Overview

The US Centers for Disease Control and Prevention (CDC) reported that in 2015 47% of all HIV-infected patients in the United States were 50 years and older, and that the largest percentage increase in HIV prevalence in the period from 2011 to 2015 occurred among those aged 65 years and older (57% increase).[1] This trend is expected to continue. The unique challenges that arise from the combination of HIV infection and aging may be new to many HIV practitioners. Consequently, HIV practitioners should incorporate approaches to optimize care for this group.

When the virus causing AIDS was first discovered in young men, life expectancy could be days to weeks. Most patients were dying of Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia and other AIDS-associated opportunistic infections, and the goals of care were palliative. Since the advent of highly active antiretroviral therapy in 1996, a diagnosis of HIV infection is no longer associated with a rapidly fatal outcome. Many HIV practitioners have seen this amazing transition from an illness that younger persons died of to an illness that older persons die with.[2] The percentage of HIV-infected patients older than 50 years is expected to increase to more than 70% by 2030, based on modeling.[3] Treatment with simple regimens can lead to durable viral suppression. However, viral suppression comes at the price of lifelong treatment and is further complicated by the expected challenges associated with aging itself.

HIV practitioners are once again struggling to define standards of care for this growing group of older HIV-infected patients. Older persons with HIV infection fall into 2 groups: those infected at a younger age who have survived with HIV infection and AIDS into older age, and those infected at an older age. For those newly infected later in life, concerns about immunosenescence and response to antiretroviral drugs provide additional complications, and these concerns have necessitated new approaches to care. In 2010, the International Antiviral Society–USA (IAS–USA) introduced recommendations[4] (biannually updated, most recently in 2016[5]) for initiation of antiretroviral therapy among HIV-infected adults older than 60 years, and in 2012, the US Department of Health and Human Services added a section on treatment of HIV-infected adults older than 50 years to its guidelines.[6] For those who have aged with HIV infection, longer duration of HIV infection and treatment exposure have resulted in more non–AIDS-related comorbidities. Optimal management for older people with HIV is still unknown. Ongoing research in HIV and aging is needed, in addition to inclusion of older persons in existing clinical trials.[7]

Approximately 20 years into the epidemic, HIV-infected infants began transitioning from pediatric to adult clinics. With expected increases in the number of older patients with HIV infection predicted worldwide,[8-9] another transition is evolving, perhaps into adult-geriatric clinics or multidisciplinary clinics with pharmacists, nutritionists, social workers, infectious disease specialists, psychiatrists, and geriatricians. Some clinics are already using these models.

The HIV and Aging Consensus Project has published its updated guidelines,[10] and Greene and colleagues also published a narrative summary of all available consensus statements and guidelines titled “Management of HIV in Advanced Age.”[11] This Cases on the Web activity explores some of the challenges HIV practitioners face as they care for an older population of HIV-infected individuals.