What Older Adults Need to Know About the Prevention, and Diagnosis, and Treatment of HIV Infection
Wednesday, April 3, 2013
A growing number of Americans with the human immunodeficiency virus (HIV) are now living long enough to reach their 60s, 70s, and beyond thanks to advances in medications and treatments. The treatment that has improved those living with HIV is called combination antiretroviral therapy (cART), developed in the mid-1990s. And like other older adults who aren’t infected with HIV, many are developing age-related health problems such as high blood pressure, and osteoporosis (“thinning bones”). As a result, these older “HIV-positive” adults are receiving treatments for HIV and age-related disorders – and this complicates their care, write the authors of an article about HIV in later life that appears in the April 3, 2013 issue of theJournal of the American Medical Association (JAMA).
The article describes the care that HIV-positive older adults need. And it describes the care of a patient, “Mr. H,” who was diagnosed with HIV at age 45 and is now 74. The article divides the care of older patients living with HIV into three basic stages: early, chronic, and advanced care.
Early Care for Older Adults: Prevention, Screening, and Diagnosis
Older adults’ misunderstandings about HIV and AIDS can increase their risks of getting infected with the virus, explained Victor Valcour, MD, of the University of California, at San Francisco, and co-author of theJAMA article. Because HIV infection can be silent for many years and since older adults often are unaware of their risk, “This can result in older people’s delaying treatment.”
An important way to lower your risk of getting infected with HIV is to use a condom when sexually active, commonly known as “safe sex”. Unfortunately, published studies note that older adults are less likely than younger to practice safe sex, the researchers report. In part this is because many older people believe that HIV is “an infection for younger people” that doesn’t affect them.
It’s important for healthcare providers to tell their older patients why and how to protect against HIV, the authors note. Among other things, healthcare professionals should ask older adults about their sex lives, and check for symptoms that may be due to HIV infection. These include: unusual types of pneumonia, anemia, fever, weight loss, rapid mental decline, and fatigue. But many different things can cause these symptoms and this can contribute to delayed diagnosis in older adults. The authors feel that older adults should be standardly offered an HIV test that they can choose to ‘opt-put’ of, rather than relying on identification of symptoms; but controversy about this approach remains among experts. When indicated, clinicians should recommend an HIV screening test. Older people diagnosed with HIV should start treatment without delay in order to get the best results.
Chronic Care for Older Adults: Monitoring Symptoms and Reducing Risks
HIV can increase risks of non-HIV health conditions such as heart disease, certain cancers, and other disorders. These health problems are known as HIV-associated non-AIDS conditions (HANA conditions), and they cause more than 60 percent of deaths related to AIDS, Dr. Valcour and co-authors explain. Because of this, it’s important that healthcare providers help older HIV-positive patients lower their risks of these conditions by, for example, quitting smoking, exercising regularly, eating fruits and vegetables, and taking other steps to reduce their risks of heart disease and cancers.
Healthcare professionals also need to monitor the medications that older adults with HIV take. Drugs can interact and cause side effects, and may increase risks of falls, delirium, and other problems. For these reasons, healthcare providers should consider non-drug treatments whenever possible, Dr. Valcour and co-authors write. For older people with depression, for example, “talk therapy” or support groups are important ways to cope with loss and loneliness and are an important addition to the treatment of depression, possibly allowing patients to take a lower doses of antidepressant and anti-anxiety drugs.
Advanced Care for Older Adults: Revising Treatment Plans
The authors define an advanced stage of HIV as one where life-expectancy is thought to be short due to HIV or its complications. This may occur, for example, in an older adult with a cancer diagnosis who opts for supportive care. Sometimes, a clear reason for the shorter life expectancy is not clear, but symptoms, such as often feeling tired and losing weight are worrisome for another illness, like cancer, but the patient opts for a limited search for causes, the authors note.
At this point, patients, their family members, and healthcare providers should begin to discuss what kind of end-of-life care they would like – if they haven’t already done so. They should also make sure that their wishes are documented appropriately.
Healthcare providers should help patients in this stage make individualized decisions about their care, including what goals to prioritize and what treatments to continue. One thing patients should continue to do, even if their life expectancy is less than one year, is to continue taking cART since it minimizes symptoms of HIV-related health problems.
This summary is from the full report titled, “Management of Human Immunodeficiency Virus Infection in Advanced Age.” It appears in the April 3, 2013 issue of the Journal of the American Medical Association. The report is authored by Meredith Greene, MD, Amy C. Justice, MD, PhD, Harry W. Lampiris, MD, and Victor Valcour, MD (corresponding author).