Page 143 - HIV/AIDS Guidelines

HIV and the Older Patient (Last updated March 27, 2012; last reviewed March 27, 2012)

Key Considerations When Caring for Older HIV-Infected Patients
• Antiretroviral therapy (ART) is recommended in patients >50 years of age, regardless of CD4 cell count (BIII),
because the risk of non-AIDS related complications may increase and the immunologic response to ART may be
reduced in older HIV-infected patients.

• ART-associated adverse events may occur more frequently in older HIV-infected adults than in younger HIV-infected
individuals. Therefore, the bone, kidney, metabolic, cardiovascular, and liver health of older HIV-infected adults
should be monitored closely.
• The increased risk of drug-drug interactions between antiretroviral (ARV) drugs and other medications commonly
used in older HIV-infected patients should be assessed regularly, especially when starting or switching ART and
concomitant medications.
• HIV experts and primary care providers should work together to optimize the medical care of older HIV-infected
patients with complex comorbidities.
• Counseling to prevent secondary transmission of HIV remains an important aspect of the care of the older HIV-
infected patient.

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = data from randomized controlled trials; II = data from well-designed nonrandomized trials or observational
cohort studies with long-term clinical outcomes; III = expert opinion

Effective antiretroviral therapy (ART) has increased survival in HIV-infected individuals, resulting in an
increasing number of older individuals living with HIV infection. In the United States, approximately 30% of
people currently living with HIV/AIDS are age 50 years or older and trends suggest that the proportion of
1
older persons living with HIV/AIDS will increase steadily. Care of HIV-infected patients increasingly will
involve adults 60 to 80 years of age, a population for which data from clinical trials or pharmacokinetic
studies are very limited.

2
There are several distinct areas of concern regarding the association between age and HIV disease. First,
older HIV-infected patients may suffer from aging-related comorbid illnesses that can complicate the
management of HIV infection, as outlined in detail below. Second, HIV disease may affect the biology of
aging, possibly resulting in early manifestations of many clinical syndromes generally associated with
advanced age. Third, reduced mucosal and immunologic defenses (such as post-menopausal atrophic
vaginitis) and changes in risk behaviors (for example, decrease in condom use because of less concern about
pregnancy and increased use of erectile dysfunction drugs) in older adults could lead to increased risk of
acquisition and transmission of HIV. 3-4 Finally, because older adults generally are perceived to be at low risk
of HIV infection, screening for HIV in this population remains low. For these reasons, HIV infection in many
older adults may not be diagnosed until late in the disease process. This section focuses on HIV diagnosis
and treatment considerations in the older HIV-infected patient.

HIV Diagnosis and Prevention
Even though many older individuals are engaged in risk behaviors associated with acquisition of HIV, they
may be perceived to be at low risk of infection and, as a result, they are less likely to be tested for HIV than
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younger persons. According to one U.S. survey, 71% of men and 51% of women age 60 years and older
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continue to be sexually active, with less concern about the possibility of pregnancy contributing to less

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-27

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