Elder Care Interprofessional Provider Sheets

HIV/AIDS: Implications for Older Adult Patients

Cristina Gruta, Pharm.D. and Ronald H. Goldschmidt, M.D., University of California, San Francisco

November 2017

TIPS FOR DEALING WITH HIV/AIDS IN OLDER ADULTS
  • Don't forget that nearly 1 out of 5 cases of HIV occurs in older adults.
  • Screen all adults for HIV, regardless of age, on an annual basis if they have HIV risk factors.
  • Be alert for signs and symptoms of HIV, which can be similar to those that occur in older individuals without HIV infection: fatigue, dementia, herpes zoster, pneumonia, weight loss, and weakness. 
  • When starting new medications in patients taking anti-retroviral (ARV) therapy for HIV, be sure to check for potential drug interactions.  You can do this by calling the HIV Management Line at 800-933-3413.

In 2014, an estimated 45% (428,724) of persons infected with HIV in this country were 50 years or older (Figure 1).  

Missed opportunities for preventing and detecting HIV infection in older adults occur because the older population has traditionally not been identified as an at-risk group. At-risk behaviors that carry risk of HIV transmission, however, occur in older adults as well as in the traditional younger high-risk groups. In addition, some older adults have undiagnosed HIV infection based on risks incurred at an earlier age, including men who have had unprotected sex with men, men and women having unprotected heterosexual intercourse, and injection drug use. The Centers for Disease Control and Prevention (CDC) recommends screening all adults up to age 64 at least once, regardless of risk factors. Beyond that, annual screening is recommended for all adults, including those 65 and older, if they have ongoing risk factors.

To make testing more accessible and feasible in busy health care settings, "opt-out testing" is the recommended approach to routine screening. This means HIV testing is a part of routine care unless a patient declines ("opts-out of") testing.

Delayed Diagnosis

When older Americans are diagnosed with HIV infection it is often later in the course of the infection. Late diagnosis places patients at significant risk of opportunistic infections, other complications of HIV infection, and death. Common reasons for delayed diagnosis include difficulty recognizing symptoms and signs of chronic HIV/AIDS, which can mimic those of illnesses typically associated with aging: fatigue, dementia, herpes zoster, pneumonia, weight loss, and weakness (Table 1). Keeping HIV in the differential diagnosis when older adults have these symptoms is important for timely diagnosis and will remain critical to improving outcomes by facilitating earlier treatment.

Table 1. Signs and Symptoms of HIV That May Be Overlooked in Older Adults

  • Dementia
  • Fatigue
  • Herpes Zoster
  • Pneumonia
  • Weakness 
  • Weight Loss

Higher Rates of Chronic Disease

Recent research also highlights that older HIV patients, as compared with their non-infected peers, suffer higher rates of chronic diseases traditionally associated with older age, such as cardiovascular disease, cancers of all types, renal insufficiency, hepatic disease, cognitive deficits, and metabolic disorders such as diabetes and dyslipidemia. This may be due partly to the chronic inflammatory state caused by HIV infection, as well as toxicity of chronic antiretroviral medications.

Higher Rates of Drug Side Effects

Older patients are at particular risk of side effects from antiretroviral drugs because of interactions with medications used to treat other chronic illnesses (Table 2), age-associated declines in kidney and liver function, and changing proportions of body fat to muscle mass. Dose adjustments are often needed.  Consider consultation with the HIV Management Line (800-933-3413) to review medication profiles of your older HIV-infected patients.

Implications for Older Adults

When the HIV epidemic was recognized in the 1980s, its first decade marked devastation for patients diagnosed with HIV.  At initial diagnosis, patients had already suffered years of immunocompromise, presented with late-stage complications, and succumbed to the disease a relatively short time after diagnosis. We have come a long way since those days, and now, in the era of "highly active antiretroviral therapy," HIV has become a manageable and treatable chronic illness with near-normal life expectancy. With more widespread awareness and earlier diagnosis, older patients can lead healthy lives with a life expectancy that closely approaches that of their uninfected peers. 

Table 2. Commonly Prescribed Antiretroviral Drugs (ARVS) And Common Medications That Interact With ARVS

Note: For questions about drug interactions, call the HIV Management Line at 800-933-3413

Commonly Prescribed ARVs Red Flag Drug Classes - Can Interact with ARVs
Protease Inhibitors (PIs)
  • Atazanavir + ritonavir or atazanavir/cobicistat
  • Darunavir + ritonavir or darunavir/cobicistat
Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
  • Efavirenz
  • Etravirine
  • Rilpivirine
Integrase Strand-Transfer Inhibitors (INSTIs)
  • Dolutegravir
  • Elvitegravir (co-formulated with cobicistat/tenofovir/emtricitabine)
  • Raltegravir
  • Acid reducing agents
    antacids, H2 receptor antagonists, proton pump inhibitors may be contraindicated or have dose limits when given with certain ARVs
  • Anti-arrhythmics
  • Anticoagulants
    including novel oral agents
  • Anticonvulsants
  • Antihyperglycemics
    metformin, certain SGLT2 inhibitors or DPP4 enzyme inhibitors
  • Antiplatelets
    vorapaxar and ticagrelor
  • Antidepressants (most)
  • Azole antifungals
  • Calcium Channel Blockers
  • Clarithromycin
  • Corticosteroids inhaled and systemic
    some options may be contraindicated
  • Erectile dysfunction agents
    adhere to dose limits if given with PIs and elvitegravir/cobicistat
  • Hepatitis C medications
    direct-acting agents (some)
  • Rifamycins
    rifampin, rifabutin
  • Statins
    simvastatin, and lovastatin are CONTRAINDICATED with PIs and elvitegravir/cobicistat

Acknowledgement: The authors gratefully acknowledge the contributions of Mina Matin, MD on earlier versions of this Elder Care.

References and Resources

Telephone Call-In Information Lines

  • National HIV/AIDS Telephone Consultation Service.  800-933-3413 - for information on HIV testing, antiretroviral treatment, resistance testing, drug interactions, management of opportunistic infections, and primary care of persons with HIV/AIDS.
  • National Clinicians' Post-Exposure 24-hour hotline. 888-448-4911 - for information on managing occupational exposures