HIV INFECTION IN ELDERLY

Presenter; Dorice Lucas(PGY3)

Supervisor: Prof.Samuel E.Kalluvya (Consultant physician,Endocrinologist )
 INTRODUCTION
• Human immunodeficiency virus (HIV) infection in older adults
defines older as ≥50 years of age.

• Older people living with HIV,experience age-related comorbidities and

geriatric conditions at relatively younger ages compared with the
general population.

• Increasing survival resulting from antiretroviral therapy (ART), the

proportion of patients with HIV who are in this older age has
increased substantially
JAMA. 2013 Apr;309(13):1397-405
EPIDEMIOLOGY
• It was estimated 5.7 million individuals age 50 years and older were living
with HIV infection by the end of 2016.

• About 21% of all PLHIV globally are 50yrs and above

• The proportion of older adults with HIV is greater in high-income/resource-

rich settings, where 33 percent of the adult population with HIV is 50 years
and older.

• While those aging with HIV comprise the majority of older adults living with
HIV, new infections in older adults also occur.

1.Beck EJ et al,2018;13(11):e0207005.
• The population of people aged 50 or over with HIV in sub-Saharan Africa is
approaching 4 million

• The number of people living with HIV(PLWH) over 50yrs old was estimated to
triple in the coming decades,6-10million by 2040.

• The Prevalence of HIV among elderly aged 50 and above is not well documented
in Tanzania

• Hollie SM etal,September 11, 2023

• Hontelez et al ,2012
• Mark JS et al,Aug 23,2017
RISK FACTORS FOR NEW INFECTIONS
• Sexual exposure is the most common mode of transmission for HIV
infection in adults older than 50 years.

• Male-to-male sexual contact is the most common HIV transmission

risk in the United States, Europe, and Australia including elderly.

• In most of the rest of the world, HIV infection in males is most

commonly acquired through heterosexual transmission.

HIV Surveillance Report, 2017; vol. 29.

• The older females can be at higher risk for HIV acquisition, due to
vulvovaginal atrophy.

• Aging females are less likely to use barrier contraception methods.

CHALENGES OF HIV INFECTION IN ELDERLY
Delayed diagnosis of HIV

• Under diagnosis of HIV infection among older patients continues to

be a significant problem, because both clinicians and older adults
underestimate risks of HIV acquisition.

• Older individuals are frequently not perceived by their clinicians as

being at risk for HIV infection and, consequently, are less likely to
be tested for HIV compared with younger adults.

• Even those who engage in sexual behaviors that increase the risk of
exposure, may not perceive themselves to be at risk for HIV or other
sexually transmitted infections (STIs).
• The diagnosis is often made late, when the patient has already
progressed to AIDS.

• Advanced HIV may present with the gradual onset of weight loss,
low-grade fever, and fatigue, leading clinicians to evaluate for cancer
in older adults but overlook HIV

• Young clinicians/HCP become uncomfortable to offer pre counselling

for HIV testing to elderly.
Prevention of HIV
• There are few prevention campaigns specifically targeted older adults, despite the number
of new infections that occur in older adults.

• Pre-exposure prophylaxis (PrEP) is a highly effective strategy for preventing HIV in people
at high risk for acquisition but no studies have specifically examined PrEP in older adults.

• Although older adults can also benefit from PrEP, they may be at higher risk of side effects
from TDF, including decline in renal function and loss of bone mineral density.

• TAF in combination with emtricitabine could be an option since it has less bone and renal
toxicity.
Mayer KH et al,Lancet. 2020;
• Older individuals are the one caring for their children who have acquired HIV
infection during there sickness or caring children whose parents have died of
AIDS, without using any protections which predispose them to acquire HIV
infection.
ANTIRETROVIRAL USE

Indications and selection

• None of the first-list ART regimens are recommended over the others
for older adults.

• The choice of ART regimen should take into account existing

medications and comorbidities, particularly liver and kidney disease.

• Many older adult have polypharmacy,which is the risk factor for

adverse drug events, drug-drug interactions, inappropriate medication,
delirium, falls, fractures, and poor adherence.
Immunologic recovery with ART
• Despite successful ART and viral suppression, immune recovery is less robust
with increasing age.

• Immune activation caused by direct HIV infection of end-organ tissues and

coinfections is thought to precipitate chronic activation of both innate and
adaptive immunologic pathways.

• These can explain the immunological none responders(INR) which is more in

elderly.
Wilson et al,2014, Desprez et al,2010 ,Macaulay et al 2013
• HIV infection promotes the so-called senescence-associated secretory
phenotype, characterized by proliferation of CD8+CD57+CD28− T-lymphocytes,
which have been implicated in increased cytokine production, decreased naïve
T-cell precursor populations, diminished humoral immunity

• The resulting inflammatory state as well as markers of immune senescence

have been correlated with frailty, neurocognitive dysfunction, functional
impairment, and mortality in older aged PLWH

Macaulay et al 2013,Knudsen et al ,2016

Adherence and viral suppression

• Older adults with HIV have a reduced risk for non-adherence to ART than
their younger counterparts.

