icon-folder.gif   Conference Reports for NATAP  
 
 
 
 
Caring for Older Adults [aging] with the Human Immunodeficiency Virus....."advance care planning is essential in older adults with HIV"
 
 
  Download the PDF here
 
------------------------
 
75% Predicted will be frail in 14 years, 60% frail now among older aging HIV+ and predicted 40% will have to be confined to old age homes as they will be disabled IWCADRH: Future challenges for clinical care of an ageing population infected with HIV: a "geriatric-HIV" modelling study - [Healthcare Costs].... Very Sobering Analysis go Aging in HIV+....60% frail - (09/15/16)
 
-----------------------
 
from Jules: the Am Geriatric Association published this yet The White house & the NIH have yet to prioritize the needs for these aging disabled patients beyond just research. Their needs go far beyond just research into inflammation medical interventions, yet these needs are ignored by The White House & the NIH. The HIV/AIDS Strategy & the Ryan White Care Act embraced by many including the political minded federal HIV staffers at the CDC, the NIH, & the White House need to embrace these aging problems & integrate them into policy discussions surrounding the HIV/AIDS Strategy, the RWCA and HRSA, AND if they don't the economic healthcare challenges of the large bolus of aging patients will rear its head soon. It costs more to provide healthcare for comorbidities than ART and these costs will emerge soon as a big issue & perhaps it is then after a number of years when this problem will get recognized. i brought HCV & HCV/HIV to the attention of many in 1998, ahead of its time, and brought aging to recognition & attention 10 years ago, also ahead of its time, and now I guess again ahead of its time I raise these concerns, don't let these patients languish & die before this gets the proper attention.
 
-----------------
 
Caring for Older Adults with the Human Immunodeficiency Virus ....."advance care planning is essential in older adults with HIV".....
 
"With increasing disease burden, individuals with HIV with multimorbidity are also at risk of fragmentation of or contradictions in care plans because of involvement of multiple clinicians in multiple settings
.....increasing proportion of older adults is living with HIV, and these adults differ from their younger counterparts in many ways, including risk of late or underdiagnosis, impaired immunological recovery, differing antiretroviral toxicities, and greater multi morbidity.......The geriatrics approach of caring for the whole person should guide management of diseases in older adults with HIV, incorporating aging phenotypes, interactions with multimorbidity, and individual preferences into person-centered care plans
 
Each older adult with HIV is a unique and complex individual. They cannot be described fully using one-dimensional classifications, such as chronological age or single disease entities. Aging occurs at different rates in different individuals and within the same individual in different organs, resulting in different aging phenotypes that chronological age alone cannot predict. In addition, viewing individuals with HIV from a single disease perspective ignores the importance of multimorbidity and the often multifactorial nature of their diseases. Most importantly, different individuals have different goals and preferences. Consequently, applying disease-centric guidelines uniformly to every individual without taking into account aging phenotypes, multimorbidity, or individual preference ignores the unique care needs of each individual and may increase treatment burden without improvements in mortality or quality of life.
 
Older adults with HIV have higher burdens of cardiovascular, metabolic, pulmonary, renal, bone, and malignant diseases.....áIt is likely that factors related to lifestyle common in individuals with HIV and chronic HIV infection, such as ART toxicity and polypharmacy, microbial translocation, and changes in inflammation and immune activation, contribute to multimorbidity,[16] with longer duration of severe immunodeficiency (CD4 count <200 cells/μL) correlating with higher comorbidity burden....
 
toxicities related to ART caused by age-related changes in physiology and increased multimorbidity. Physiologically, older adults have age-related declines in renal and hepatic function, the primary metabolic pathways for drug detoxification. Moreover, many individuals have comorbidities that alter drug metabolism (e.g., hepatitis C coinfection causing liver dysfunction) or necessitate multiple medications that increase the likelihood of drug-drug and drug-disease interactions.
 
