Faced
with
an
aging
population
with
HIV,
clinicians
will
need
to
help
these
older
patients
navigate
a
healthy
route
from
antiretroviral
therapy
(ART)
initiation
through
complex
comorbidities
to
an
increased
focus
on
maintaining
function
toward
the
end
of
life,
according
to
a
new
report.
The
Lancet
HIV
Commission
report
on
aging
and
HIV
outlines
a
three-phase
approach
to
managing
affected
patients:
-
Establishing
a
therapeutic
alliance
with
patients -
Maintaining
health
despite
increasingly
complex
conditions -
Focusing
on
patients’
priorities
for
preserving
cognitive
and
physical
capacities
“Public
health
HIV
prevention
messages
about
safe
sex,
HIV
screening,
and
early
HIV
diagnosis
need
to
be
better
tailored
to
older
people.
People
older
than
50
years
are
200-400%
more
likely
to
experience
a
delayed
HIV
diagnosis
and
treatment
than
people
younger
than
50
years,
which
can
endanger
their
health,
prolong
the
period
in
which
their
viral
load
is
detectable,
and
expose
other
people
to
infection,”
wrote
a
group
led
by
Amy
Justice,
MD,
of
Yale
University
in
New
Haven,
Connecticut.
Relative
to
younger
people,
older
people
are
assumed
to
be
at
lower
risk
of
HIV
infection,
which
can
lead
to
delayed
diagnosis
and
treatment.
That
sets
them
back
in
their
ability
to
have
healthy
aging,
cautioned
Justice
during
a
presentation
at
the
International
AIDS
Conference
in
Rio
de
Janeiro.
Aging
with
HIV
also
puts
people
at
greater
risk
of
conditions
such
as
cardiovascular
disease,
liver
disease,
and
some
cancers
—
all
at
earlier
ages
than
their
counterparts
without
HIV.
In
managing
the
health
of
older
adults
with
HIV,
clinicians
must
remember
that
physiological
age
versus
chronological
age
for
people
with
HIV
can
be
very
different,
noted
Justice.
“ART
has
dramatically
extended
survival;
it’s
a
miracle
of
modern
medicine,”
she
said.
“But
most
people
living
with
HIV
do
not
have
a
normal
life
expectancy.”
People
aging
with
HIV
are
heterogeneous,
added
co-author
Keri
Althoff,
PhD,
of
Johns
Hopkins
University
in
Baltimore.
“We
have
individuals
who
were
infected
many
decades
ago
and
have
survived,
we
have
individuals
with
perinatally
acquired
HIV
and
have
survived
many
years,
and
we
have
younger
individuals
who
are
just
initiating
treatment,”
she
noted.
“This
is
the
time
—
this
is
the
moment
—
to
help
start
that
aging
trajectory.”
The
full
report
was
published
simultaneously
in
the
Lancet
HIV.
Follow
the
Three-Phase
Clinical
Path
“In
all
phases,
it’s
important
to
support
ART
adherence,
good
mental
health,
a
healthy
lifestyle,
and
self-care,”
said
Brenda
Crabtree,
MD,
of
Salvador
Zubiran
National
Institute
of
Medical
Sciences
and
Nutrition
in
Mexico
City,
another
contributor
to
the
report.
The
recommended
first
clinical
phase
is
building
a
therapeutic
relationship
with
older
patients
who
are
initiating
ART.
During
this
phase,
tackling
substance
use,
reduced
self-care,
and
screening
and
treatment
are
critical,
as
is
the
initiation
of
a
well-tolerated
ART
regimen,
Crabtree
noted.
“Older
people
might
face
synergistic
stigma
from
ageing
and
HIV
infection
and
therefore
avoid
HIV
testing,
even
when
they
suspect
that
they
have
HIV.
Health-care
providers
should
ask
older
people
about
sexual
health,
consider
HIV
as
a
possible
explanation
for
symptoms
commonly
associated
with
acute
or
chronic
HIV
infection,
and
ask
about
substance
use,”
the
group
wrote.
The
second
phase
combines
management
of
chronic
HIV
with
the
prevention,
screening,
and
treatment
of
comorbid
disease,
explained
coauthor
Tristan
Barber,
MD,
of
University
College
London.
Phase
two’s
goals
include
monitoring
a
patient’s
physiological
age,
following
primary
care
guidelines,
and
minimizing
the
harms
of
polypharmacy
involving
HIV
drugs
and
those
for
aging’s
comorbid
conditions.
What
physiological
age
is
an
older
person
with
HIV?
“I
always
say
to
students
training
in
my
clinic
that
we
have
to
think
not
only
about
people’s
birthday
age,
but
also
their
HIV
age,”
Barber
said.
Being
a
70-year-old
who
acquired
HIV
in
1990,
for
example,
“you’re
a
very
different
70-year-old
to
someone
who
acquired
HIV
in
2020,”
he
noted.
The
inflection
point
between
the
second
and
third
clinical
phases
comes
with
about
10
years
of
life
remaining.
Predicting
that
point
can
be
challenging,
Barber
conceded.
With
the
transition,
clinicians
and
patients
move
to
the
phase
three
goals
of
focusing
on
individual
patient
preferences
for
receiving
care,
conducting
a
comprehensive
geriatric
assessment,
and
planning
for
end
of
life.
Growing
Needs
for
a
Growing
Population
The
need
for
better
healthy
aging
strategies
in
HIV
will
only
grow
in
the
next
decades,
according
to
the
report.
Right
now,
the
median
age
among
the
estimated
39
million
people
with
HIV
globally
is
41
years,
and
11.5
million
of
those
people
are
older
than
age
50
years.
By
2040,
20.2
million
people
older
than
50
could
have
HIV,
accounting
for
51%
of
everyone
with
HIV
and
pushing
the
total
population’s
median
age
to
50
years.
At
that
point,
almost
every
one
of
those
older
people
with
HIV
(96%)
will
likely
be
living
in
low-
or
middle-income
countries,
researchers
projected.
In
the
U.S.,
HIV
prevalence
is
on
the
rise
in
those
older
than
50.
The
estimated
prevalence
of
diagnosed
and
undiagnosed
HIV
infections
is
highest
in
those
age
55-64
years,
at
728.1
cases
per
100,000
population,
topping
the
prevalence
rate
of
those
age
25-34
years,
at
487.1
per
100,000.
The
authors
say
they
expect
to
see
HIV
incidence
among
older
adults
increase
proportionately
with
prevalence
if
prevention,
screening,
and
diagnostic
programs
aren’t
targeted
at
that
group.
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