• It was found that ART adherence levels were similar among older and
younger adults in Africa.

• Another study done in Uganda showed both ART access and self-reported
adherence were better than expected in both groups.
Najeebbullah et al 2019,Enid Schatz et al 2019.
• The viral set point for the elderly is high as in children, which can
lead to early progression to Advance HIV disease.
Drug-drug Interaction

• A number of potential drug-drug interactions increase with the

number of prescribed drugs and is higher in those patients on PI among elderly .

• A 65% of the patients showed at least one potential drug-drug

interaction and 6.6% a severe potential drug-drug interaction.

Carla B et al 2017.
Polypharmacy

• A high burden of medication use and drug-drug interaction, potentially

inappropriate medications, are issues for older patients who have
multiple comorbidities.

• A thorough review of all medications and supplements is an important

component of care for older patients with HIV.
NON-AIDS MORBIDITY
Successful ART has lengthened survival in individuals with HIV and has led to changing
patterns of morbidities and mortality.

Cardiovascular disease
• Increased survival among individuals with HIV has increased prevalence of metabolic
disorders such as glucose intolerance and diabetes mellitus, lipodystrophy, and
dyslipidemia.

• There is also a theory of alteration in tryptophan metabolism, which has been associated
with an increased risk of atherosclerosis, depression, AIDS-related cancer, and all-cause
mortality

Bipath et al ,2015
Neurologic complications

• Neurocognitive disorders- The most severe form of HIV-associated

neurocognitive disorders is HIV-associated dementia.

• Peripheral neuropathy-Increased age is a risk factor for peripheral

neuropathy
Malignancy - HIV infection is associated with an increased risk of
certain malignancies, especially those related to infectious etiologies
and smoking.

Bone health - Certain lifestyle and hormonal factors contribute to

decreased bone density and fragility fractures.
• Antiretroviral toxicities, especially from TDF also contribute
Liver disease - Coinfection with HBV and HCV is common in
patients with HIV because of shared routes of transmission.
• Chronic liver disease is a frequent finding in older adults with HIV.

Pulmonary disease - Chronic obstructive pulmonary disease, lung

cancer, pulmonary hypertension, pulmonary fibrosis, and pulmonary
infections are more in HIV infection individuals but occur most in
elderly.
Menopause - Menopause may occur earlier in females with HIV, and
they may be more likely to experience menopausal symptoms, which
can contribute to depression and anxiety.

Hypogonadism - It is s common in males with HIV and has been

associated with advanced disease and, in the ART era, persistent
viremia.
Geriatric syndromes and functional impairment

• Older adults with HIV may also be dealing with geriatric syndromes such as
falls, frailty, functional impairments and disability.

• Frailty also appeared to be more common in PLWH with active viremia than
HIV-uninfected comparators but less common among PLWH with a suppressed
viral load

• These geriatric syndromes may also occur at relatively younger ages in adults
with HIV compared with the general population.

Greene M et al,AIDS Behav. 2018. Akgun et al 2014.

Social isolation and loneliness

• In the general population, social isolation and loneliness are

associated with mortality.

• Older adults with HIV may have higher rates of social isolation and
loneliness than the general population .
MANAGEMENT

• Early initiation of ART is recommended if there are no opportunistic

infections requiring deferral because of fast progression and
predominantly late presentation.
• Prescription of ARVs and other medications should aim at reducing
toxicity,adverse effects because of renal and hepatic dysfunction,drug
–drug interactions and overlapping toxicities because of polypharmacy
• Screening for NCD and monitoring drug toxicity with laboratory work
up.
• Screening and treatment of mood disorders including anxiety and
depression and to identify adherence support.
Choice of ARVs among elderly PLHIV
• TAF should be the preferred ARV and in its absence ABC because of increase
risk of renal dysfunction, osteoporosis and pathological fractures.
• In case of metabolic syndrome and severe hepatic dysfunction DTG should be
used cautiously or replaced with EFV in first line and ATV/r in second line.
• ABC should be used with caution in elderly PLHIV with risk for or existing
coronary artery disease.

National intergrade HIV,Viral hepatitis and STI management guideline,Sept 2023;Tanzania

Co- medication with ART
• For PLHIV with Type 2 DM on metformin on concurrent DTG based
regimens, the dose of metformin should not exceed 1gm per day.
• Regularly check the blood sugar as the risk of hypoglycemia is higher.

National intergrade HIV,Viral hepatitis and STI management guideline,Sept 2023;Tanzania

THANK YOU