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HUMAN IMMUNODEFICIENCY VIRUS INFECTION

Learning Objectives

  • Recognize the shift in the epidemiology of human immunodeficiency virus (HIV) over the last three decades.

  • Identify older adults at risk for HIV infection and include HIV testing in routine care.

  • Recognize that some comorbidities may present earlier or have a higher prevalence among older adults with HIV.

  • Integrate the principles of geriatrics (eg, management of multimorbidity and polypharmacy) into the care of older adults with HIV.

Key Clinical Points

  1. Antiretroviral therapy (ART) 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 older.

  2. HIV is often unrecognized in older adults because of subtle or nonspecific presentation (anemia, fatigue, weight loss, pneumonia) and provider bias that older adults are not at risk.

  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 ART.

DEFINITION

HIV is the virus that causes acquired immunodeficiency syndrome (AIDS). HIV destroys CD4+ T cells vital to defense of infections, and when untreated, leads to a progressively immunocompromised state with an increased risk for opportunistic infections, cancers, and other complications.

EPIDEMIOLOGY

One of the most amazing success stories of our lifetime is the transformation of HIV infection from a rapidly fatal disease that manifested in the first AIDS cases in early 1980s to a chronic health condition, with this shift driven in part by the tremendous advocacy of the HIV community. With early initiation of effective ART, HIV-1 RNA can now be quickly reduced to undetectable levels. Not only does this decrease the risk of immune suppression and associated comorbidities, but effective ART essentially eradicates between person transmission of HIV. This discovery that Undetectable = Untransmittable (or U = U) has resulted in a transformative experience for many people living with HIV, as they can now live without the fear of transmitting HIV to partners or close contacts. Unfortunately, despite early initiation of ART, we have yet to fully eradicate HIV, with rare exceptions occurring in the setting of bone marrow transplantation. As a result, a growing number of people are now living, and aging, with HIV. In the United States and Europe, as of 2018, over 50% of people living with HIV are age 50 or older, with approximately 20% age 65 or older.

In addition to aging with HIV, many older adults continue to become newly infected with HIV: more than 15% of new HIV diagnoses in the United States are in adults aged 50 or older. Those aging with HIV are more likely than other aging individuals to use psychoactive substances including alcohol, marijuana, and opioids, which can both interfere with antiretroviral adherence and ...

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