Many older adults have conditions such as heart disease or diabetes that can complicate HIV treatment. Anyone can get HIV, including older adults. Many risk factors for HIV are the same for adults of any age. But like many younger people, older adults may not be aware of their HIV risk factors. Some age-related factors can put older adults at risk for HIV infection.
Issue Section:. Berger, Y. This centre offers, general practitioners support in screening NCDs in geriatric patients. Although the geriatric Geriatric hiv had Geriatric hiv more frequently exposed to first-generation ARVs, including protease inhibitors and thymidine Lycra runway models nucleoside reverse transcriptase inhibitors, they were less likely to Geriatri complex regimens consisting of 4 ARVs or more and more likely to receive a dual therapy. Geriatic toHIV diagnoses remained stable among people aged 50 and older in the US and dependent areas.
Signalen voor een hartinfarct. GERIATRICIANS IN HIV CLINICS?
Cardiovascular disease risk factors in HIV patients — association with antiretroviral therapy. Cancers commonly associated with severe immunodeficiency were reported in clinical trials, however it is unknown at this time if this is directly related to Raltegravir treatment. AIDS risk behaviors among late middle-aged and elderly Americans. They also need to be careful about interactions between the medications used to treat HIV and those used to treat common age-related conditions such as hypertension, diabetes, elevated cholesterol, and obesity. More news from Netherlands. HIV infection, drug use, and onset of natural menopause. PDF documents can be viewed with Geriatric hiv free Adobe Reader. Efavirenz should be taken on an empty stomach avoid fatty foods ; take before bedtime or 2—3 hours before bedtime CNS symptoms usually resolve or diminish Geriatric hiv 2—4 weeks of therapy; warn patients to limit risky activities until effects are known. HIV testing in the older adult usually Brass english volume measure an enzyme immunoassay EIA screening test to detect HIV antibodies followed by a confirmatory test such as a Western blot or immunofluorescence assay IFA if the screening test is positive. Abnormalities on physical exam that can point to an HIV diagnosis include facial seborrhea, angular chelitis, thrush, gingivitis, aphthous ulcers, hairy leukoplakia of Motor dysfunctions of the stomach highly indicativediffuse lymphadenopathy, hepatosplenomegaly, onychomycosis and other dermatophytoses. As of in the United Kingdom, 8. Related topics. Other problems were not included due to a lack of reliable data. Diagnosis, prediction, and natural course of HIV-1 Geriatric hiv lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study.
As HIV-infected adults on successful antiretroviral therapy ART are expected to have close to normal lifespans, they will increasingly develop age-related comorbidities.
- In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis.
- Though new HIV diagnoses b are declining among people aged 50 and older, around 1 in 6 HIV diagnoses in were in this group.
- CME Credit Available: 1.
- Rather than focusing on disease, those tested clinical principles focus on function.
Metrics details. This cross-sectional study was conducted between June and May The NCD diagnoses were based on guidelines defined criteria, including cardiovascular disease, hypertension, type 2 diabetes, chronic kidney disease, dyslipidaemia, chronic obstructive pulmonary disease. MM was classified as the presence of two or more co-morbidities.
The medications prescribed for the treatment of comorbidities were collected in both HIV positive and HIV negative group from patient files and were categorized using the Anatomical Therapeutic Chemical ATC classification. PP was defined as the presence of five or more drug components other than anti-retroviral agents. When the HIV-positive group was stratified based on the duration of HIV infection, most of the co-morbidities were significantly more frequent than in control patients, except for hypertension and cardiovascular disease, while COPD was more prevalent in the control group.
Aging populations are about to become the next global challenge for global public health. Advances in medicine and socio-economic development have substantially reduced morbidity and mortality due to infectious conditions and, to some extent, non-communicable diseases NCD [ 1 ].
Moreover, the longer survival of people with chronic conditions explains the increasing proportion of people living with NCDs.
Empirical studies based on surveys and general practice records show that MM is highly prevalent among older adults [ 4 ], and is associated with more medication prescriptions polypharmacy, PP , the greater use of healthcare services, greater disability and mortality, and a poorer health-related quality of life [ 5 , 6 , 7 ]. In the relatively new context of global aging, Human Immunodeficiency Virus HIV infection is less an exception than a paradigm.