IDSA recommends baseline bone densitometry (DXA) screening for osteoporosis in postmenopausal women and in men aged 50 and older with HIV.....risk of osteoporosis, including smoking, alcohol abuse, glucocorticoid therapy, low physical activity, immune dysfunction, persistent inflammation, and side effects of antiretroviral medications.....cancer screening unrelated to acquired immunodeficiency syndrome (AIDS) such as mammography annually in women with HIV aged 50 and older and colorectal cancer screening in individuals with HIV aged 50 and older with average risk and greater than 10-year life expectancy, older adults with HIV should continue to be screened for AIDS-related malignancies......Cognitive impairment in individuals with HIV is associated with older age and lifestyle and HIV-related risk factors.áNeither the CDC nor the IDSA offers guidelines on HIV-associated neurocognitive impairment, although the European AIDS Clinical Society guideline provides an algorithm for its diagnosis and management......Age is also a risk factor for peripheral neuropathy.ápain should be considered the fifth vital sign and should be assessed at every visit......Polypharmacy in older adults with HIV is more prevalent because of greater multimorbidity, multiple HIV-related factors affecting cytochrome P450 isoenzymes and renal function, and underrepresentation of older adults with HIV in pharmacokinetic studies. Polypharmacy in individuals with HIV may contribute to medication fatigue, nonadherence to ART, falls, and poor medication quality prescribing.....research on the effects of substance use in elderly adults with HIV is limited, evidence in younger cohorts suggests deleterious outcomes including poor medication adherence, end-organ damage, risky sexual activity, psychiatric comorbidities, adverse social consequences such as criminal activity or homelessness, malignancy, cognitive impairment with resulting injuries such as falls and fractures, and overall mortality."
 
á-----------------------------------
 
Caring for Older Adults with the Human Immunodeficiency Virus
 
Journal of the The American Geriatrics Society
 
29 September 2016
 
Aroonsiri Sangarlangkarn, MD, MPH,* and Jonathan S. Appelbaum, MD From the *HIV Netherlands Australia Thailand Research Collaboration,áThai Red Cross AIDS Research Centre, Bangkok, Thailand; and Department of Clinical Sciences, Florida State University College ofáMedicine, Tallahassee, Florida.
 
Abstract
 
Increasing proportions of older adults are living with the human immunodeficiency virus (HIV). It is estimated that more than 50% of individuals with HIV in the United States are aged 50 and older. Part of this group consists of individuals who have aged with chronic HIV infection, but a large proportion also results from new HIV diagnosis, with approximately 17% of new HIV diagnoses in 2013 occurring in individuals aged 50 and older. Although many of the recommendations on management of HIV infection are not age-specific, individuals with HIV aged 50 and older differ from their younger counterparts in many aspects, including immune response to antiretroviral therapy, multimorbidity, antiretroviral toxicities, and diagnostic considerations. This article outline these differences, offers a strategy on how to care for this unique population, and provides special considerations for problem-based management of individuals with HIV aged 50 and older.
 
The prevalence of human immunodeficiency virus (HIV) infection in the older population is increasing for two reasons: persons with known HIV infection are living longer, and newly acquired infections continue to occur in older people.á
 
Currently, more than half of all people living with HIV in the United States are aged 50 and older,[1] and approximately 17% of new HIV diagnoses occur in people aged 50 and older.[2]
 
The most common mode of HIV transmission in adults aged 50 and older is through sexual contact.[3] In men, male-to-male sexual contact is the most common transmission risk,[2] whereas heterosexual contact is the most common in women. This may be due to a false sense of security among older adults, who view sexually transmitted infections (STIs) as a condition of the young and may forgo safe-sex practices based on this perception.[4] They may also forgo barrier contraceptives when unwanted pregnancy is no longer a concern. Even though sexual exposure is the most common mode of HIV transmission in individuals with HIV aged 50 and older, safer-sex behavioral campaigns have not been inclusive of older adults,[5] and the Centers for Disease Control and Prevention (CDC) recommends routine screening for HIV only up to the age of 64.[6] Injection drug use also remains a significant risk factor for transmission of HIV in older adults.[7]
 
Accelerated or Accentuated Aging in Older Adults with HIV
 
For many years, there has been a debate surrounding how HIV infection affects the aging process: Acceleration (causing the development of certain age-associated comorbidities at an earlier age) or accentuation (increasing certain age-associated comorbidities at any given age). These age-associated comorbidities include conditions such as coronary artery disease, cerebrovascular disease, osteoporotic fractures, dementia, and frailty. Although traditional lifestyle risk factors such as smoking are more-prevalent in individuals with HIV, statistical adjustment for these traditional risk factors did not seem to affect the prevalence of some age-associated comorbidities, suggesting that HIV infection may have an independent effect on increasing multimorbidity.[8]
 
Current evidence seems inconclusive but suggests that the answer may depend on the types of clinical outcomes examined. For example, a few studies have suggested that the prevalence of frailty phenotype[9] and gait speed decline[10] may be accelerated in individuals with HIV. On the contrary, two other studies[11, 12] showed that, although the HIV-infected population had higher excess and relative rates of age-associated comorbidities such as cardiovascular diseases and chronic kidney disease, they did not occur significantly earlier after diagnosis of HIV or the start of antiretroviral therapy (ART) than in uninfected controls, suggesting a model of accentuated rather than accelerated aging. It is likely that more research on the basic science and the person-centered clinical outcomes of aging with chronic HIV infection is needed before firm conclusions can be made.
 
