Clinical Geriatrics

Case Presentation
Mrs. H was a pleasant 93-year-old African-American woman who presented to her primary care physician for fatigue, pruritis, and weight loss of 40 pounds over 6-8 months. Her medical history included depression, hypertension, arthritis, stroke, and diverticulitis. At the time of her presentation, her medications included paroxetine, hydrochlorothiazide, and aspirin. Mrs. H’s physician did an extensive work-up that revealed a positive HIV enzyme-linked immunosorbent assay (ELISA) and positive rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests. The patient was told she “had AIDS and was going to die.” At the time of diagnosis, Mrs. H had a CD4 of 152 and an HIV viral load of 110,000. She denied known risk factors for HIV. She had been married for several decades, but her estranged husband had died several years prior to diagnosis, and she was not sure of his cause of death. Mrs. H had also lost a son to AIDS several years earlier.

A family member arranged for the patient to come to the Johns Hopkins Hospital emergency department, and she was admitted to the medical service. Mrs. H was started on highly active antiretroviral therapy (HAART) with a dosage adjustment for her diminished renal function; as renal function improved, dosing was frequently re-adjusted. The patient also had poor eyesight and difficulty swallowing large pills, both of which had a negative impact on her ability to tolerate HAART. Several times, she became noncompliant secondary to side effects such as abdominal pain and nausea. Over time, the team used altered dosing and scheduling to reduce side effects, used liquid formulations for some medications, and met with family members to help them with organizing medications. Mrs. H also was limited in her ability to cook due to poor eyesight and some motor dysfunction from stroke, and failed to gain weight. She was provided with nutritional supplements and nutritional counseling, and had significant recovery of her baseline weight. Paroxetine was tapered with no recurrence of depression.

Mrs. H is now age 96, and has a CD4 of 339 and a viral load of 1700. Her ongoing diverticulitis and arthritis are more of a concern for her than HIV, and she is comfortable with her HAART regimen, with only minimal side effects.

Introduction
As the world struggles to find solutions to the AIDS pandemic, in developed countries HIV infection has largely become a chronic, treatable disease as a result of the discovery of HAART. At least one-tenth of people living with HIV/AIDS in the United States are over the age of 50, a percentage that is likely to increase as infected persons live longer.¹ In addition, a new trend has shown an increase in new HIV diagnoses in individuals over the age of 50.² This population is poorly described. The older population with HIV/AIDS has an extremely complicated picture, with many patients having complications of HIV, adverse effects from antiretroviral treatment, mental illness, substance abuse, and multiple medical comorbidities. Studies in both older and younger patients with HIV/AIDS tend to exclude patients with comorbidities, and provide an inadequate description of the barriers to effective treatment. A relative paucity of data is available about HIV/AIDS in older populations (age > 50), with virtually no data on patients older than age 65. The number of elderly people with HIV/AIDS should be expected to grow. It is not known if data gathered in younger patients can be extrapolated to an older age group, and there are clear differences that need to be addressed in the geriatric population with HIV/AIDS.

A critical distinction is also missing from the HIV/AIDS literature: Most work fails to delineate older adults with new infections from old infections in adults who have aged with HIV/AIDS.