HIV Care Along the Age Spectrum
Antiretroviral therapy (ART) is recommended for all individuals with HIV to reduce morbidity and mortality and to prevent HIV transmission.1 However, challenges may vary in different age populations; for example, psychosocial turmoil may interfere with adherence in young adults, while comorbidity may pose significant problems in older adults. Consider barriers to HIV care across the age spectrum, along with potential strategies to help patients of all ages achieve optimal clinical outcomes.
YOUTH LIVING WITH HIV (YLWH)
In 2017, youth aged 13 to 24 accounted for approximately 1 in 5 new HIV diagnoses in the United States, with most new infections disproportionately affecting young black/African-American and Hispanic/Latino gay and bisexual men.2
Of the estimated 50,900 YLWH in 2016, 44% were unaware of their infection—the highest rate of undiagnosed HIV in all age groups— and in 2015, only 36% received HIV care, 27% were retained in care, and 25% were virally suppressed—the lowest rate of suppression seen in all age groups.2
As for potential barriers to HIV care, in addition to low rates of adherence and viral suppression, YLWH have also shown high risk of virologic rebound and virologic failure.3 All of these factors have the potential to result in increased HIV transmission risk in YLWH and a future adult generation with drug-resistant virus.
Adolescents may also have difficulty understanding the benefit of taking medication when they are asymptomatic, especially if it causes side effects, and may not want to be different from their peers.1 Learning to cope with having a chronic medical condition and navigating complex health systems can be challenging.4
- Some approaches for helping YLWH may include1, 3, 5:
- Offering a welcoming “youth friendly” clinic environment with flexible clinic hours, in a location that does not trigger substance use
- Providing a team-based approach with a range of services beyond medical care
- Using peer navigators to help young patients build relationships with HIV care networks
- Communicating via technologies ubiquitous among youth, such as text messaging and video chat
- Maintaining patients’ confidentiality, especially patients covered under their parents’ insurance
- Simplifying regimens and implementing inconspicuous reminder systems (apps, timers, pill boxes)
- Transitioning youth effectively to adult care with early multidisciplinary planning to address adolescent-specific issues
OLDER ADULTS LIVING WITH HIV
On the other end of the age spectrum, people aged 50 and over account for nearly half of people living with HIV (PLWH) in the United States and accounted for 17% of new HIV diagnoses in 2016.6 Older adults may also be less aware of their HIV risk and receive a late diagnosis.
Among older PLWH in 2015, 95% were aware of their infection, 69% received care, 56% were retained in care, and 60% were virally suppressed.6
While older patients tend to be more adherent than younger patients, some factors related to nonadherence may be more prevalent in this age group, such as high pill burden and medication cost, complex dosing requirements, limited health literacy, neurocognitive impairment, and depression.1
- Additionally, healthcare professionals face several distinct challenges in caring for older adults with HIV, including1, 7, 8:
- Age-related comorbidities that complicate HIV management
- Polypharmacy, which can lead to increased drug-to-drug interactions
- Early onset of frailty and other age-related clinical syndromes
- High rates of traditional risk factors, such as smoking, substance abuse, and obesity
- Chronic inflammation—found in PLWH even when virally suppressed on ART and associated with chronic illnesses—overall fitness, and increased mortality
Multidisciplinary teams can work together to help tackle complex health issues and optimize medical care in older PLWH.1 A 2018 update to the HIV and Aging Consensus Project—a set of clinical best practices for the treatment and care of older patients with HIV published by the American Academy of HIV Medicine (AAHIVM), American Geriatrics Society (AGS), and the AIDS Community Research Initiative of America (ACRIA)—highlights insights from the geriatric literature that may help inform care of older patients living with HIV, which include9:
- A need to look beyond CD4 count, viral load, and AIDS-defining conditions toward a more comprehensive risk index of morbidity and mortality, eg the VACS Index
- Careful consideration of toxicity risk from HIV and non-HIV medications, especially those with the potential for cumulative cognitive effects
- The development of care strategies to prevent and reverse functional decline, which include early ART as well as behavioral interventions to support improved adherence, smoking cessation, decreased alcohol consumption, decreased obesity, and increased exercise
1. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. AIDSinfo website. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0. Published October 25, 2018. Accessed May 21, 2019.
2. HIV and youth. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/group/age/youth/index.html. Published April 10, 2019. Accessed May 21, 2019.
3. Saberi P, Ming K, Dawson-Rose C. What does it mean to be youth-friendly? Results from qualitative interviews with health care providers and clinic staff serving youth and young adults living with HIV. Adolesc Health Med Ther. 2018:65-75. doi: 10.2147/AHMT.S158759.
4. Lee L, Yehia BR, Gaur AH, et al. The impact of youth-friendly structures of care on retention among HIV-infected youth. AIDS Patient Care STDS. 2016;30(4): 170-177. doi: 10.1089/apc.2015.0263.
5. Zanoni BC and Mayer KH. The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. AIDS Patient Care. 2014;28(3): 128-135. doi: 10.1089/apc.2013.0345.
6. HIV among people aged 50 and over. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/group/age/olderamericans/index.html. Published September 18, 2018. Accessed May 21, 2019.
7. Escota G, O’Halloran J, Powderly W, et al. Understanding mechanisms to promote successful aging in persons living with HIV. Int J Infect Dis. 2018;66:56-64. doi: 10.1016/j.ijid.2017.11.010.
8. Wing E. HIV and aging. Int J Infect Dis. 2016;53:61-68. doi: 10.1016/j.ijid.2016.10.004.
9. Assessing frailty and functional capacity: managing the care of older adults with HIV. HIV-Age.org website. http://hiv-age.org/clinical-recommendations/. Published January 24, 2018. Accessed May 21, 2019.
VACS=Veterans Aging Cohort Study.