Management of HIV patients has evolved in recent years as the population of patients ages. Treatment with HIV medicines is recommended for everyone with HIV, and treatment recommendations are the same for older and younger adults. However, age-related factors can complicate HIV treatment in older adults.1 To ensure optimal management of these patients, communication and two-way education between HIV physicians and physicians caring for older people, are key. This is part one of a series of articles.
A new report from the Lancet Commission states that a “dangerous complacency” in the response to the global HIV pandemic is risking a resurgence of the disease.2
Authors of the report led by the International AIDS Society say that HIV rates persist in high risk, marginalised populations and they warn that a resurgence of the epidemic is likely as the largest generation of young people age into adolescence and adulthood.
Stalling of HIV funding in recent years endangers HIV control efforts and historic ‘exceptionalism’ of HIV treatment and care may no longer be sustainable; services will likely need to be part of wider healthcare supporting related diseases and conditions.
The authors call on HIV researchers, healthcare professionals and policymakers to collaborate and make common cause with their counterparts in global health. The report combines the expertise of more than 40 international experts who make recommendations for how HIV and global health can work together to advance global health and improve the HIV response.
There were 38.8 million people living with HIV worldwide in 2015-2016, and around two million new cases diagnosed in 2015. There were one million AIDS-related deaths in 2016, and overall more than 35 million people have died of AIDS-related causes since the start of the epidemic.
Worldwide, 44% of all new HIV infections occurred in people from marginalised groups (such as gay and bisexual men, people who inject drugs, sex workers, transgender people, and the sex partners of people in these groups), and health systems struggle to reach and engage these groups.2
At the same time, care for HIV is also changing as the population of people with HIV is steadily growing older due to the effectiveness of antiretroviral therapy (ART). Between 2012 and 2016, the number of people older than 50 years living with HIV increased by 36% worldwide. As this group have an increased risk of many age-related diseases (such as cardiovascular disease, neurocognitive disorders, renal disease and some cancers), a focus on prevention and management of non-communicable diseases (NCDs) for people with HIV is needed, creating a crossover with global health and wider health services.
According to the Terence Higgins Trust, older people are the fastest growing group of people living with HIV in the UK. New diagnoses of HIV in the over 50s continue to increase, with the proportion of new diagnoses in this group almost doubling over the last decade, from 9.6% in 2007 to 18% in 2016.3
HIV funding has, however, remained flat in recent years, at about US$19.1 billion, roughly US$7 billion short of the estimated amount needed to achieve the UNAIDS 90-90-90 targets. This is happening as a growing number of people are receiving ART and will require sustained access for decades to come—in June 2017 approximately 20.9 million people worldwide were receiving the drugs (57% of people with HIV), increasing from 680,000 people in 2000.
Many people do not notice symptoms when they first acquire HIV. It can take as little as a few weeks for minor, flu-like symptoms to show up, or more than 10 years for more serious symptoms to appear, or any time in between. Signs of early HIV infection include flu-like symptoms such as headache, muscle aches, swollen glands, sore throat, fevers, chills, and sweating, and can also include a rash or mouth ulcers. Symptoms of later-stage HIV or AIDS include swollen glands, lack of energy, loss of appetite, weight loss, chronic or recurrent diarrhoea, repeated yeast infections, short-term memory loss, and blotchy lesions on the skin, inside the mouth, eyelids, nose, or genital area.4
There is an increasing prevalence and late diagnosis in the over 50s. The reasons for the trend towards late diagnosis are not clear, but are likely to do with the fact that HIV prevention, counselling, testing, and education efforts are largely directed at the younger generation. This may be because widely-held societal beliefs are that after the age of 50 years, people become either sexually inactive or are in monogamous heterosexual relationships.5
The fact that the majority of newly infected older people have acquired HIV through sexual transmission indicates that these beliefs are simply not true and there is evidence that older men with or at risk of HIV infection are sexually active, participate in risky sexual behaviour, and need safer sex interventions.
