Half of adults who live with HIV and are accessing care are now aged 50 years and older, and around one in 11 are aged 65 years and older. Noticeably, older adults with HIV in all countries are also more likely to have comorbidities and become ‘frail’ early compared with older adults without HIV.
This is according to a new research review that will be presented at this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2024) by Prof. Giovanni Guaraldi of the University of Modena and Reggio Emilia in Modena, Italy.
As it is, at least in Europe, more older people are being diagnosed with HIV (one in five new diagnoses are in those aged 50 and over) and late diagnosis happens in those older people. Noticeably, around half of the cases of newly diagnosed in the over-50s presented with white blood cell CD4 count below 350 cells per mm³ of blood within three months of diagnosis, meaning they have increased risk of mortality in the following year by five-fold.
While this is challenging, Guaraldi noted the progress made, with the difference in remaining life expectancy comparing those people living with HIV and those without HIV infection aged 21 years decreasing from 22 years in 2003-06 down to nine years in 2014-2016. Yet across that same period, there was no change in the difference of years lived without developing other conditions (multimorbidity) with those living with HIV living 15 fewer years without multimorbidity compared with those not infected. Today, in another sign of progress, a young person diagnosed with HIV promptly can expect the same life expectancy as those not living with HIV.
By age 65 years, around 70% of those living with HIV for 20 years or more are living with multiple other conditions, compared with around 50% for those infected for less than 20 years and close to 40% for those not living without HIV. These figures steadily increase as those with HIV age, but the gap narrows between those with and without HIV (see graph in presentation). A similar trend is shown for polypharmacy (taking multiple prescribed drugs) in those living with HIV.
Guaraldi noted the hidden phenomenon of accelerated aging or ‘early frailty’ in those living with HIV. Frailty is a clinical syndrome based on presence of specific signs and symptoms, including weight-loss, exhaustion, lack of physical activity, decreasing grip strength, and walking speed. He reviewed a study showing frailty levels higher in people living with HIV compared with those not living with HIV, across all age groups from age 50 years and up, with rates some five times higher in those aged 65 and older. Another study showed older adults living with HIV twice as likely to become frail as their HIV negative peers.
For Guaraldi, frailty and poor outcomes are not inevitable, and ways of avoiding this include early diagnosis of HIV and initiation of antiretroviral treatment (to avoid risk of rapid progression and cognitive impairment), but also a careful analysis of all their other medications and taking people off them (deprescribing) where possible.
There are also drugs that should be avoided in older people with HIV where possible, due to drug-drug interactions and also drugs that increase the risks of frailty. Examples in this extensive list include the alfalitics drug class used for treating high blood pressure, and benzodiazepines that can increase the risk of falls.
Finally, Guaraldi noted social and care challenges faced by older people living with HIV, explored in the recent paper he co-authored in The Lancet HIV, discussing, among other issues, the problems that they can face entering long-term aged care facilities and opening up about their diagnosis to new doctors and people that they are not familiar with – and an array of other problems, including exacerbated challenges of daily living, mental health problems including ‘survivor guilt’ and stigma, and the increasing isolation caused by the COVID-19 pandemic.
“Ageism can enhance several HIV-related issues, including self-inflicted stigma, and loneliness. At-risk communities are particularly susceptible to experiencing these aspects. Ageism can be considered the last pillar of the stigma cascade affecting older people living with HIV, and also the most important barrier to achieving healthy ageing in people living with HIV.”
Guaraldi and his colleagues recommended:
- Reshaping clinical care systems to meet the needs of older people living with HIV, including geriatric syndrome screening, integrated care, and support and referral systems that include provision of adequate time for medical visits with a focus on improving wellness and functional status; and
- Training of HIV doctors and clinicians on how to provide comprehensive care for older people living with HIV.
“The model of care for older people living with HIV needs to extend beyond virological success by adopting a geriatric mindset, which is attentive to the challenge of ageism and is proactive in promoting a comprehensive approach for the aging population,” Guaraldi and his team stated.
Guaraldi similarly emphasised that with the advances in care and treatment, people living with HIV can age healthily with the right support. Already, there is the first-ever known patient with HIV to reach age 100 years, The ‘Lisbon Patient’ Miguel, who died in August 2019 months after celebrating his 100th birthday. He did not have multiple other conditions or polypharmacy, and lived alone and independently, and had never in his life been admitted to hospital.
“We are now in an entirely new era where living into your 70s, 80s and even 90s with HIV is now possible and becoming more and more common,” Guaraldi concluded. “We must make sure that we do everything we can, socially, physically and medically, to ensure people living with HIV live as healthy a life as possible as they reach their later years.”
