Caring for Older Adults with HIV and AIDS

According to the Centers for Disease Control and Prevention’s most recent projections, roughly half of all Americans infected with HIV (human immunodeficiency virus) will be 50 years of age or older by 2015. This striking statistic is both encouraging and daunting. It is encouraging because it reflects the remarkable success of antiretroviral and other HIV treatments in combating AIDS (acquired immune deficiency syndrome). Yet, it is daunting because many HIV-positive patients in their 50s and early- to mid-60s—patients who are aging but are not chronologically considered seniors—are developing multiple, complex health problems typically associated with more advanced age.

The simultaneous presence of both HIV- and age-associated health problems among these patients makes determining how best to proceed with treatment particularly challenging. An important report, titled “The HIV and Aging Consensus Project: Recommended Treatment Strategies for Clinicians Managing Older Patients with HIV” (www.aahivm.org/hivandagingforum), was recently published by the HIV & Aging Consensus Project, a joint undertaking of the American Academy of HIV Medicine (AAHIVM), the American Geriatrics Society (AGS), and the AIDS Community Research Initiative of America (ACRIA), to provide healthcare providers with much-needed strategies for optimizing treatment in this complex population. The report provides the first clinical treatment strategies for managing older patients with HIV, making it an invaluable resource to clinicians caring for aging and older adults infected with the virus.

The HIV & Aging Consensus Project was led by Wayne McCormick, MD, MPH, Director, AGS Board of Directors, and Professor of Medicine, University of Washington School of Medicine, Seattle, and Jonathan Appelbaum, MD, AAHIVS, Director, Internal Medicine Education, Florida State University College of Medicine, Tallahassee. The report notes that while some HIV-positive patients in their 70s are robust, active, and aging successfully, many adults between 50 and 65 years of age are “experiencing high rates of comorbid illnesses.” These include liver disease, cardiovascular disease, kidney impairment, non–AIDS-related cancer, osteoporosis, neurocognitive decline, and frailty. The report includes chapters outlining strategies for reducing risks of, screening for, initiating treatment of, and monitoring of these and other HIV- and age-associated health problems in comorbid and multimorbid middle-aged and older patients. It also includes helpful and relevant chapters about immunizations, sexual health, and advance directives.

Throughout, the report incorporates and reflects what its authors describe as key “lessons from geriatrics.” Among other things, the strategies reflect geriatric medicine’s complex understanding of frailty and disability in later life—an understanding that recognizes the diverse, often overlapping contributors to both. The strategies also reflect geriatric medicine’s approach to standard screening and treatment guidelines, which are based on the needs of populations free of multimorbidity and may not be appropriate for older patients with HIV or AIDS. In addition, the strategies reflect our focus on syndromes rather than on individual diagnoses. “[It] may be more important to identify organ systems at risk rather than labeling all diagnoses present in an individual,” the authors note. “Some diagnoses (eg, vitamin D deficiency) may never become symptomatic, whereas organ system failure is always associated with substantial morbidity and mortality.”

Acknowledging that “there remain substantial gaps” in the knowledge base, the authors plan to continually update the strategies on an interactive Website where practitioners and researchers can report on their work with older HIV-positive patients. Additional information about the project’s efforts is available on the AAHIVM Website at www.aahivm.org.

You can also learn more about the project and report at the AGS Annual Scientific Meeting, which will run from May 3 through 5, in Seattle, WA. A workshop slated for May 3 will be dedicated to the report and include presentations by Dr. McCormick; Kevin P. High, MD, AGS member, Wake Forest School of Medicine; and Kelly A. Gebo, MD, MPH, Johns Hopkins University. I hope you can attend.

According to Dr. McCormick, the majority of complex, aging patients with HIV are now seen by HIV specialists. As we all know, geriatricians and other geriatrics healthcare professionals are well-versed in the care of complex older patients, but are in increasingly short supply in the United States. Despite this shortage, we can still play a role in the care of aging HIV-positive patients. How best to do this? First, geriatricians should focus on the most complex of these patients, even if these patients are somewhat younger than those we typically see in our practices. We can also play a consulting role in collaborations with HIV specialists and other healthcare professionals, and become involved in projects such as the one that produced the new strategies. Those of us in geriatrics can and should be involved as this area continues to evolve, given our knowledge and skills, experience in managing complex chronic diseases, understanding of the importance of advance directives and goals of care, respect for patient choices, and commitment to keeping patients as independent as possible and preserving their quality of life.

There is another important way geriatrics healthcare professionals can help address the rapidly increasing numbers of older HIV-positive patients: By raising awareness, among our patients, that nearly one in every five new cases of HIV infection in the United States is in an adult 50 years of age or older. To help you get the word out and to help encourage safe sexual activity in older adults, the AGS Foundation for Health in Aging recently updated and reissued an easy-to-understand tip sheet that explains the importance and basics of practicing safe sex in later life. The tip sheet can also be downloaded at http://www.healthinaging.org. I encourage you to share it with your patients.

Finally, we encourage you to answer the poll question at clinicalgeriatrics.com: Should geriatricians be actively involved in the care of adults 50 years of age and older with HIV/AIDS? We also welcome your feedback on this topic, which may be published as a letter to the editor in an upcoming issue of Clinical Geriatrics, at amusante@hmpcommunications.com.

Dr. Spivack is Medicare Medical Director, OptumHealth Care Solutions, United Healthcare, Westport/Trumbull, CT; Founder, Connecticut Geriatrics Society; Consultant in Geriatric Medicine, Greenwich Hospital, Greenwich, CT, and Stamford Hospital, Stamford, CT.

Send your comments and questions for Dr. Spivack to: amusante@hmpcommunications.com