[ from Jules: there is no question for me that at least some comorbdities as underscored by the authors just above are accelerated in HIV, perhaps some may not be. But I am very familiar with the immune affects of HIV & I am convinced that HIV accelerates the aging immunity process, its just that perhaps for a few specific comorbidities perhaps earlier onset may not occur, but for sure HIV+ experience all comorbidities in much greater excess vs HIV- and in older HIV+ over around 65 the depleted immune system which occurs in all people is more depleted in HIV+ and in happens earlier & it has worse affects because the impact on the depleted aging immune system for many HIV+ will be greater & have more impact - thus the outcomes in the clinic we are seeing now - many patients experiencing prematurely & in their 50s & 60s higher rates of falls, osteopenia, osteoporosis, fractures, frailty, cognitive impairment. In the end this so-called debate of accentuation vs acceleration is useless & not meaningful clinically because what is true & real - is that patients ARE suffering excessive numbers of comorbidities & all too often at earlier ages. Many studies show the higher rates of multi-comorbidities & polypharmacy in HIV+ vs HIV-negatives. Of note a history of substance abuse & injection drug use, as week as other lifestyle behaviors, & certainly current use contributes much & is associated in HIV+ with frailty, cognitive impairment & falls & fractures. Diet, exercise & lifestyle behaviors also contribute. Nadir CD4 & current CD4 are contributors as well, and of course detectable viral load is an important negative factor. ]
 
Pathological Differences Between HIV-Infected Older Adults and Their Younger Counterparts
 
Immune Response to ART

 
Despite successful viral suppression with ART, older adults have less-robust immunological recovery than their younger counterparts, with associated greater mortality.[13] Research has shown that HIV infection and the process of aging produce inflammation and immune activation, which is more pronounced in individuals with HIV than in uninfected counterparts of the same age despite effective ART. This process, sometimes called "inflammaging," includes an increase in the number of CD8 T-cells, a shift in the balance of T-regulatory responses, and a generalized chronic inflammatory state associated with various cytokines, including interleukin-6, tumor necrosis factor alpha, and transforming growth factor beta.[14] This excessive immune activation and inflammation has been shown to hinder CD4 T-cell immune reconstitution and promote disease progression in individuals with HIV. Consequently, early HIV diagnosis and treatment in older adults with HIV are of great importance.
 
Greater Multimorbidity
 
Older adults with HIV are at greater risk of multimorbidity,[8] defined as the development of multiple chronic conditions that do not simply coexist but together interact to worsen health outcomes. Older adults with HIV have higher burdens of cardiovascular, metabolic, pulmonary, renal, bone, and malignant diseases.[8] For example, individuals with HIV are at greater risk of strokes and acute myocardial infarction.[15] It is likely that factors related to lifestyle common in individuals with HIV and chronic HIV infection, such as ART toxicity and polypharmacy, microbial translocation, and changes in inflammation and immune activation, contribute to multimorbidity,[16] with longer duration of severe immunodeficiency (CD4 count <200 cells/μL) correlating with higher comorbidity burden.[8]
 
Multimorbidity has important ramifications for health outcomes. It is associated with self-reported poor health, declines in self-rated health status, and greater mortality (adjusted odds ratio = 11.87, 95% confidence interval = 5.72-24.62).[17] With increasing disease burden, individuals with HIV with multimorbidity are also at risk of fragmentation of or contradictions in care plans because of involvement of multiple clinicians in multiple settings.[18]
 
Antiretroviral Toxicities
 
Older adults with HIV may have toxicities related to ART caused by age-related changes in physiology and increased multimorbidity. Physiologically, older adults have age-related declines in renal and hepatic function, the primary metabolic pathways for drug detoxification. Moreover, many individuals have comorbidities that alter drug metabolism (e.g., hepatitis C coinfection causing liver dysfunction) or necessitate multiple medications that increase the likelihood of drug-drug and drug-disease interactions. Current guidelines recommend that all individuals with HIV be treated with ART, regardless of CD4 count. The recommended ART regimens are listed in Table 1, with multiple combinations available in once-daily dosing tablet forms (Table 2).
 

table1

Integrase strand transfer inhibitors (INSTIs) have among the fewest side effects and drug interactions of all the antiretroviral medications, and the current International Antiviral Society-USA guidelines recommend only INSTI as the anchor drug in ART.[19] Boosted protease inhibitors are less favored for the initial treatment of HIV. They may cause considerable drug-drug interactions because they are potent CYP3A inhibitors and may increase serum lipids and lipodystrophy.
 
