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This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #26

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LEARNING OBJECTIVES

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Learning Objectives

  • Identify seniors at risk for HIV infection and include HIV testing in appropriate situations.

  • Recognize HIV-associated non-AIDS conditions (HANA) that commonly afflict those aging with HIV.

  • Integrate the principles of geriatrics (eg, management of multimorbidity and polypharmacy) into the care of HIV-infected patients.

  • Recognize and address social isolation issues in those aging with HIV.

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Key Clinical Points

  1. HIV is often unrecognized in older adults because of provider bias that older adults are not at risk and dismissal of clinical clues (frequent pneumonia, weight loss, progressive cognitive decline) as typical of older age.

  2. HIV treatment has turned HIV into a chronic disease that one ages with over many decades. More than 50% of all people living with HIV in the United States are age 50 or greater.

  3. While AIDS-associated conditions have declined markedly, comorbid illnesses occur more frequently than in age-matched, HIV-uninfected control populations leading to early multimorbidity, polypharmacy, and functional decline even in those with HIV controlled by antiretroviral therapy.

  4. In those above 70 aging with HIV, social isolation is very common. Many have been estranged from family and have had friends die earlier in life; there are a number of social and clinical implications (eg, recognition of depression, need for support services in the community).

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DEFINITION

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Human immunodeficiency virus (HIV) is a retrovirus that infects and destroys helper T cells leaving untreated patients vulnerable to opportunistic infections and cancers. HIV-1 is the most common subtype and is distributed worldwide. HIV-2 is primarily found in West Africa.

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EPIDEMIOLOGY

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One of the most amazing success stories of our lifetime is the transformation of HIV infection from a rapidly fatal disease to a chronic health condition. As a direct result of suppression of the HIV virus with antiretroviral therapy, transmission rates have also dropped. However, with one exception occurring in very exceptional circumstances (ie, bone marrow transplant), we have yet to cure anyone of HIV infection. As a result, a growing wave of people living, and aging, with HIV infection (Figure 128-1) are reaching middle and advanced age. As of 2010, 52% of those living with HIV infection in San Francisco and 42% of those in New York City were 50 years of age or older. As of 2011, 70% of HIV-infected individuals receiving care within the national US Veterans Administration Healthcare System were 50 years of age or older. Across the United States, the percentage of adults living with HIV infection who are 50 years of age or older grew from 17.4% in 2001 to 36.2% in 2010.

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FIGURE 128-1.

More people are living with HIV in the United States than ever before. (From www.aids2012.org.)

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With increased prevalence, transmission ...

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