17 May 2021

Adapting Geriatric Principles to Enhance the Care of Older Adults Living with HIV

HIV care has grown and evolved many times. From heartbreaking hospice care, to managing the severe side effects of handfuls of medications, to one pill once a day. These advancements successfully resulted in the transformation of HIV from a devastating fatal transmissible infection to a chronic condition.

Today, people living with HIV are estimated to live a near normal lifespan, and when adherent to antiretroviral therapy are not at risk of transmitting HIV (undetectable = untransmittable)^1,2. While the gap in life expectancy between people living with and without HIV has narrowed, people living with HIV do experience early and in excess non-HIV associated medical conditions (high blood pressure, diabetes, kidney disease) including geriatric syndromes such as frailty, cognitive decline and polypharmacy (traditionally defined as taking more than five medications a day)^3,4. In fact, people living with HIV accumulate age associated co-morbidities about a decade earlier than HIV seronegative persons⁵.

Despite a decade of evidence describing the changing medical needs of older adults living with HIV, HIV care primarily focuses on HIV outcomes (antiretroviral therapy or ART adherence and viral load suppression). In 2020, the Health Resources and Services Administration published the first set of reference guides to optimize HIV care for people aging with HIV, which outline the healthcare challenges of older adults with HIV, common gaps in medical care and unique social challenges.

Yet, widespread implementation of these recommendations is hampered by the shortage of local geriatric expertise, perceived lack of need for these services by older adults with HIV, insufficient HIV clinician awareness of the changing needs of older adults, and lack of financial support to bolster these efforts.

The principles of HIV and geriatric care are similar with one general difference; HIV medicine focuses on ART adherence and addressing barriers to care while geriatric medicine prioritizes safety, function, independence and quality of life.

HIV clinicians can incorporate geriatric principles into their care now by considering the 6Ms: Matters most, Mind, Mobility, Medications, Multi-complexity and Modifiable⁶.

1. Have conversations about what matters most and use personal health preferences to prioritize preventive health screenings and non-HIV health recommendations.
2. Consider integrating simple cognitive screens into clinical care and optimize the mind by diagnosing and treating mood disorders and exploring factors that may also impact cognition such as social isolation and substance use.
3. Inquire about and encourage mobility by providing exercise prescriptions and addressing falls preventions through home safety evaluations and balance training.
4. Comb through medication lists with an eye not only on focused on ART drug interactions but also with the intent to deprescribe medications that may alter the mind or impact mobility (i.e. muscle relaxants, antihistamines, hypnotics).
5. Step back and take a look at how multi-complexity impacts personal safety, social isolation and intersectional stigma.
6. Lastly, it is key to focus on modifiable factors that may impact multiple systems such as physical activity, nutrition, substance use, connection, and stress.

All people living with HIV are aging with HIV and it is time for HIV care to evolve again to meet those needs.

Article By: Dr. Maile Young Karris is an Associate Professor of Medicine at the University of California Davis, in San Diego and recently presented on this topic for DKBmed 

1. Eisinger, R. W., Dieffenbach, C. W. & Fauci, A. S. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. Jama 321, 451-452 (2019).
2. Marcus, J. L. et al. Narrowing the gap in life expectancy between HIV-infected and HIV-uninfected individuals with access to care. Journal of acquired immune deficiency syndromes (1999) 73, 39 (2016).
3. Greene, M. et al. Geriatric syndromes in older HIV-infected adults. Journal of acquired immune deficiency syndromes (1999) 69, 161 (2015).
4. Guaraldi, G. et al. The increasing burden and complexity of multi-morbidity and polypharmacy in geriatric HIV patients: a cross sectional study of people aged 65–74 years and more than 75 years. BMC geriatrics 18, 1-10 (2018).
5. Guaraldi, G. et al. Premature age-related comorbidities among HIV-infected persons compared with the general population. Clinical infectious diseases 53, 1120-1126 (2011).
6. Erlandson, K. M. & Karris, M. Y. HIV and Aging: Reconsidering the Approach to Management of Comorbidities. Infectious Disease Clinics 33, 769-786 (2019).

Links:

HRSA’s HIV/AIDS Bureau Releases Two New Aging with HIV Reference Guides | HIV.gov

Continuing Medical Education for Health Care Providers | DKBmed

STOP HIV in LGBTQ Seniors | DKBmed