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Piecing the Puzzle Together: Addressing Medical Challenges in Older PWH

Jonathan Appelbaum, MD, FACP, AAHIVS
Program Director

Laurie L. Dozier Jr, MD, Education Director
Professor of Internal Medicine
Department of Clinical Sciences
Florida State University College of Medicine
Tallahassee, Florida

Jonathan Appelbaum, MD, FACP, AAHIVS: consultant: Merck, Theratechnologies, ViiV Healthcare.

View ClinicalThoughts from this Author

Released: August 17, 2022

Key Takeaways

  • Aging people with HIV face many medical and psychosocial challenges, including consequences of early experiences in the epidemic such as late HIV diagnosis and low CD4+ cell count nadir, incomplete or short-lived virologic suppression with early regimens, and toxicity associated with early antiretroviral agents.
  • Opportunities exist to ensure that the healthcare system is equipped to best care for the aging HIV population.
  • HIV infection is just one piece of the puzzle—many other issues should be considered and addressed.

Older people with HIV (PWH) often are underrepresented in medical research, particularly in clinical trials for new medications. For many years, patients older than 65 years of age have been excluded from clinical trials. This is beginning to change, but because older patients are more predisposed to comorbidities of aging (eg, renal or hepatic impairment), they still may be subject to study exclusion despite the lack of age cutoffs.

This is just one of the many challenges faced by the aging population of PWH. Others include multimorbidity, polypharmacy, geriatric syndromes, and psychosocial issues. Timing of their HIV diagnosis (earlier vs later in life and earlier vs later in the epidemic), CD4+ cell count nadir, onset of opportunistic infections, and experience with earlier less-suppressive regimens including agents with toxic adverse events may vary among aging PWH and impact their experiences and overall wellness, adding challenges.

Consequences of Early Experiences in the Epidemic
Patients diagnosed with HIV early in the epidemic, before highly effective antiretroviral therapy was available, may have been exposed to several different HIV treatments (eg, zidovudine monotherapy, early less-suppressive dual- and triple-combination therapies) that were associated with barriers to adherence, such as high pill burdens, inconvenient dosing, and treatment-limiting toxicities. This led to incomplete virologic suppression, ongoing viral replication, drug resistance, and short- and long-term drug toxicities of antiretroviral drugs. Concomitant comorbidities added another layer of complexity. Finally, many PWH experienced stigma because HIV and trauma, such as the loss of friends and loved ones.

On the other hand, although many older PWH may be experiencing comorbidities of aging, older patients who were more recently diagnosed with HIV do not usually have the consequences of many failed antiretroviral therapy regimens.

A low CD4+ cell count nadir at the time of HIV diagnosis can further exacerbate the experiences of older PWH. Patients who were diagnosed with advanced HIV or AIDS—ie, with very low CD4+ cell counts and elevated HIV-1 RNA—were subject to prolonged immune suppression and elevated systematic inflammatory responses. Risk for opportunistic infections and cardiometabolic toxicities (eg, cardiovascular disease, diabetes mellitus, bone disease) also were increased in this subset of patients. Late HIV diagnosis still occurs in practice, but not as commonly as it did earlier in the epidemic.

Medical Challenges in Aging PWH
Adding HIV infection to many underlying problems of aging—such as diabetes, hypertension, obesity, hyperlipidemia, and renal or liver disease—creates additional challenges when caring for older PWH. A holistic approach to multimorbidity is a geriatric concept to optimize patient care and improve outcomes. When a healthcare professional focuses on only 1 disease in a patient who has multiple comorbidities (eg, focusing on HIV to the exclusion of other diseases), their patient is not well served, and such a practice can profoundly affect outcomes in a negative way, creating downstream effects of other comorbidities.

Another aspect to consider when caring for older PWH is psychosocial challenges, especially mental health issues, loneliness, and social isolation. Patients may carry with them decades of experienced stigma and discrimination. These factors can detrimentally impact their health. We must remember that psychosocial issues are as important as medical issues and should be integrated into the paradigm when assessing older PWH.

Providing Care for the Aging HIV Population
How can we best provide care for aging PWH? In a 15- or 20-minute visit, how can one address all their issues? As the HIV population ages, are we prepared to care for these patients? These questions are all very pertinent.

In my experience, managing my patient’s HIV infection has become a less concerning issue because HIV is more easily treated today than in earlier phases of the epidemic. We have access to single-tablet regimens with high genetic barriers to resistance and improved tolerability. As such, we may see patients once or twice per year, check their HIV-1 RNA, and run metabolic panels to assess for adverse events. However, for our older PWH with complex medical issues, more time often is needed to address non-HIV diseases, and, again, this should be done in a holistic way.

Whether our healthcare system is equipped to provide care for this complex aging population is a major concern. It may be difficult to determine the best places for patients to receive care. Patients may be receiving care from HIV specialists who are not trained as geriatricians, or they may be cared for by primary care physicians (PCPs) who have little geriatric experience—and not all geriatricians and PCPs are comfortable with HIV management. Geography may add a barrier, as specialists (either HIV physicians or geriatricians) may not be available in all locales, particularly in rural areas.

From the patient’s point of view, many people who have had an ongoing relationship with their HIV physician may prefer that physician to manage all aspects of their care. They may be less willing to see new healthcare professionals or have others take over certain aspects of their care. However, some HIV physicians may not feel comfortable taking care of non-HIV issues and may find referring their patients to a PCP or geriatric care a better approach.

It is important to remember that HIV infection is just one piece of the puzzle. Many issues need to be considered and addressed in a holistic way. To do this successfully, we need to ensure that our healthcare system is well equipped to provide care for our aging PWH—supporting both our healthcare professionals and our patients.

Your Thoughts?
How are aging PWH with multimorbidity cared for in your community? Is your HIV population aging? Is that a challenge? Join the discussion by posting a comment.

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