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Division of HIV/AIDS Treatment and Care
National Center for AIDS/STD Control and Prevention
Dr Yan Zhao has no relevant conflicts of interest to report.
With the scaling up of antiretroviral therapy (ART), the life expectancy of people with HIV (PWH) has been significantly extended. According to UNAIDS statistics in 2020, the number of PWH aged 50 years or older reached 8.1 million globally, and the number in the Asia-Pacific region reached 1.4 million, second only to the East and Southern Africa at 3.7 million.
HIV-Associated Inflammation and Aging
The available evidence suggests that the inflammatory response to HIV infection induces a chronic immune activation that accelerates the typical rate of biological aging. In addition, past/long-term use of first-generation antiretroviral drugs, especially the oldest protease inhibitors, has been associated with fat atrophy, mitochondrial toxicity, and biological aging beyond calendar years. With PWH living longer, aging and the management of age-related comorbidities in PWH have become a global issue of concern.
Comorbidities, Age, and Duration of Infection
Vonder and colleagues presented data at the 18th European AIDS Conference (EACS 2021) showing that increasing age, longer duration of HIV infection, and history of AIDS were significantly associated with a greater number of comorbidities. The authors noted that the burden of comorbidities by age among long-term survivors of HIV (diagnosed prior to 1996) resembled the burden in control participants who were 10 years older. It is as though having HIV accelerates the aging trajectory, and they concluded that longer duration of HIV infection and diagnosis prior to the introduction of highly active ART are factors that may warrant enhanced emphasis on comorbidity screening among older PWH.
Frailty in PWH
In recent years, HIV researchers have shown increasing interest in geriatric syndromes among PWH 50 years of age or older, including frailty, cognitive impairment, and falls. Frailty is common among older PWH and increases the risk of poor health outcomes, such as falls, disability, hospitalizations, and death. A study from Zhejiang Province, China, in PWH older than 40 years of age found significantly greater rates of prefrailty (28.1% vs 11.9%) and frailty (6.1% vs 0.6%) among PWH compared with their age-, sex-, and education level‒matched HIV-negative controls (P <.01). Symptoms of neurocognitive impairment, depression, and insomnia were independently associated with prefrailty/frailty in this study. These data underscore the potential of multimorbidity and functional decline (frailty) to increase the risk of disability and significantly reduce the quality of life among aging PWH.
A multistate Markov model study presented by Milic and colleagues at EACS 2021 showed that sex and multimorbidity predict initial transition from a fit to prefrailty phenotype among PWH, but frailty index and duration of HIV predict the transition to the frailty phenotype and its reversibility. The authors concluded that the frailty phenotype and frailty index should be used to monitor the aging trajectory in older PWH, perhaps improving the prediction of adverse health outcomes and prognosis. These frailty indicators could be combined with enhanced comorbidity screening as part of a comprehensive approach to caring for aging PWH.
Impact in Asia-Pacific Region
Among the approximately 240,000 new HIV infections in the Asia-Pacific region in 2020, UNAIDS estimates that 19,000 occurred in patients 50 years of age or older. On World AIDS Day 2020, the WHO reported that Chinese people 60 years of age or older were contracting HIV at the fastest rate of any age group in China. So, aging poses important new challenges in the care of PWH in the Asia-Pacific region. High-quality research and expert guidance on the treatment of older PWH are needed. For example, how best to manage multimorbidity and reduce disease burden among older PWH remains a problem to be solved. Furthermore, polypharmacy associated with multimorbidity greatly increases the risk of drug‒drug interactions with ART, and the concomitant increased pill burden may negatively impact ART/non-ART medication adherence. Facing dual challenges from HIV infection and age-related multimorbidity, HIV specialists and primary care providers need to work together to develop an integrated care approach to improve quality of life among older PWH.
How will new data from EACS 2021 influence your management of older PWH? Answer the polling question and join the conversation by posting in the discussion section. For more from EACS 2021, download Capsule Summaries of these and other key studies and watch on-demand webcasts featuring expert insights on the clinical implications of the latest data.