The increasing age of people living with HIV PLWH is the net result of increased survival due to effective antiretroviral therapy ART and older age at the time the infection is acquired [ 9 ]. This allowed to study the impact of HIV specific risk factors such as ART exposure and toxicity, immune dysfunction or dysregulation, and chronic immune activation and inflammation [ 14 , 15 , 16 , 17 , 18 , 19 ]. These data have not been published so far. Therefore, the clinical presentation and aging trajectory of geriatric patients aging with HIV infection is still unknown.
A further aim is to investigate the extent to which the geriatric care model applies to HIV positive patients. Finally, it is intended to identify the contemporary morbidity, mortality and disability factors affecting healthy life expectancy of geriatric HIV positive patients.
In this analysis we compared prevalence and risk factors of individual non-communicable diseases, multi-morbidity and polypharmacy amongst HIV positive and HIV negative controls at enrolment into the GEPPO cohort. The HIV-negative subjects were selected from those attending a single geriatric clinic located in the same geographical area as the coordinating site Modena. This centre offers, general practitioners support in screening NCDs in geriatric patients. Given the easy access and free of charge of any diagnostic procedure in geriatric patients, this cohort is representative of the general Italian population.
Both HIV positive and HIV negative participants gave their written informed consent, at the time of their initial visit. The demographic covariates and clinical outcomes of the HIV positive and HIV negative subjects were characterised and compared. They included: age, gender, BMI, smoking status. Ex- and never-smokers were grouped together and compared to current smokers. The NCDs diagnoses were based on guidelines defined criteria [ 21 ].
The cardiovascular disease CVD category consisted of diagnoses of myocardial infarction, coronary artery disease, peripheral vascular disease, stroke and angina pectoris, as well as coronary artery bypass grafting and angioplasty, based on records in patient files. MM was defined as the presence of two or more NCDs [ 2 , 3 ].
The medications prescribed for the treatment of NCDs were collected from patient files in both HIV positive and HIV negative groups and were categorized using the Anatomical Therapeutic Chemical ATC classification in which the drugs are divided into different groups based on therapeutic indication [ 22 ].
The analysis considered the prevalence of the six most frequently prescribed classes other than ART with particular regards of cardiovascular active agents including statins, beta-blocker, ACE-inhibitors, anti-hypertensives and acetyl-salicylic acid ASA and psychoactive agents including benzodiazepines BDZ.
Polypharmacy was defined as the presence of five or more drug components other than ART. In the participating Centres the study size of the HIV-positive patients was represented by the whole of HIV infected patients meeting inclusion criteria, who presented at routine medical visits in the enrolment period year Missing data on outcomes were indicated in the tables as different denominators for parentage values. These times were chosen for two main reasons. Firstly they paralleled the tertile distribution of this variable.
This was performed to avoid co-linearity between these two variables. HIV positive individuals were thinner and more frequent smokers. In the group of individuals above the age of 75 HIV negative had the same prevalence of smoke habits as HIV-positive ones The age at HIV diagnosis was significantly higher The prevalence of COPD was higher in the controls fig.
HTN: Hypertension. A second model restricted to HIV patients only data not presented in fig. Abbreviations — MM: Multimorbidity. There was no difference in the prescription of and antidepressants or acetylsalicylic acid ASA , ace-inhibitors ACE and beta-blockers, commonly used in primary or secondary cardiovascular disease prevention.
Abbreviations — PP: polypharmacy. A second model restricted to HIV patients only data non-presented in fig. Significant predictors identified in the original model were confirmed. However, it must be acknowledged that this phenomenon may change in future years. In the contemporary setting of immediate access to new-generation ART, it can be hypothesised that the prevalence of NCDs and MM will be reduced in the years to come [ 23 ]. The prevalence of comorbidities was different in the HIV-positive patients and controls.
There was no difference in the prevalence of CVD or HTN as has been observed in other cohorts [ 27 ], possibly due to strategies used to reduce CV risk factors, the increasing use of lipid-friendly ART agents, and reduction of immunodeficiency state. We still need research to investigate the multifactorial nature of MM and the impact of this condition on quality of life, functional status impairment, health service use, and mortality. HIV, proportionally with its duration is a risk factor for PP.
The greater the number of medicines patient takes, the greater the risk of adverse effects, and the greater the risk of drug—drug interactions, leading to poor health outcomes, hospitalisations and mortality [ 28 ].