Nucleoside reverse transcriptase inhibitors continue to be components of a complete antiretroviral regimen. The major toxicities include renal and bone (tenofovir disoproxil fumarate) and cardiovascular (abacavir). A list of the common side effects and drug interactions is shown in Table S1. A newer formulation of tenofovir, tenofovir alafenamide, has been shown to have much less renal and bone toxicity.[20] Because cardiovascular events have been linked to abacavir use, it should be avoided when possible.
 
Diagnostic Considerations
 
Prior research has found that healthcare professionals often underestimate the level of sexual activity of older adults and their risk of STI exposure.[4] Moreover, many symptoms of early HIV infection mimic those of aging and may be difficult for practitioners to differentiate. Symptoms of acute HIV infection such as headache, loss of energy, loss of appetite, influenza-like symptoms, and weight loss are common in older adults, and a myriad of conditions associated with old age, such as malignancy and frailty, can cause them.
 
With inaccurate perception of HIV exposure risk and symptom mimicry, underdiagnosis and late diagnosis of HIV infection are common in older adults.[4] Late diagnosis is associated with delayed treatment, impaired response to ART, greater morbidity and mortality, lost opportunity to prevent onward transmission, and greater healthcare costs.[21] As a result, it is essential that clinicians maintain a high suspicion and routinely screen older adults for HIV, regardless of risk perception. Although CDC guidelines recommend routine screening up to the age of 64,[6] the rationale or research evidence for this age cutoff was not included, and continued screening in older adults should be considered, because risk perception may be inaccurate in this population. Based on cost-effectiveness, providers may consider risk-based testing[22] or screening up to age 75 if individuals are sexually active, and the prevalence of HIV in the population is greater than 1%.[23] They should alsoároutinely ask about risk factors related to HIV infection, including sexual behaviors and substance use. Future research should explore diagnostic yields of testing algorithms developed specifically for individuals with HIV aged 65 and older, because evidence in this age group is limited, and transmission patterns may differ from those in younger individuals with HIV.
 
Management Strategy for the Care of Older Adults with HIV
 
Each older adult with HIV is a unique and complex individual. They cannot be described fully using one-dimensional classifications, such as chronological age or single disease entities. Aging occurs at different rates in different individuals and within the same individual in different organs, resulting in different aging phenotypes that chronological age alone cannot predict. In addition, viewing individuals with HIV from a single disease perspective ignores the importance of multimorbidity and the often multifactorial nature of their diseases. Most importantly, different individuals have different goals and preferences. Consequently, applying disease-centric guidelines uniformly to every individual without taking into account aging phenotypes, multimorbidity, or individual preference ignores the unique care needs of each individual and may increase treatment burden without improvements in mortality or quality of life.
 
Understanding that not all 50-year-old individuals with HIV should be approached the same way, clinicians may use the Veterans Aging Cohort Study (VACS) Index[24] to distinguish between those who are aging well and those who may appear phenotypically older than their chronological age. The VACS Index creates a score consisting of preassigned points for age, routinely monitored indicators of HIV disease, and general indicators of organ system injury. It has been shown to assist clinician assessment of severity of illness[25] and predict cause-specific and all-cause mortality.[24] Based on prognosis predicted using the VACS index, clinicians can elicit individual preferences, identify diseases and risk factors that affect these goals, calculate the likely effects and lag time to benefit of various disease-centric guidelines on these goals, and use this information to prioritize interventions and guide shared decision-making with individuals and caregivers.[18] Indices of frailty or measures of physical function may also be used, because they have been shown to correlate with advanced HIV disease[26] and mortality.[27]
 
Special Considerations for Problem-Based Management of Individuals with HIV Aged 50 and Older
 
This section outlines problem-based practice guidelines specific to individuals with HIV aged 50 and older that should be considered in addition to usual HIV care in younger individuals, although because research on appropriate disease management specific to individuals with HIV aged 50 and older is limited, much of current problem-based clinical guidelines for this population extrapolate data from guidelines for uninfected adults of the same age. It is likely that, as more individuals with HIV age, and older adults with HIV become better represented in research trials, future problem-based guidelines for this population will need to be adjusted.
 
