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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 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

In addition to low rates of adherence and viral suppression, YLWH have also shown high risk of virologic rebound and virologic failure. 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.3

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

“Adolescents may also have difficulty understanding the benefit of taking medication when they are asymptomatic...
and may not want to be different from their peers.1

  • 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 PLWH in the United States and accounted for 17% of new HIV infections in 2015. Older adults may be less aware of their HIV risk and often receive a late diagnosis.6

  • Various factors contribute to the burden of chronic illness in older adults, including1, 7:
  • Age-related comorbidities that complicate HIV management
  • Early onset of frailty and other age-related clinical syndromes
  • Polypharmacy—which can lead to increased drug-to-drug interactions
  • High rates of traditional risk factors, such as smoking, substance abuse, obesity
  • Neurocognitive impairment 
  • Limited health literacy
  • Social isolation and depression

Additionally, some biological mechanisms for aging may affect PLWH at higher rates, such as chronic inflammation, found in PLWH even when virally suppressed on ART and associated with chronic illnesses, overall fitness, and increased mortality.8

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 but also behavioral interventions to support improved adherence,  smoking cessation, decreased alcohol consumption, decreased obesity, and increased exercise

VACS = Veterans Aging Cohort Study

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