Page 145 - HIV/AIDS Guidelines

medications (e.g., anti-emetics). They also may self-medicate with over-the-counter medicines or
supplements. In the HIV-negative population, polypharmacy is a major cause of iatrogenic problems in
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geriatric patients. This may be the result of medication errors (by prescribers or patients), nonadherence,
additive drug toxicities, and drug-drug interactions. Older HIV-infected patients probably are at an even
greater risk of polypharmacy and its attendant adverse consequences than younger HIV-infected or similarly
aged HIV-uninfected patients.
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Drug-drug interactions are common with ART and easily can be overlooked by prescribers. The available
drug interaction information on ARV agents is derived primarily from pharmacokinetic studies performed in
a small number of relatively young, HIV-uninfected subjects with normal organ function (see Tables 14-16b).
Data from these studies provide clinicians with a basis to assess whether a significant interaction may exist.
However, the magnitude of the interaction may be different in older HIV-infected patients than in younger
HIV-infected patients.

Nonadherence is the most common cause of treatment failure. Complex dosing requirements, high pill
burden, inability to access medications because of cost or availability, limited health literacy including lack
of numeracy skills, misunderstanding of instructions, depression, and neurocognitive impairment are among
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the key reasons for nonadherence. Although many of these factors likely will be more prevalent in an aging
HIV-infected population, some data suggest that older HIV-infected patients may be more adherent to ART
than younger HIV-infected patients. 19-21 Clinicians should assess adherence regularly to identify any factors,
such as neurocognitive deficits, that may make adherence a challenge. One or more interventions such as
discontinuation of unnecessary medications; regimen simplification; or use of adherence tools, including
pillboxes, daily calendars, and evidence-based behavioral approaches may be necessary to facilitate
medication adherence (see Adherence to Antiretroviral Therapy).

Non-AIDS HIV-Related Complications and other Comorbidities
With the reduction in AIDS-related morbidity and mortality observed with effective use of ART, non-AIDS
conditions constitute an increasing proportion of serious illnesses in ART-treated HIV-infected populations. 22-24
Heart disease and cancer are the leading causes of death in older Americans. Similarly, for HIV-infected
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patients on ART, non-AIDS events such as heart disease, liver disease, and cancer have emerged as major
causes of morbidity and mortality. Neurocognitive impairment, already a major health problem in aging
patients, may be exacerbated by the effect of HIV infection on the brain. That the presence of multiple non-
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AIDS comorbidities coupled with the immunologic effects of HIV infection could add to the disease burden of
an aging HIV-infected person is a concern. 27-29 At present, primary care recommendations are the same for
HIV-infected and HIV-uninfected adults and focus on identifying and managing risks of conditions such as
heart, liver, and renal disease; cancer; and bone demineralization. 30-32

Discontinuing Antiretroviral Therapy in Older Patients
Important issues to discuss with aging HIV-infected patients are living wills, advance directives, and long-
term care planning including financial concerns. Health care cost sharing (e.g., co-pays, out-of-pocket costs),
loss of employment, and other financial-related factors can cause interruptions in treatment. Clinic systems
can minimize loss of treatment by helping patients maintain access to insurance.

For the severely debilitated or terminally ill HIV-infected patient, adding palliative care medications, while
perhaps beneficial, further increases the complexity and risk of negative drug interactions. For such patients,
a balanced consideration of both the expected benefits of ART and the toxicities and negative quality-of-life
effects of ART is needed.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents I-29

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