Immunizations
 
Live attenuated varicella vaccination, which has been approved in adults aged 50 and older without HIV can be given to adults with HIV without evidence of immunity with CD4 counts of 200 cells/μL or greater,[28] because no vaccine-strain varicella zoster virus infection has been documented in individuals with HIV with CD4 counts above this threshold.[29]
 
Although the CDC has no recommendation on zoster vaccine in individuals with HIV aged 60 and older with a CD4 count of 200 cells/μL or greater, it may be reasonable to vaccinate this group of individuals according to the Infectious Disease Society of America (IDSA) recommendation.[30]
 
A recent study showed superior immunogenicity in adults aged 65 and older who received high-dose inactivated influenza vaccine (IIV) than in those who received standard dosing. Similar results were shown in a small clinical trial of individuals with HIV aged 18 and older.[31] The CDC recommends high-dose IIV as an equivalent option to standard-dose IIV in adults aged 65 and older regardless of HIV status.[28] Live influenza vaccine should not be used in individuals with HIV.
 
Individuals with HIV aged 19 and older should receive 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23), but the interval between the two types of vaccine and the number of doses needed differ in individuals with HIV aged 65 and older. In pneumococcal vaccine-na´ve persons, PCV13 should be given first, followed by PPSV23 at least 8 weeks after. In persons who previously received PPSV23 at age 65 and older, only PCV13 should be given, at least 1 year after the prior dose of PPSV23. In persons who previously received PPSV23 before age 65, PCV13 should be given at least 1 year after the prior dose of PPSV23, followed by a second dose of PPSV23 at least 5 years after the prior dose of PPSV23[32] (Table 3).
 
Age-Related Sexual Changes
 
Older adults with HIV may experience menopause and hypogonadism, resulting in age-related sexual changes that affect sexual function and behaviors. For example, menopause may result in vaginal dryness, and freedom from unwanted pregnancy and the need for contraception may lead to lack of barrier protection and greater risk of STIs.
 
Consequently, providers should routinely ask about sexual history and symptoms and provide safe-sex counseling for older adults and their partners at every visit, because risk perception can be misleading in this population.
 
Although it is unclear whether age of onset of menopause differs between individuals with HIV and their uninfected counterparts, it is suspected that the transition through menopause for individuals with HIV differs.[33] First, HIV-related effects such as chronic inflammation may lead to ovarian dysfunction, resulting in altered natural history and symptoms of menopause in individuals with HIV. Moreover, the effect of estrogen depletion may compound the already-greater risk of dyslipidemia, cardiovascular disease, and osteoporosis in this population. Last, symptoms of menopause may be difficult to distinguish from those of other chronic illnesses in older adults with HIV, with research showing that providers and individuals themselves underrecognize menopausal symptoms.[33] Treatment options according to the IDSA guideline[30] are similar to uninfected individuals, with hormone replacement therapy recommended in women with severe menopausal symptoms but only for a limited period of time and at the lowest effective dose. Hypogonadism is common and occurs prematurely in men with HIV.[34] Diagnosis is challenging because symptoms of hypogonadism may overlap with those of other chronic illnesses commonly found in older adults with HIV. According to the IDSA guidelines,[30] morning serum testosterone level may be assessed in older men with HIV with low libido, erectile dysfunction, low bone mass or low-trauma fractures, hot flashes, or sweats. Low levels should be confirmed with repeat testing. Free testosterone measurement should be considered because of changes in sex hormone-binding globulin with aging. Treatment options are similar to those in uninfected individuals.
 
Hypertension
 
Goal blood pressure for elderly adults without HIV is controversial and presents a challenge for clinicians, with even less evidence to guide management in the population with HIV.
 
