File 1 of 1 from HHS Adult ART Guidelines: HIV and ART in Older People

HIV and ART in Older People


HIV and ART in Older People
Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents

January 2020

About This Presentation
These slides were developed using the Guidelines updated in December 2019.
The intended audience is clinicians involved in the care of patients with HIV.
Because the field of HIV care is rapidly changing, users are cautioned that the information in this presentation may become out-of-date quickly.
It is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.
March 2020

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
Developed by the Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents – A Working Group of the Office of AIDS Research Advisory Council (OARAC)
March 2020

Increasing number of older people with HIV, resulting from prolonged life through effective ART
In 2016, 48% of people with HIV in the US were age ≥50, 8% ≥65
17% of persons with new HIV diagnoses were age ≥50
Burden of aging-related diseases is significantly higher among persons with HIV than in the general population
ART is especially important for older people: greater risk of non-AIDS complications and potentially blunted immunologic response to ART
Early HIV diagnosis is important; also counseling to prevent HIV transmission

March 2020

Introduction: Areas of Particular Concern
HIV screening rates are low (d/t perception of low risk)
Reduced mucosal and immunologic defenses, and changes in risk behaviors may increase risk of HIV acquisition and transmission
HIV may affect biology of aging, causing earlier manifestation of conditions usually seen at older ages
Aging-related comorbidities, need for more non-ART medications – may complicate HIV clinical care
March 2020

HIV Screening and Diagnosis in Older Persons
Older persons less likely to be tested for HIV
<5% of age 50-64 have been tested
Risk behaviors often not recognized – important to screen for sexual and other risks, do HIV and STI education, testing, prevention (including PrEP)
Late diagnosis of HIV is common: 36% of adults aged ≥55 had AIDS at time of diagnosis (vs. 27% of age 35-44)
March 2020

Age and HIV Disease Progression (1)
Aging is associated with immune activation and inflammation
Chronic HIV also associated with immune activation and inflammation; this decreases with ART but does not normalize
HIV may cause immune senescence and accelerate aging (conflicting data)
Age-associated comorbidities (e.g. myocardial infarction, stroke, non-AIDS cancers) may be more common
March 2020

Age and HIV Disease Progression (2)
Frailty phenotype (decreased muscle mass, weight, physical strength, energy, and activity) may occur earlier and more commonly
In people with HIV, associated with cardiovascular disease (CVD), diabetes, falls and fractures, cognitive impairment, lower quality of life, hospitalization, mortality
Menopause may occur at earlier age, but unclear role of HIV
Osteopenia risk higher in cisgender women with HIV
March 2020

ART in Older Persons
Older people have decreased immune recovery on ART, and increased risk of serious non-AIDS events
Early ART and viral suppression (VS) may be particularly important in older people
Benefit demonstrated in RTC and cohort studies
Rates of VS are higher than in younger people

ART selection: consider comorbidities and drug-drug interactions
Higher risk of ART-related adverse effects (AEs), e.g., renal, liver, CNS, bone
TDF and boosted PIs: greater risk of bone mineral density loss
Hepatic and renal clearance of ARVs may decrease with age; monitor for AEs

March 2020

ART and Other Medications in Older Persons
Common cause of iatrogenic complications
More common in older people with HIV than in those without HIV
Regularly assess any barriers, e.g., neurocognitive deficits or menopausal symptoms
Discontinue unnecessary medications, simplify regimens, use adherence aids

Drug-drug interactions (DDI)
E.g., between ARV and non-ARV medications, or between non-ARV medications
Information on DDI largely from PK studies of healthy young HIV-uninfected persons
DDI may be more significant in older people with HIV

March 2020

Optimizing ART
Simplify regimens
Minimize toxicities and DDIs
Bone health:
Switch off TDF or boosted PIs if high risk for fragility fracture
Monitor bone mineral density in men aged ≥50 and postmenopausal cisgender women
Renal: monitor closely; avoid TDF and ATV
March 2020

Non-AIDS HIV-Related Complications
AIDS-related illness is uncommon with effective ART, but high burden of age-related diseases -- likely from both HIV-related and non-HIV-related factors
E.g., CVD, cancer, cognitive impairment, liver disease
Hypertension and hypercholesterolemia = most common comorbidities
Cigarette smoking - higher rate of current or former smoking vs adults without HIV
HIV-specific guidelines are available for evaluation/management of bone health, kidney disease, CVD
General guidelines for hyperglycemia and hyperlipidemia are applicable to people with HIV, though not validated in HIV and may underestimate CVD risk
March 2020

HIV-Associated Neurocognitive Disorder (HAND) (1)
Difficulty with memory, attention, information processing, executive and motor function
Prevalence unclear; up to 30% of those on ART with VS
Risk increases with age; faster cognitive decline in people with HIV
Differentiating from Alzheimer disease or other dementia can be difficult
Likely multifactorial: direct HIV effects, comorbidities/coinfections, vascular disease, mental health disorders, social isolation, polypharmacy
March 2020

HIV-Associated Neurocognitive Disorder (HAND) (2)
Increases risk of poor adherence, loss to follow up, morbidity and mortality
Screen regularly for neurocognitive impairment
Optimal primary-care screening method is unknown – MOCA appears more sensitive than MMSE, but is not specific
If symptoms: refer neurologist for evaluation or neuropsychologist for neuropsychological testing
March 2020

Mental Health Disorders
Prevalence unclear; depression and anxiety may be more common in people with HIV age >60 vs those without HIV
Social isolation exacerbates
Suicide risk higher in people with HIV, though age may not further increase risk
Screen for depression, other mental health disorders
Management: generally same as for older people without HIV: behavioral approaches (e.g., psychotherapy, cognitive behavioral therapy, group therapy), pharmacological treatment
Integrated care models are likely to be most effective
March 2020

Unique challenges: greater incidence of health complications and comorbidities
Some worsened by HIV and/or ARV drugs
Requires complex management; additional medical and social services may be required to effectively manage both HIV and comorbid conditions.
Collaboration of HIV experts, primary care providers, geriatricians, and other specialists to optimize care
Prioritize modifiable health-related problems
Discuss living wills, advance directives, and long-term care planning
March 2020

Websites to Access the Guidelines
AETC National Coordinating Resource Center
March 2020

About This Slide Set
This presentation was prepared by Susa Coffey, MD, for the AETC National Resource Center in March 2020.
See the AETC NCRC website for the most current version of this presentation: