Skip to main content

Aging with HIV

 
From the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

It has been over three decades since the first cases of AIDS were observed in the United States, and in one month we will be marking the 30th anniversary of dual publications in Science attributing a novel retrovirus as the potential cause of AIDS.

Since this time, and in large part due to the development of antiretroviral therapy, mortality due to HIV & AIDS has significantly decreased, so much so that it is now considered a chronic rather than an acutely fatal disease.  With these changes, HIV is also now becoming a disease of the elderly.  By 2015, half of HIV positive individuals will be older than 50 years of age.

This is the background to what I consider one of the most important review articles in JAMA this year. Starting off with a case of a 74 year old who was diagnosed with HIV in 1984 (when AIDS was almost a uniformly fatal disease) the authors, Meredith Greene, Amy Justice, Harry W. Lampiris, and Victor Valcour, walk us through the prevention and management of HIV in Advanced Age.

Here are a couple issues presented in the article that should make this a must read for any provider caring for older adults (you can read the entire manuscript here):

Under-diagnosis: There is a delay in the diagnosis of HIV due in part to common misconceptions that HIV is a disease of the young and that older adults aren’t at risk because they don’t have sex (or at least we dont ask about it.)

Screening:   Age as a cut off for screening is changing. Because of shifting demographics seen in HIV infections, routine opt-out screening is now recommended regardless of age.

Antiretroviral Treatment: CD4 counts should not change the decision of when to initiate antiretroviral therapy.  In the US, antiretroviral therapy should be started in all older patients regardless of CD4 counts.

Psychosocial Care Matters: Older HIV-positive adults are at risk for social isolation, which has been shown to negatively impact health outcomes (see here)

Prognostication: Patients overall goals and life expectancy should play a role in decisions around health care maintenance and prevention in this population (and they included a link to ePrognosis!) 

Advance Care Planning & Palliative Care:  Discussions and documentation of end-of-life preferences need to occur more frequently and Palliative Care can play an "emerging role in improving quality of life" in these patients

The review also does a beautiful job in helping clinicians understand how specific antiretrovirals are chosen in older HIV positive adults and common drug interactions between antiretrovirals and other medications.

To wrap things up, I'll end with a quote from the article on where we need to be going as a field:
Optimal models of care must be identified—with HIV specialists, primary care clinicians, and geriatricians working together to make successful aging for this population achievable.
Well said!

by: Eric Widera (@ewidera)

Comments

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Does “compassionate deception” have a place in palliative care?

by: Olivia Gamboa (@Liv_g_g)

There is broad consensus in the medical community that lying to patients is unethical.  However, in the care of patients with dementia, the moral clarity of this approach blurs.  In her recent New Yorker article, “The Memory House,”  Larissa MacFarquhar provides an excellent portrait of the common devices of artifice, omission and outright deception that are frequently deployed in the care of patients with dementia.  She furthermore explores the historical and ethical underpinnings of the various approaches used in disclosing (or not) information to patients living with dementia.

Ms. MacFarquhar introduces the idea of “compassionate deception,” or the concept that withholding truths, or even promoting outright falsehoods, is a reasonable and even ethical choice for those caring for patients with dementia.  To the extent that it helps a person with dementia feel happier and calmer, allowing them to believe in a gentler reality (one in which, say, their spo…