The aging HIV patient and geriatric syndromes: “Will you still treat me when I’m 64?”
People living with HIV are getting older due both to extended survival and to an increase in new diagnoses over the age of 50. Dr. Julian Falutz, a geriatrician from the McGill University Health Centre, discussed the impact of geriatric syndromes on the health and well-being of people living with HIV.
Geriatric syndromes are common conditions in the elderly that usually involve multiple symptoms. While few people with HIV could yet be classed as elderly, comorbidities do occur earlier in people living with HIV. Comorbidities in the population over 50 are becoming more prevalent according to a recent EUROSida analysis. By 2030, 75% of the HIV-positive population will be over 50, and the proportion of those with more than three comorbidities will have increased significantly.
Dr. Falutz talk focused on two traditional geriatric syndromes: frailty, and falls and impaired mobility.
Frailty is a state of increased vulnerability to stressors. In the general elderly population, frailty is associated with hospitalization, loss of independence, and death. A large study of gay and bisexual men living with HIV suggested that low CD4 counts in a person’s past increased the risk of frailty and that frailty was increased in HIV-positive men over 50 years old (Althoff K et al, 2011). A study of the aging HIV population at San Francisco General (over 50) suggested that 10% of patients were frail. In people with HIV, frailty predicts survival over 5 years, and the development of multi-morbidities in those who had one or less comorbidities at the start of the study (Guaraldi G et al, 2015).
Mobility and falls – HIV patients have a slower gait speed than the general population and gait speed declines faster than in the general population. There is some evidence of reduced lower limb strength and power in people with HIV, which develops at a younger age than the general population (Richert L et al, 2014). Some measures of reduced mobility were associated with early death in people with HIV (Greene M et al, 2014). HIV diagnosis by itself does not increase a person’s risk of falling, even in older populations, however decreased lower limb strength may. Overall, people living with HIV are more likely to have restricted activities of daily living compared to HIV-negative people the same age (Morgan EE et al, 2012).
Is successful aging with HIV possible? Absolutely. Treat early and be aware of the risk factors for multi-morbidity. Avoid multiple prescriptions whenever possible. Assess and manage the risks for functional decline. Multidisciplinary management of HIV is important to support successful aging.
Aging with HIV: Challenges and potential solutions
Richard Harding from the Department of Palliative Care, Policy and Rehabilitation at King’s College London discussed rehabilitation services for people living with HIV and strategies for dealing with the complex care increasingly needed by older people living with HIV.
UK data about the self-reported quality of life among people living with HIV indicates that not only is the population getting older but they are experiencing significant disability. A study of 778 HIV outpatient clinic patients (Harding et al, 2012) revealed that:
- 28% reported problems walking around
- 20% reported problems with self-care
- 35% experienced barriers to their usual activities
- 40% experienced pain.
The average age of these patients was just over 40. Research also shows that people aging with HIV have a higher quality of life when they have better measures of mobility, such as faster gait or chair rise. Independence and maintaining mobility should be a major focus of HIV rehabilitation.
So what are recommendations for rehabilitation services for older adults living with HIV? The systematic review by Ontario’s Kelly O’Brien is the most comprehensive look at HIV rehabilitation, producing eight overarching recommendations. Dr. Harding also stressed the need to learn from non-HIV research dealing with the needs of frail people aging with chronic disease.
Dr. Harding described the Kobler HIV rehabilitation class being implemented in the UK. It promotes both self-management and aerobic exercise and resistance, with rehabilitation professionals providing individualized care. It is a ten-week program with two meetings a week. Adherence to eight out of 20 sessions was achieved by about half of participants, and those who participated regularly had improvements in measures of strength and physical and mental health-related quality of life (Brown D et al, 2016).
Dr. Harding discussed other important HIV rehabilitation projects in the UK, including the development of UKROC – a rehabilitation collective that currently collects data from all in-patient HIV rehabilitation in the UK. This allows for the ongoing evaluation of care and is enabling the development of a rehabilitation complexity scale and benchmarks for complex care. This data is being used for capacity planning and the development of appropriate services. Data collection is about to expand to include out-patient services.
Traditionally PROMs (patient reported outcome measures) have been used as research tools. Dr. Harding’s team feels that these measures will be key to finding simple ways of understanding what matters most to patients, prioritizing care, and sharing information with other professionals. A review of HIV-specific PROMs was recently published (Engler et al, 2017). His team is now working on Positive Outcomes – research to identify and implement PROMs that will support routine practice and ultimately improve the quality of care.
Dr. Harding also highlighted the need to focus on palliative care, and the recommendations of the World Health Organization’s better practices guide on palliative care for older adults with chronic disease.
Medication challenges in the aging HIV population
Alice Tseng from the University Health Network presented a brief case report illustrating the complexities of treating people with both HIV and other comorbidities. In particular, this report looked at the interactions between antiretroviral drugs (ARV) and the oral anticoagulant, warfarin, used to treat some forms of cardiac disease. Multiple case reports in the literature show that interactions between the protease inhibitor, ritonavir, and warfarin reduce the absorption of warfarin substantially so that the patient may require anywhere from 45-100% more drug to reach an effective treatment level.
Dr. Tseng described the experience of an HIV-positive man who switched to a simpler ARV drug regimen containing darunavir with the booster cobicistat, instead of the atazanavir boosted with ritonavir regimen he had used for more than 10 years. He had been on a stable dose of 10 mg warfarin for over a year. With the switch in drugs, blood work from the patient began to show very high levels of warfarin above what was needed, and he began experiencing nose bleeds (a side effect of warfarin). Over a period of months his dose of warfarin had to be reduced from 10 mg, down to 8.5, then 7.5 and finally 4 mg before his warfarin levels stabilized at a therapeutic level.
Dr. Tseng’s team hypothesizes that this happens because of the metabolic pathways in the liver used by ritonavir (CYP1A2, 2B6, 2C9, 2C19 and UGT). They suggest that when switching from ritonavir to cobicistat, levels of drugs using these pathways should be monitored and adjusted downward as needed.