Half of those with HIV in developed countries are at least age 50, at higher risk of frailty and multiple comorbidities

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A new research review to be presented at a pre-congress day for this year’s European Congress of Clinical Microbiology & Infectious Diseases (ECCMID 2024) will focus on the growing prevalence of HIV in older adults, with—using England as an example—half of adults accessing care aged now 50 years and older, and around 1 in 11 aged 65 years and older. Similar trends exist in Italy and other countries of Western Europe. Older adults with HIV in all countries are also more likely to have comorbidities and become frail earlier than older adults without HIV.

Presenter Professor Giovanni Guaraldi, University of Modena and Reggio Emilia, Modena, Italy, will also discuss the problem of more older people being diagnosed with HIV (one in 5 new diagnoses in those aged 50 and over) and late diagnosis in those older people, with (again using the example of England) around half of those cases newly diagnoses in the over-50s presenting with white blood cell CD4 count below 350 cells per mm3 of blood within 3 months of diagnosis, increasing their risk of mortality in the following year five-fold.

Despite the challenges, Prof. Guaraldi will also highlight 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 9 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. A similar trend is shown for polypharmacy (taking multiple prescribed drugs) in those living with HIV.

Prof. Guaraldi will also discuss 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 will review 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+. Another study shows older adults living with HIV twice as likely to become frail as their HIV negative peers.

He will discuss that 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. He will also cover 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, he will refer to the 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.

Prof. Guaraldi and colleagues explain, “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 aging in people living with HIV.”

Among the many recommendations, the researchers advise that “clinical care systems need to be reshaped 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 that “HIV doctors and clinicians should receive training on how to provide comprehensive care for older people living with HIV.”

They say, “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.”

Prof. Guaraldi will also emphasize that with the advances in care and treatment, people living with HIV can age healthily with the right support. He will refer to 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.

Prof. Guaraldi concludes, “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. 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.”


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