Clinical Geriatrics

According to the Centers for Disease Control and Prevention’s most recent projections, roughly half of all Americans infected with HIV (human immunodeficiency virus) will be 50 years of age or older by 2015. This striking statistic is both encouraging and daunting. It is encouraging because it reflects the remarkable success of antiretroviral and other HIV treatments in combating AIDS (acquired immune deficiency syndrome). Yet, it is daunting because many HIV-positive patients in their 50s and early- to mid-60s—patients who are aging but are not chronologically considered seniors—are developing multiple, complex health problems typically associated with more advanced age.

The simultaneous presence of both HIV- and age-associated health problems among these patients makes determining how best to proceed with treatment particularly challenging. An important report, titled “The HIV and Aging Consensus Project: Recommended Treatment Strategies for Clinicians Managing Older Patients with HIV” (www.aahivm.org/hivandagingforum), was recently published by the HIV & Aging Consensus Project, a joint undertaking of the American Academy of HIV Medicine (AAHIVM), the American Geriatrics Society (AGS), and the AIDS Community Research Initiative of America (ACRIA), to provide healthcare providers with much-needed strategies for optimizing treatment in this complex population. The report provides the first clinical treatment strategies for managing older patients with HIV, making it an invaluable resource to clinicians caring for aging and older adults infected with the virus.

The HIV & Aging Consensus Project was led by Wayne McCormick, MD, MPH, Director, AGS Board of Directors, and Professor of Medicine, University of Washington School of Medicine, Seattle, and Jonathan Appelbaum, MD, AAHIVS, Director, Internal Medicine Education, Florida State University College of Medicine, Tallahassee. The report notes that while some HIV-positive patients in their 70s are robust, active, and aging successfully, many adults between 50 and 65 years of age are “experiencing high rates of comorbid illnesses.” These include liver disease, cardiovascular disease, kidney impairment, non–AIDS-related cancer, osteoporosis, neurocognitive decline, and frailty. The report includes chapters outlining strategies for reducing risks of, screening for, initiating treatment of, and monitoring of these and other HIV- and age-associated health problems in comorbid and multimorbid middle-aged and older patients. It also includes helpful and relevant chapters about immunizations, sexual health, and advance directives.

Throughout, the report incorporates and reflects what its authors describe as key “lessons from geriatrics.” Among other things, the strategies reflect geriatric medicine’s complex understanding of frailty and disability in later life—an understanding that recognizes the diverse, often overlapping contributors to both. The strategies also reflect geriatric medicine’s approach to standard screening and treatment guidelines, which are based on the needs of populations free of multimorbidity and may not be appropriate for older patients with HIV or AIDS. In addition, the strategies reflect our focus on syndromes rather than on individual diagnoses. “[It] may be more important to identify organ systems at risk rather than labeling all diagnoses present in an individual,” the authors note. “Some diagnoses (eg, vitamin D deficiency) may never become symptomatic, whereas organ system failure is always associated with substantial morbidity and mortality.”

Acknowledging that “there remain substantial gaps” in the knowledge base, the authors plan to continually update the strategies on an interactive Website where practitioners and researchers can report on their work with older HIV-positive patients. Additional information about the project’s efforts is available on the AAHIVM Website at www.aahivm.org.

You can also learn more about the project and report at the AGS Annual Scientific Meeting, which will run from May 3 through 5, in Seattle, WA. A workshop slated for May 3 will be dedicated to the report and include presentations by Dr. McCormick; Kevin P. High, MD, AGS member, Wake Forest School of Medicine; and Kelly A. Gebo, MD, MPH, Johns Hopkins University. I hope you can attend.