This is a dilemma for prescribers, who try to keep the number of medicines to a minimum while ensuring that patients receive what evidence-based guidelines advocate as being in their best interest [ 29 ]. Apparently, ID physicians and geriatricians use different drugs to treat the same comorbidities. An important difference regards the use of statins. Studies have underlined the need to increase statin prescription in HIV-positive patients due to increased cardiovascular risk.
However, the use of statins in the elderly is a concern in the context of sarcopenia and fall risk [ 30 ]. Possibly geriatricians more than ID physicians are more concerned of this issue and this may be reflected by the fewer statin prescriptions received by the HIV negative controls in the GEPPO cohort. This may reflect the aversion of former intravenous drug users to use psychoactive drugs that may induce dependence.
As expected males had increased risk of comorbidities but this was not the same for PP in the Italian national health system context were drugs for NCDs are provided for free in geriatric patients. Our data claim for a tailored approach to NCDs, and highlight the development of drug de-prescription strategies in the management of PP. The benefit of de-prescribing in HIV positive geriatric patients has never been evaluated so far. People of this age frequently visit geriatric clinics because of age-related comorbidities.
Therefore, our cohort provides a new opportunity to compare HIV-infected patients with HIV-negative controls better representative of the general population than subjects attending centres for sexually transmitted diseases or intravenous drug user facilities used in previous studies. This study has a number of limitations. Some of these are intrinsic to cross-sectional nature of observational studies, which cannot reveal any causative association between variables.
The prevalence of comorbidities, although standardized in cohort studies may overestimate disease condition. This is the case of DLM, where use of statins is used as diagnostic criteria. For this reason, ART exposure was not considered as a covariate, also because it requires properly designed clinically study.
Cumulative smoke pack year was not addressed, because not routinely collected in all the clinics. A major limitation of this study was the lack of information on geriatric syndrome, including frailty and falls.
Geriatric syndromes, better than NCDs capture the healthy aging outcome that all geriatric studies should address ref. To the best of our knowledge, the GEPPO is the first geriatric cohort of HIV-positive patients that may contribute to identify unmet clinical and research needs in terms of comorbidities and their implications for PP. This model highlights the need for evidence-based screening and monitoring protocols to ensure high-quality care.
Health in an ageing world--what do we know? Relationship between multimorbidity and health-related quality of life of patients in primary care. Qual Life Res. Starfield B. Challenges to primary care from co- and multi-morbidity. Prim Health Care Res Dev. A systematic review of prevalence studies on multimorbidity: towar a more uniform methodology. Ann Fam Med. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly.
Arch Intern Med. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Multimorbidity prevalence and patterns across socioeconomic determinants: a cross-sectional survey.
BMC Public Health. Total water intakes of community-living middle-old and oldest-old adults. Aging with HIV vs. HIV seroconversion at older age: a diverse population with distinct comorbidity profiles. PLoS One. Time trends for risk of severe age-related diseases in individuals with and without HIV infection in Denmark: a nationwide population-based cohort study. Lancet HIV. The growing burden of non-communicable disease among persons living with HIV in Zimbabwe. Premature age-related comorbidities among HIV-infected persons compared with the general population.
Clin Infect Dis.
It is important for generalists to recognize certain signs and symptoms that may be suggestive of ongoing HIV infection. The successes of HIV medicine — improved life span and quality of life — may be offset by an increased burden of age-related diseases, prescription of multiple medicines and a growing proportion of patients who have complications with their HIV treatment, the authors say. CD4 count at presentation for HIV care in the United States and Canada: are those over 50 years more likely to have a delayed presentation? They also need to be careful about interactions between the medications used to treat HIV and those used to treat common age-related conditions such as hypertension, diabetes, elevated cholesterol, and obesity. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Cancer risk in the Swiss HIV Cohort Study: associations with immunodeficiency, smoking, and highly active antiretroviral therapy. Course Outline.
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As HIV-infected adults on successful antiretroviral therapy ART are expected to have close to normal lifespans, they will increasingly develop age-related comorbidities. As of Dec , 16, subjects Durations of HIV infection and of ART were slightly but significantly different, median at 19 and 18 years, and 15 and 16 years in the elderly and geriatric group, respectively.
This group had been more exposed to first generation protease inhibitors and thymidine analogues. In the geriatric group all co-morbidities were significantly more frequent, except dyslipidemia, 4. Despite more co-morbidities and more advanced HIV infection the geriatric population achieve similar high rate of virologic suppression than the elderly population.
