ORLANDO — Physicians will see more elderly people with HIV, because of both more new infections among the population and prolonged survival of people with HIV, according to a physician epidemiologist.
Physicians should be screening their senior patients for HIV risk. Ask about sexual activity and counsel them about prevention of sexually transmitted diseases, Dr. Kelly A. Gebo advised.
Older people, in general, have a lack of awareness about HIV risk factors, said Dr. Gebo, associate professor and director of undergraduate research studies at John Hopkins Bloomberg School of Public Health in Baltimore. A lack of HIV prevention targeted at seniors is partly to blame, she said.
As a result, seniors with HIV infection often are diagnosed late in the disease. “The average CD4 count is about 250 in our practice at time of diagnosis. We'd like to diagnose them earlier,” she said.
Many older people are newly single and believe that HIV affects only younger people—two additional challenges to HIV prevention in this population. Erectile dysfunction drugs that increase senior sexual activity may play a role, and some older women stop using condoms once the risk of pregnancy passes with menopause, Dr. Gebo noted.
“I ask everyone from 12 to 112 about alcohol, sexual history, and drug use,” she said, while acknowledging that some physicians aren't as comfortable as she asking seniors about these delicate issues.
In a subsequent presentation, Dr. Kevin P. High suggested how doctors could phrase a recommendation for HIV testing: “I don't believe this is likely, but I would not be doing my job in 2010 if I did not test you for HIV. It's a very treatable illness, and we ought to test.” He added, “I've never had anyone say no.”
Almost 18% of HIV diagnoses in 2007 were made in people older than 50 years, according to the Centers for Disease Control and Prevention. This proportion is expected to grow, Dr. Gebo added.
Compared with younger people, elderly people with HIV get less immunologic boost from some treatments and have shorter survivals. In addition, seniors with HIV can experience an acceleration of the effects of normal aging, including greater bone loss, muscle mass decreases, and memory loss, Dr. Gebo said.
Inflammation could be at the root of seniors' HIV vulnerability. “We all know inflammation is bad in cardiovascular disease,” said Dr. High, professor of infectious diseases at Wake Forest University, Winston-Salem, N.C. Inflammation “is more present in HIV than in age-matched, HIV-negative adults. We think that is the reason for the disease acceleration in older patients with HIV,” he added.
On the plus side, older people are generally more compliant than younger people with their medication regimens. Adherence to prescriptions is particularly important to combat HIV infection because of an elevated risk for viral resistance, Dr. Gebo said.
Another plus, she added, is that older patients tend to experience better virologic suppression following treatment. In response to an audience question, she said that the improved suppression reported in this population was independent of their better medication compliance.
“Unfortunately, it is not all good news for these older patients,” Dr. Gebo said. Evidence suggests that the decrease in immune system strength that comes with normal aging can diminish the efficacy of antiretroviral agents.
Frailty is another factor working against older people with HIV, Dr. High pointed out. The risk for frailty is increased ninefold by HIV infection, he said. For example, only 1%-2% of 55-year-old HIV-negative men will meet the definition for frailty (J. Acquir. Immune Defic. Syndr. 2009;50:299-306). In contrast, 14% of men of the same age with an 8-year-old HIV diagnosis will meet the definition.
Disclosures: Dr. Gebo and Dr. High reported no financial conflicts of interest.