr. Aronsiri Sangarlangkarn of the Thai Red Cross AIDS Research Center in Bangkok, Thailand.

"The geriatrics approach of caring for the whole person should guide management of diseases in older adults with HIV, incorporating aging phenotypes, interactions with multimorbidity, and individual preferences into person-centered care plans," they add in a paper online September 29 in the Journal of the American Geriatrics Society.

Dr. Appelbaum told Reuters Health, "Over half of all people infected with HIV in (the United States) are now over the age of 50 and almost one-fifth of new infections occur in this population."

"Aging with HIV along with the other diseases that occur more commonly in older patients (such as high blood pressure, diabetes, arthritis, to name a few) is increasingly complex to manage," he said by email.

"Geriatricians who specialize in the care of older people may not be aware of the implications and treatment strategies of older patients infected with HIV," he observed.

The coauthors provide an approach for caring for older adults with HIV that takes into consideration factors such as aging, comorbidities, and differences in immune response to therapy that characterize individuals with HIV who are 50 and older.

For example, they note that HIV infection and the aging process together produce "excessive immune activation and inflammation" that can promote disease progression. "Consequently, early HIV diagnosis and treatment in older adults with HIV are of great importance," they write.

They also point out that older adults with HIV may have toxicities related to antiretroviral therapy caused by age-related changes in physiology and increased by multimorbidity. To help clinicians make informed therapy choices, they provide a list of common side effects and drug interactions.

"Special considerations may be given to the increasing legalization of marijuana in the United States, because it is likely that this will present challenges to HIV providers," they write. Although marijuana may improve mood and appetite and reduce pain, it also "may cause cough, phlegm production, wheezing, and airflow obstruction."

They add, "Of particular concern in older adults with HIV, smoking marijuana may also lead to greater risk of lung cancer and impaired cognition."

The authors recommend use of the Veterans Aging Cohort Study (VACS) Index, which can help distinguish between those who are aging well and those who may appear older than their chronological age, as a tool that can help in disease management. (The VACS calculator is available here: https://bit.ly/2eaBnSd.)

"The VACS Index may be used to identify aging phenotypes and can provide useful prognostic information to help providers prioritize interventions and guide shared decision-making with individuals and caregivers," they conclude.

Dr. Aimee Lopes, an HIV specialist at Sharp Rees-Stealy Medical Group in San Diego, California, told Reuters Health, "Caring for the aging HIV population has been a topic of increased interest and concern in the HIV medical community for some time."

"There is concern about the increased incidence of cardiovascular disease, strokes, certain types of malignancies, frailty, osteoporosis and dementia at earlier ages in our HIV population over the age of 50," she said by email.

Many factors contribute to increased morbidity and mortality in this population, she observed.

"It is thought that the ongoing presence of controlled HIV disease still continues to cause increased amounts of inflammation in the human body. It is likely that the results of such ongoing inflammation coupled with medication side effects and other normal aging issues contribute to the complexity of this patient population," she explained. "Research on this topic is ongoing. We hope to have more clear answers in the future."

Dr. Lopes added, "We are also seeing a fair amount of new HIV infections being acquired in persons over the age of 50. As physicians, we need to remain vigilant in screening and counseling our aging patients about their risk for HIV and other sexually transmitted diseases."

Dr. Allison Webel, an HIV expert at Case Western Reserve University in Cleveland, Ohio, told Reuters Health by email, "As people age, their immune system naturally diminishes. This natural aging process is accelerated by HIV, leading to a higher prevalence and greater severity of other chronic health problems that older, HIV-uninfected adults face, including cardiovascular disease, cancer, and bone diseases, as well as symptoms such as fatigue."

"Older adults with HIV, in particular, face the challenge of polypharmacy," she added. "There is ongoing research examining new medication strategies to reduce the risk and severity of these health conditions. However, new research is needed to examine non-pharmacological approaches tailored to this unique population to stop smoking, reduce substance use, increase moderate-to-high intensity and resistance exercise, and improve diet."

SOURCE: https://bit.ly/2efvWxf

J Am Geriatr Soc 2016.