A multidisciplinary approach should be developed to face the incoming challenge of aging HIV population. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. As a benefit of long term suppressive antiretroviral therapy with improved tolerability, the number of aging HIV infected individuals is increasing with about half of them above 50 years of age or over in high-income countries [ 1 , 2 ].
Both life expectancy and mortality rates improved over time linked with coverage improvement, quality and tolerability of ART regimens and HIV care[ 3 , 4 ].
However, large differences in life expectancy persist between certain sub-groups of patients according to sex, race, HIV transmission risk group, lifestyle and CD4 cell counts at ART initiation[ 3 , 5 , 6 ].
It is well-established that multimorbidity increases with age, moreover comorbidities, including cardiovascular diseases, diabetes, cancer, cognitive dysfunction, depression and osteopenia are more frequent in the HIV population[ 7 — 11 ]. Many age-related illnesses can be driven by HIV itself, and drug toxicities may play a role in specific organ systems and interact with medical conditions typically associated with advanced age[ 2 , 12 ].
Due to the increased risk of age-related co-morbidities among HIV-positive adults, it is possible that life expectancy may plateau or decrease in the future. However, the concept of premature aging of HIV-infected persons appears to be controversial, particularly when considering the investigation of the effects of age on non—AIDS-defining malignancies[ 13 ].
Even if aging HIV cohorts included subjects aged 50 years and older, so far few of them have focused on geriatric population of HIV-infected patients aged 75 and over. The objective of this study was to assess to which extent the HIV geriatric population aged 75 and older differed from the HIV elderly population in terms of demographic and immuno-virological characteristics, ART history and current ART, and comorbidities.
These reference centres maintain prospective databases of all HIV infected patients seeking care in the centres and providing written consent. The data collection has been approved by the French national commission on informatics and liberty CNIL. The database is implemented via an electronic medical[ 14 ]. For the purpose of the study we selected all HIV patients aged 50 year-old and over at the last visit, with at least one visit since and still on follow-up at the censoring date Dec 31 st Continuous variables were described by their medians and interquartile ranges IQR and compared between groups using a Mann-Whitney test.
Categorical variables were described by proportions and compared by chi-square tests. R software version 3. Among them 16, subjects were aged between 50 and 75 years and classified in the elderly group and subjects were aged 75 years or older and classified in the geriatric group. The geriatric group represented 1. Socio-demographics and clinical characteristics of the elderly and geriatric groups are presented in Table 1.
The elderly group had been less frequently exposed than the geriatric group to first-generation protease inhibitors and nucleoside reverse transcriptase inhibitors, Exposure to non-nucleoside reverse transcriptase inhibitors and integrase inhibitors was similar between both groups Table 3. Co-morbidities were significantly more frequent in the geriatric group, except for dyslipidemia Table 4.
The most frequent comorbidities in the geriatric group were dyslipidemia In the geriatric group, This study describes an aging HIV-infected population and because of the large population size we were able to compare an elderly population aged 50 to 74 years to a geriatric population aged 75 and over. To our knowledge our study is the first one to describe HIV and ART history, as well as comorbidities in a geriatric HIV population and shows that the high rate of virologic suppression is similar within the 2 groups despite more frequent comorbidities, a longer exposure to first generation protease inhibitors and thymidine analogs and more frequent non classical antiretroviral regimen in the geriatric group.
Interestingly, the geriatric group had a significantly shorter duration of HIV infection than the elderly group, and had a significantly longer duration of antiretroviral therapy than the elderly population. Of note, and in contrast with the elderly group, geriatric patients had acquired HIV mainly through heterosexual contact, which could contribute to a lower perception of the risk of HIV infection and to increased delay for HIV testing.
Studies on missed opportunities for HIV diagnosis have identified old age and being heterosexual has significant risk factors for being diagnosed late [ 15 , 16 ]. Although the geriatric population had been more frequently exposed to first-generation ARVs, including protease inhibitors and thymidine analogue nucleoside reverse transcriptase inhibitors, they were less likely to receive complex regimens consisting of 4 ARVs or more and more likely to receive a dual therapy.
This suggests that with newer ARVs, the need for complex antiretroviral regimens consisting of multiple drugs because of cumulative or cross-resistance is decreasing.
