ESSENTIALS OF DIAGNOSIS
The proportion of persons living with HIV over age 50 continues to dramatically increase. Globally, older adults represent 20% of persons currently living with HIV.
Infections such as recurrent bacterial pneumonia, thrush, and symptoms such as neurocognitive changes should prompt HIV testing in the older adult.
People living with HIV are at increased risk for other chronic conditions such as cardiovascular disease, osteoporosis, and geriatric syndromes (eg, falls, frailty). They are also at increased risk for polypharmacy, including drug-drug interactions with antiretroviral medications.
Currently, 36.9 million individuals are living with HIV worldwide and 5.7 million are age ≥50 years. The Centers for Disease Control and Prevention (CDC) estimates that >1 million people are living with HIV (PLWH) in the United States. Of PLWH in the United States, 50% are aged ≥50 years. In 2017, persons over the age of 50 also accounted for 17% (n = 6640) of all newly diagnosed cases in the United States. Similar to younger adults, most new infections among older adults occurred in men who have sex with men. Heterosexual women accounted for the second largest group of newly diagnosed persons. Given the availability of effective, well-tolerated treatments, the number of older adults living with HIV is expected to grow.
The classification of those aged ≥50 years as “older” has been used since the beginning of the AIDS epidemic, and it is now well established that PLWH have higher rates of multimorbidity and polypharmacy and experience earlier onset of geriatric syndromes including frailty and falls. Ongoing debate exists as to whether this represents accelerated or accentuated aging in this population. These findings are likely mediated through factors such as chronic inflammation despite treatment of HIV, toxicity from antiretroviral medications, and lifestyle factors that are more common among PLWH such as tobacco and alcohol use. Regardless of the mechanism, providers caring for this rapidly growing population must be prepared to address the complications faced by those aging with HIV.
Older adults are at risk for acquiring HIV due to a number of social and biological factors. The availability of medications to treat erectile dysfunction has led to increased sexual activity in older males. Additionally, older adults are more likely to engage in condomless sex acts, given that unwanted pregnancy is no longer a concern. Moreover, age-related vaginal wall dryness and thinning can increase a woman’s risk of contracting HIV. HIV prevention campaigns targeting an older demographic remain scarce, and many older adults are also simply unaware of their risk. Clinicians also often fail to recognize that older adults may be sexually active or using drugs, and hence do not discuss safer sex practices or substance use. As a result, older adults are screened less frequently and diagnosed with advanced HIV at higher rates than their younger counterparts.