Page 144 - HIV/AIDS Guidelines

condom use. Another national survey reported that among individuals age 50 years or older, condoms were
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not used during most recent intercourse with 91% of casual partners or 70% of new partners. In addition,
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results from a CDC survey show that in 2008 only 35% of adults age 45 to 64 years had ever been tested for
HIV infection despite the 2006 CDC recommendation that individuals age 13 to 64 years be tested at least
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once and more often if sexually active. Clinicians must be attuned to the possibility of HIV infection in
older patients, including those older than 64 years of age who, based on CDC recommendations, would not
be screened for HIV. Furthermore, sexual history taking, risk-reduction counseling, and screening for
sexually transmitted diseases (STDs) (if indicated), are important components of general health care for HIV-
infected and -uninfected older patients.

Failure to consider a diagnosis of HIV in older persons likely contributes to later disease presentation and
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initiation of ART. One surveillance report showed that the proportion of patients who progressed to AIDS
within 1 year of diagnosis was greater among patients >60 years of age (52%) than among patients younger
than 25 years (16%). When individuals >50 years of age present with severe illnesses, AIDS-related
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opportunistic infections (OIs) need to be considered in the differential diagnosis of the illness.

Initiating Antiretroviral Therapy
Concerns about decreased immune recovery and increased risk of serious non-AIDS events are factors that
favor initiating ART in patients >50 years of age regardless of CD4 cell count (BIII). (See Initiating
Antiretroviral Therapy in Treatment-Naive Patients.) Data that would favor use of any one of the Panel’s
recommended initial ART regimens (see What to Start) on the basis of age are not available. The choice of
regimen should be informed by a comprehensive review of the patient’s other medical conditions and
medications. A noteworthy limitation of currently available information is lack of data on the long-term safety
of specific antiretroviral (ARV) drugs in older patients, such as use of tenofovir disoproxil fumarate (TDF) in
older patients with declining renal function. The recommendations on how frequently to monitor parameters of
ART effectiveness and safety for adults age >50 years are similar to those for the general HIV-infected
population; however, the recommendations for older adults focus particularly on the adverse events of ART
pertaining to renal, liver, cardiovascular, metabolic, and bone health (see Table 13).

HIV, Aging, and Antiretroviral Therapy
The efficacy, pharmacokinetics, adverse effects, and drug interaction potentials of ART in the older adult
have not been studied systematically. There is no evidence that the virologic response to ART is different in
older patients than in younger patients. However, CD4 T-cell recovery after starting ART generally is less
robust in older patients than in younger patients. 11-14 This observation suggests that starting ART at a younger
age will result in better immunologic and possibly clinical outcomes.

Hepatic metabolism and renal elimination are the major routes of drug clearance, including the clearance of
ARV drugs. Both liver and kidney function may decrease with age, which may result in impaired drug
elimination and drug accumulation. Current ARV drug doses are based on pharmacokinetic and
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pharmacodynamic data derived from studies conducted in subjects with normal organ function. Most clinical
trials include only a small proportion of study participants >50 years of age. Whether drug accumulation in the
older patient may lead to greater incidence and severity of adverse effects than seen in younger patients is
unknown.

HIV-infected patients with aging-associated comorbidities may require additional pharmacologic
intervention, making therapeutic management increasingly complex. In addition to taking medications to
manage HIV infection and comorbid conditions, many older HIV-infected patients also are taking
medications to ameliorate discomfort (e.g., pain medications, sedatives) or to manage adverse effects of

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-28

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