Back to Basics: The Importance of Primary Care in Aging Patients With HIV

I recently saw an older patient who had been diagnosed with HIV in 1998, started efavirenz/emtricitabine/tenofovir disoproxil fumarate in 2004, and was switched to bictegravir/emtricitabine/tenofovir alafenamide in 2017. He had an undetectable viral load, and his CD4+ count was up to 798 cells/mm³ from a nadir CD4+ cell count of 225 cells/mm³. Most would consider this a successfully treated patient. However, as soon as he walked in, I noted that his face was covered with severe seborrheic dermatitis. When I asked how long he had been experiencing the skin symptoms, he said it had been 6 years. He also had a large, fluctuant, and erythematous furuncle on his temple that had also been present for a while. In addition, his ears were full of cerumen, and he had a tinea infection on his chest and back. His labs revealed that he had syphilis with an rapid plasma reagin titer of 1:256 and that he had HBV immunity but no HAV immunity. What had gone wrong with his care?

Overlooking the Basics in Care of Aging Patients With HIV
Aging patients with HIV need coordinated care from a clinician or multiple clinicians with expertise in HIV medicine, primary care, and gerontology. In the early days of the epidemic, primary care providers were at the forefront of HIV care. At that time, most patients with HIV were younger, so the HIV infection was the primary concern. Patients were suffering from a myriad of secondary infections and debilitating adverse events from both HIV and the available medications—those were the issues that required immediate attention.

Now many of our patients are older and suffer the complications of aging, which is intensified by the acceleration of aging associated with HIV. This acceleration is evidenced by early onset of cardiovascular disease, cognitive impairment, cancer, and diabetes in patients with HIV compared with aging individuals who do not have HIV.

For too many patients, the focus of the medical establishment remains entirely on their HIV infection. Today, many patients see infectious disease (ID) specialists for their HIV care. Many patients report that the entire visit with their HIV specialist consists only of a discussion of their CD4+ cell count and HIV-1 RNA. Some of these specialists are willing to provide primary care to their patients but may be uncertain what to focus on beyond the HIV infection. In addition, many ID specialists are overwhelmed with treating transplant patients, immunosuppressed patients, and life threatening infections in the hospital, including serious cases of COVID-19.

What Primary Care Issues Are Most Important for Our Aging Patients?

1. Controlling blood pressure. Blood pressure recommendations have been continually updated. Based on current guidelines, a good target for someone older than 60 years of age is < 140/90 mm Hg, depending on cardiovascular risk.
2. Screening for diabetes and control of glucose. Elevated glucose on a fasting lab indicates that glycated hemoglobin (A1C) levels should also be checked. A1C takes time to develop and provides a better picture of glucose control over several months. An A1C between 5.7% and 6.5% suggests impaired fasting glucose or “prediabetes.” People in this range have a greater probability of progressing to diabetes during the next 10 years. Changes in weight, diet, and exercise help to significantly reduce this risk. An A1C of ≥ 6.5% warrants a diabetes diagnosis—medication may be indicated in addition to lifestyle changes.
3. Screening for thyroid disease. Thyroid disease is common in persons older than 60 years of age, particularly in women. Screening is suggested for high-risk patients, including those with diabetes, or in patients with signs or symptoms of thyroid disease, such as hypertension and palpitations.
4. Vaccines. Many providers fail to keep up with the vaccine status of their patients. Vaccines to consider include
   • Measles, mumps, and rubella: Because vaccination rates have recently dropped, it remains critical to ensure our older patients are protected.
   • Hepatitis A and B: Patients should be tested for HBV and HAV (in addition to HCV), and antibody titers should be evaluated. If antibody titers are insufficient, the patient should be vaccinated.
   • Influenza: Every year 10,000-60,000 people die in the United States from influenza. Older people and children are particularly at risk for hospitalization and death. We should continue to vaccinate our aging patients and remind younger patients of the importance of vaccination to minimize transmission to vulnerable individuals.
   • Herpes zoster: Before 2017, only a live shingles vaccine was available, which is contraindicated for immunocompromised patients, including patients with HIV. Now a recombinant vaccine is available that is even more effective—approximately 95% effective—and is safe for patients with HIV. This vaccine is indicated for people older than 50 years of age and is recommended by the DHHS guidelines for patients with HIV aged 50 years or older.
   • Human papilloma viruses (HPVs): HPVs are associated with several cancers including anal, cervical, penile, and head and neck cancers. The 9-valent HPV vaccine protects against the viruses responsible for 95% of cervical cancers. The vaccine is approved for persons younger than 45 years of age. 
   • Tetanus: A tetanus vaccine should be given every 10 years, unless a patient experiences a puncture wound, in which case a booster should be given if it has been 5 years or longer since the patient’s last booster. 
   • Pneumococcus: Pneumococcal pneumonia is the most common kind of community-acquired pneumonia. Two preventive vaccines are recommended for adults 65 years of age or older, but vaccination should be considered earlier in patients with HIV. The 13-valent vaccine, PCV13, is often given first. The 23-valent vaccine, PPSV23, cannot be given until 1 year after PCV13 for patients on Medicare. However, if rapid initiation of immunity is needed, including in immunocompromised individuals, it is safe to give PPSV23 as early as 8 weeks after PCV13.                                               
5. Prostate cancer screening. Discuss the risks and benefits of screening in cis-men and transgender women. Men who are 55-69 years of age should decide if they want a prostate-specific antigen test. It is currently not recommended to screen men older than 70 years of age.
6. Breast cancer screening. Cis-women and transgender men aged 55 years or older should get a mammogram at least every 2 years. Remember that even if a transgender man has had a double mastectomy, residual breast tissue often remains, and normal screening recommendations apply. However, a breast ultrasound or CT scan may be more effective post surgery.
7. Cervical cancer: Regular screening is recommended for cis-women and transgender men who have not had a hysterectomy with removal of the cervix. Women older than 65 years of age without a history of abnormal results or cervical cancer and who have had either 3 negative Pap test results in a row or 2 negative cotest (Pap test plus HPV test) results in a row can stop having cervical cancer screenings.
8. Sexually transmitted infection testing. The CDC recommends annual testing for gonorrhea, chlamydia, and syphilis for patients with HIV. It is recommended that men who have sex with men should be tested for oral, anal, and urethral gonorrhea. However, remember that many heterosexual individuals also have anal sex and oral sex, so providers should talk to patients about their sexual activity and test as appropriate.
9. Colon cancer screening. All patients aged 45-75 years should be screened by colonoscopy every 10 years. Patients with a higher risk of colorectal cancer, as indicated by a family history, might need to start screening earlier and more often. If there are benign polyps, then screening every 3-5 years is recommended. If the patient refuses colonoscopy, then a stool DNA screening test can be done. However, these tests only detect colon cancer and do not identify benign or dysplastic lesions or abnormal colon pathology, such as diverticula or colitis.

This list is not exhaustive—other primary care issues will also need attention in patients with HIV. Treating the patient mentioned above for his severe seborrhea and treating his furuncle with doxycycline has cleared his face and given him new confidence. However, it is concerning that these problems were ignored for years. A primary care approach to our patients that focuses on all of their healthcare needs, not just their CD4+ cell count and HIV-1 RNA, is vital for maintaining good health and quality of life as our patients age.

Your Thoughts?
What are your experiences with basic preventive or primary care needs in patients with HIV? Please answer the polling question and share your thoughts in the discussion section.