On the other hand, because of a higher prevalence of co-morbidities, a higher number of co-medications, or an age-related chronic renal impairment, adaptation of treatment to avoid cumulative toxicities or drug-drug-interactions is probably more frequently needed in geriatric patients, which could explain the more frequent use of dual therapy in this population. Use of nucleosidic- and PI- sparing regimens to avoid the cumulative toxicity of antiretroviral therapy represents a major issue, particularly in aging subjects highly ART experienced, confronted with lipodystrophy, renal, cardio-vascular and other co-morbidities.
Dual therapy has been shown to be a possible switch option in virologically suppressed patients, as long as certain conditions are fulfilled[ 17 ]. Some of these dual therapies have been evaluated among them combination of an integrase inhibitor plus a non nucleosidic reverse transcriptase inhibitor, lamivudine or maraviroc with a benefit on lipid profile and bone mineral density[ 18 — 20 ]. The combination of one integrase inhibitor plus one non nucleosidic reverse transcriptase inhibitor was the dual therapy most frequently prescribed in the geriatric group.
Recent data of the ANRSETRAL study showed the robust and potent activity with an excellent safety profile of the dual therapy raltegravir plus etravirine in subjects over 45 years virologically suppressed and with a long history of antiretroviral therapy and frequent lipodystrophy[ 21 ].
The dual therapy in maintenance of dolutegravir plus either rilpivirine or lamivudine have also shown reassuring results both on efficacy and renal tolerability, with the advantage of a simple once-daily regimen[ 22 ] [ 18 ]. These data suggest that physicians are more and more concerned about prevention of comorbidities and long-term toxicities. In the general population, co-morbidities are increasing with age and are not linear but rather significantly accelerate at older age.
Our result is consistent with the study of Guaraldi at al. Some studies have shown a higher and earlier frequency of these comorbidities in the HIV population compared with the general population[ 5 , 24 ]. Some of these comorbidities may be induced or worsened by ART.
In our study geriatric patients had been more often exposed to first generation antiretrovirals including oldest PI favouring metabolic syndrome, and increasing cardiovascular risk and thymidine analogs responsible for lipoatrophy and mitochondrial toxicity. Many similarities on immunological alterations have been observed between middle-aged HIV-infected individuals and non-HIV geriatric subjects[ 28 ].
It is of importance to point out that very few elderly patients have been included in studies assessing HIV aging and the relative impact of HIV infection and other parameters on inflammatory and immune disorders has not yet been fully studied in this population[ 29 ]. Hentzien et al. They showed that age-related comorbidities—particularly cardiovascular diseases and chronic renal disease—were the main prognostic factors for mortality, at the same weight as CD4 cell count[ 30 ].
In this context of highly experienced elderly patients, our study shows that the choice of ARV was driven by presence of co-morbidities as well as prevention of long-term toxicities without impairing virologic suppression. Polymedication is a major issue in the geriatric and elderly populations, with the risk of increased adverse drug events, drug-drug interactions, inappropriate medications and poor adherence [ 31 ]. In a recent study, Greene et al.
The multidisciplinary approach that is recommended for ART management including physicians, virologists and pharmacists to optimize HIV infection management should integrate geriatricians for the patients that enter elderly age [ 33 , 34 ]. Furthermore individuals who died before Dec 31, were not included in the study and this does not allow to evaluate the frequency and reasons of death in this aging population. In summary, our study points out that a geriatric HIV population is emerging and highlights the burden and challenge of this geriatric HIV population who despite more co-morbidities and more advanced HIV infection achieve similar high rate of virologic suppression than the elderly population.
A systematic multidisciplinary approach, involving general practitioners, infectiologists, geriatricians, pharmacists should be developed to face the incoming challenge of HIV-infected population advancing to geriatric age. Foltzer, K. Bouiller, L. Hustache- Mathieu, C. Chirouze, Q. Lepiller, F. Bozon, O Babre, P. Laurichesse, O. Lesens, M. Vidal, N. Mrozek, C. Aumeran, O. Baud, V. Corbin, P. Letertre, S. Casanova, C. Jacomet Clermont-Ferrand B. Hoen, I. Lamaury, I. Fabre, E. Curlier, R.
Ouissa, K. Schepers, C. Herrmann-Storck, N. Dournon Guadeloupe D. Merrien, P. Guimard, O. Bollangier, S. Leautez, M. Morrier La Roche sur Yon F.
Ader, F. Biron, A. Boibieux, L. Cotte, T. Ferry, P Miailhes, T. Perpoint, S.