Another factor contributing to late diagnosis in the over 50s is that physicians are missing opportunities to test for HIV in older patients. Amongst the reasons for HIV not being considered as a differential in the elderly patient, is the fact that many of the “indicator conditions” that should prompt an HIV test, such as bacterial pneumonia and recurrent herpes zoster, are much more common amongst older people and can be easily explained away by “ageing”.5
Healthcare providers may not think to ask older adults about their HIV risk factors, including sexual activity, and may not recommend HIV testing. Also, some older people may be embarrassed to discuss HIV testing with their healthcare providers.
For all these reasons, HIV is more likely to be diagnosed at an advanced stage in many older adults. When diagnosed late, HIV is more likely to advance to AIDS.1
Treatment with HIV medicines is recommended for everyone with HIV, and HIV treatment recommendations are the same for older and younger adults. However, age-related factors can complicate HIV treatment in older adults.1
HIV and HAART are associated with metabolic problems and cardiovascular disease as well as with neurocognitive impairment and renal disease. These associations are compounded by advancing age and mean that there is a need for both physicians caring for HIV patients and those caring for older patients to be aware of the complex interaction between age-related pathologies and HIV.5
Liver and kidney functions decline with age. This decline may make it harder for the body to process HIV medicines and increase the risk of side effects.
Older adults with HIV may have other conditions, like diabetes and heart disease, that can make it more difficult to manage HIV infection. In addition, HIV may affect the ageing process and increase the risk of age-related conditions such as dementia, bone loss, and some cancers. Taking HIV medicines and medicines for other conditions at the same time may increase the risk of drug-drug interactions and side effects.
The immune system may not recover as well or as quickly in older adults taking HIV medicines as it does in younger people.1
Despite these age-related factors, some studies have shown that older adults are more adherent to their HIV medicine regimens—meaning they take their HIV medicines every day and exactly as prescribed—than younger adults.1
Last year, Terrence Higgins Trust published a pioneering report into the first generation of people with HIV growing older, titled ‘Uncharted Territory’.7This report, produced by peer researchers—a team of volunteers living with HIV in the UK aged 50 and over—was designed to give an insight into the experience of what it is like to grow older with HIV, and the challenges they face.
The report stated that more than 30 years on from the start of the HIV and AIDS epidemic in the UK, the reality of living with HIV is unrecognisable. While stigma and discrimination unfortunately still remain, the availability of effective HIV treatment means that an HIV diagnosis is now no longer the fatal health condition that took the lives of many—far too many—individuals in the prime of their lives.
In the report many people reported that they were already struggling to remember to take multiple medications, as well as remember all the healthcare appointments their health conditions necessitated. Nearly eight out of 10 (79%) were concerned about memory loss and cognitive impairment in the future and how they would cope with managing multiple health conditions.
People were also concerned about how they would take care of themselves and manage daily tasks in the future. The study showed that a quarter of respondents said they would have no one to help them if they ever needed support with daily tasks.
The research also highlighted the fundamental fear that individuals would not be able to access social care, that financial barriers would prevent them being able to afford the care that they need. This is particularly problematic for those diagnosed pre-1996, who are more likely to be dependent on benefits as their sole source of income.
Altogether, 82% of over 50s living with HIV were concerned about whether they would be able to access adequate social care in the future and 88% had not made any financial plans to fund future care needs.
The report added that there is a new phenomenon as more people than ever before are diagnosed with HIV aged 50 or over. The result is that the proportion of people living with HIV who are aged over 50 years will continue to rise. This is uncharted territory.
Alison Bloomer, Managing editor, GM
Conflict of interest: none declared
1. https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/25/80/hiv-and-older-adults (acessed 31/07/18)
2. https://www.thelancet.com/commissions/global-health-HIV (acessed 31/07/18)
3. https://www.tht.org.uk/news/uncharted-territory-challenges-living-long-term-hiv (accessed 31/07/31)
4. https://www.nia.nih.gov/health/hiv-aids-and-older-people (accessed 31/07/18)
6. NICE. https://www.nice.org.uk/guidance/ng60/chapter/Recommendations#reducing-barriers-to-hiv-testing (accessed 31/07/18)
7. https://www.tht.org.uk/sites/default/files/2018-03/uncharted_territory_final_low-res.pdf (accesseed 31/07/18)