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Q&A: Treating older adults with HIV
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One of the most vulnerable populations that is often overlooked when it comes to treating and preventing HIV is older adults.
Prior research has demonstrated that stigma due to age is common among older Americans living with HIV, which can often intensify transmission of the virus. According to data presented at the 125th Annual Convention of the American Psychological Association, older adults aged 50 years and older make up for almost half of all people living with HIV. Because older adults remain underserved, investment in education, testing and programs to address HIV in this population is urgently needed.
Because September 18 is National HIV/AIDS and Aging Awareness Day, Infectious Disease News spoke with Mark Brennan-Ing, PhD, director for research and evaluation at the AIDS Community Research Initiative, or ACRIA, to learn more about the challenges of treating and preventing HIV in an aging population and how to overcome them. – by Savannah Demko
How does HIV complicate the aging process?
HIV may complicate the aging process in myriad ways. Biologically, HIV causes changes in the immune system and is associated with chronic inflammation, both of which are associated with greater incidence of age-related comorbidities that exacerbate declines in immune function associated with aging (ie, immunosenescence). Psychologically, people aging with HIV have much higher rates of depression compared with noninfected adults, which is associated with treatment nonadherence and greater functional disability. Socially, older adults with HIV often lack the informal social support networks of family and friends that most other older adults rely on for caregiving and other types of assistance needed to remain independent in the community. Unfortunately, there are very few programs and services available from government, health care providers and community-based agencies that address the unique needs of the older HIV-positive adult.
Many aging patients with HIV are treated by their primary care physician. In your opinion, how prepared are generalists in the United States to treat both HIV and its associated comorbidities, such as cardiovascular disease and diabetes?
From my understanding, the bigger issue would be having primary care physicians (PCPs) who are willing to accept a patient with HIV. Most PCPs are familiar with conditions common to aging through their training, and so addressing specific comorbidities (eg, diabetes) for the patient with HIV is probably similar to what they would do for a patient who does not have HIV with regard to treatment, referral and so on. The bigger issue is whether PCPs are adequately prepared to care for aging patients regardless of HIV status. PCPs may not have had training in principles of geriatric care, which address some of the unique medical issues of the aging patient. Furthermore, a referral to a geriatrician may not be possible, given the growing shortage of this specialty in the U.S. and other high-income countries.
What are some of the challenges in caring for older adults living with HIV, and how can physicians overcome them?
The challenges of caring for the patient with HIV who is aging are similar to those of caring for other aging patients. The difference is that the older adult with HIV may be confronting these issues decades earlier than their noninfected peers. The older person with HIV frequently experiences multiple comorbid conditions, or multimorbidity, leading to a greater burden of disease than among those without HIV. In fact, older people with HIV are much more likely to die from chronic conditions associated with aging than an AIDS-related condition. High levels of multimorbidity can lead to numerous prescribed medications in addition to HIV treatment, which can result in polypharmacy and harmful drug interactions. Physicians can successfully address these issues by incorporating geriatric care principles into their practice, such as using multidisciplinary care teams, involving patients and their significant others in developing a care plan, focusing on functional ability rather than trying to treat every symptom that the patient is experiencing and employing palliative care when necessary.
How does stigma due to age affect older adults living with HIV?
Ageism, or stigma resulting from age, increases the likelihood that an older person may become infected with HIV. HIV is still perceived as a young person’s disease, and so health care providers may not address sexual health and risk behaviors with older patients. Nearly one in five new HIV infections in the U.S. are detected in those aged 50 years and older. And the older you are at time of HIV diagnosis, the more likely you are to receive a dual diagnosis of HIV and AIDS. The greater proportion of older adults who receive a dual diagnosis is due to late testing, that is, by the time the HIV test is provided the patient has already progressed to AIDS. Because of this, newly diagnosed older adults have already experienced considerable damage to their immune systems, which puts them at risk for poorer clinical outcomes. For the person who has grown older with HIV, internalized ageism may put them at risk for poorer physical and mental health outcomes. For example, an older person with internalized ageism may ignore signs and symptoms of disease they perceive to be a “normal” part of aging and forgo potentially helpful or even life-saving medical treatment.
What is the take-home message for clinicians who treat older adults living with HIV?
Aging with HIV presents numerous challenges for the patient, as well as for medical and nonmedical health and social service providers. Many of these patients never expected to grow old. Providers need a better understanding of the aging process and should be encouraged to learn about principles of geriatric care and incorporate them into their practice. Although most of the scientific literature focuses on the problems and pathologies of the older person with HIV, we need to also be mindful that many of these individuals are long-term survivors who have successfully coped and adapted to living with this once-terminal disease. There is resilience in this population, and providers should leverage the important personal and social resources that have allowed the HIV-positive adult to face the challenges of aging to maximize clinical outcomes and a decent quality of life.
Reference:
Brennan-Ing M. Session 2126. Presented at: 125th Annual Convention of the American Psychological Association; August 3-6, 2017; Washington D.C.
Disclosure: Brennan-Ing reports no relevant financial disclosures.