Frailty among older persons living with HIV: a new burden for their clinical care

Alfonso Zamudio-Rodriguez holds a master’s degree in Public Health and is interested in frailty of older persons living with HIV. He develops his work in the department of Dr. Ávila-Funes @geriatriainnsz at the National Institute of Medical Science and Nutrition Salvador Zubiran, Mexico City.

Population ageing remains a continuous challenge for health care providers due to the escalating number of patients with chronic conditions. This represents a considerable economic burden for health systems across the globe. Ever since its debut in the 80’s, prevention, early diagnosis, and treatment of human immunodeficiency virus (HIV) infection has captured the attention of the scientific community. Highly active antiretroviral therapy (HAART) radically modified the paradigm of living with HIV by prolonging survival and improving the prognosis of a previously terminal disease. Today, thanks to HAART, HIV is a chronic condition with a life expectancy similar to that of the general population and a significantly improved quality of life. However, the changes in survival for HIV infected individuals have unearthed the appearance at an earlier age of health problems that used to be observed exclusively in older adults.

By the same token, HIV-associated non-AIDS (HANA) conditions such as osteoporosis, ischemic heart disease, or some cancer types are now observed at earlier ages in those living with HIV, especially in those with a more protracted disease course and HAART treatment. These conditions have a substantial impact on individuals living with HIV by increasing the incidence of adverse health-related outcomes. The origin of HANA conditions seems to be multifactorial due to their occurrence independently of disease duration, viral suppression, immunological response to treatment, and even socioeconomic status, thus emphasizing the need for further investigation on the matter so appropriate measures can be proposed.

HIV has thus been proposed as an ageing promoter that favors the development of age-related diseases, including the so-called geriatric syndromes, in younger adults. This reality requires the infectious diseases and HIV specialists to learn from the geriatrician’s experience to better tend for their patients who represent a growing population, especially where health systems have difficulties in the management of older adults and people living with HIV.

The frailty phenotype, a hallmark of geriatric medicine, is related to adverse health-related outcomes independently and via its association to inflammation and HANA conditions in HIV patients. Hence its presence could serve as a prognostic factor potentially modifying management or as a deterioration indicator in clinical trials.  However, age remains one of the most important frailty risk factors and the literature comprising individuals aged 65 or older living with HIV is scarce since they tend to be excluded from clinical trials. Fortunately, HIV cohort studies are now systematically including individuals “older” than 50 years. This has allowed the recognition of multiple determinants of the frailty-phenotype beyond age such as HIV infection consequences (low CD4+ counts), the presence of concomitant chronic conditions, and socioeconomic factors. The latter are of great interest for developing countries since poor education and low income affect the prognosis of older adults living with HIV.

Why should health systems care about older adults living with HIV in developing countries? There are several reasons to be mentioned. (a) These individuals represent a growing part of the population, (b) there are no preventive campaigns that target this specific group, (c) the diagnosis of HIV in older adults tends to happen late than sooner due to a low-index of suspicion and attributing symptoms to other conditions; (d) as with regular geriatric patients, older adults living with HIV require a multidisciplinary approach; and (e) there should be specialized programs that adapt to this group so they can have adequate care.

Although several areas of uncertainty remain for the treatment of older adults living with HIV, mostly related to HAART pharmacology, the inclusion of individuals older than 65 y and/or with comorbidities in clinical trials is a huge step forward. These will increase external validity and will favor a more realistic decision-making process when managing such patients.

At the moment, most therapeutic recommendations regarding older adults living with HIV derive from experience rather than evidence, and some of them stem from pure intuition such as giving HAART independently of CD4+ count, closely monitor adverse drug-related side-effects that target the heart, kidneys, and liver; avoid polypharmacy and potentially harmful drug interactions; and tailoring HAART treatment.

It seems that individuals that get infected with the virus later in life have better adherence to their treatment when compared to those that grew old with HIV and this should be used in favor of such patients. Also, promoting a multidisciplinary approach that incorporates the geriatric experience into the HIV medicine field will better define the frailty phenotype in these patients building up to a better care of this population. Finally, we must advocate for prevention campaigns that highlight older adults as a vulnerable group and advocate for healthier sexual practices in late adulthood.

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