The Systolic Blood Pressure Intervention Trial (SPRINT) evaluated a subgroup of ambulatory uninfected adults aged 75 and older and demonstrated that a systolic blood pressure (SBP) target of less than 120 mmHg resulted in lower rates of cardiovascular events and death from any cause than a target of less than 140 mmHg.[35] There was no substantial difference in major adverse events, with only slightly higher rates of hypotension, syncope, and acute changes in renal function.[36] Nevertheless, the study was limited in multiple areas. First, it excluded individuals with diabetes mellitus, heart failure, prior stroke, and postural decrease in blood pressure. Homebound and institutionalized individuals were also excluded. With greater risk of frailty and multimorbidity in older adults with HIV, it is unclear whether or how these results should be applied, although with greater risk of metabolic diseases, stroke, and acute myocardial infarction in individuals with HIV with high blood pressure,[15] it could be argued that strict blood pressure control is especially warranted in older adults with HIV. Second, mean SBP achieved in the target group was 123 mmHg, suggesting that cardiovascular benefits can perhaps still be achieved at goals greater than 120 mmHg.[36]
 
Current hypertension guidelines for individuals without HIV have not taken SPRINT results into account, and there are no specific hypertension goals for individuals with HIV. The Eighth Joint National Committee recommends a blood pressure goal of less than 150/90 mmHg in adults aged 60 and older with hypertension and less than 140/90 mmHg for all adults with hypertension and diabetes mellitus or nondiabetic chronic kidney disease.[37] Based on the recent SPRINT results, providers may consider a stepwise approach, beginning with a SBP goal of less than 140 mmHg. If this is achieved without adverse effects, a lower SBP goal of less than 130 mmHg may be considered.[36]
 
Diabetes
 
Although primary care guidelines for the management of persons infected with HIV from the IDSA did not include age-specific glycemic goals for individuals with HIV, the American Academy of HIV Medicine and the American Geriatrics Society recommend a target glycosylated hemoglobin (HbA1c) of 8% for older adults with HIV with frailty, with less than a 5-year life expectancy, at high risk of hypoglycemia, or at high risk of polypharmacy.[38] This recommendation mirrors the guideline on standards of medical care in diabetes mellitus from the American Diabetes Association.[39] HbA1c may underestimate average blood glucose because of high red blood cell turnover in individuals with HIV, and new-onset or worsening diabetes mellitus may result from interactions between corticosteroid use (including nasal sprays or inhalers) and certain ART such as protease inhibitors boosted with ritonavir or cobicistat.
 
Osteoporosis
 
Certain lifestyle and HIV-related factors put individuals with HIV at higher risk of osteoporosis, including smoking, alcohol abuse, glucocorticoid therapy, low physical activity, immune dysfunction, persistent inflammation, and side effects of antiretroviral medications. Viral suppression should be achieved with ART, and modifiable risk factors should be addressed. For example, a switch from tenofovir disoproxil fumarate to tenofovir alafenamide[20] or supplementation with vitamin D plus calcium[40] may help reduce bone loss in individuals with HIV.
 
The IDSA recommends baseline bone densitometry (DXA) screening for osteoporosis in postmenopausal women and in men aged 50 and older with HIV.[30] Bisphosphonates may be considered as first-line treatment, with a follow-up DXA 1 year after to monitor response to therapy.
 
Malignancy
 
As with the general population, age is a risk factor for multiple types of malignancies in individuals with HIV. In addition to cancer screening unrelated to acquired immunodeficiency syndrome (AIDS) such as mammography annually in women with HIV aged 50 and older and colorectal cancer screening in individuals with HIV aged 50 and older with average risk and greater than 10-year life expectancy, older adults with HIV should continue to be screened for AIDS-related malignancies. According to the IDSA, cervical Papanicolaou tests should be performed in women with HIV at initiation of care, at 6 months, and then annually thereafter if results are normal. Men who have sex with men, women with a history of receptive anal intercourse or abnormal cervical Papanicolaou test results, and all individuals with HIV with genital warts should receive anal Papanicolaou tests annually. Although individuals with HIV are at greater risk of lung cancer, the current IDSA guidelines do not address this, and providers may adopt a screening strategy similar to that in the general population. Future research on cancer screening in individuals with should avoid recommendations focusing on age cutoff and build risk and cost-effectiveness models that incorporate aging phenotype, life expectancy, and care preferences in a whole-person approach.
 
Neurocognitive Disorders
 
Cognitive impairment in individuals with HIV is associated with older age and lifestyle and HIV-related risk factors. Individuals with HIV are susceptible to HIV-associated neurocognitive disorders (HAND) and other causes of cognitive impairment common individuals without HIV, such as Alzheimer's and vascular dementia. The absence of higher cortical dysfunction such as aphasia, agnosia, or apraxia helps distinguish HAND from Alzheimer's dementia, and background hypertension or episodes of lacunar strokes may indicate vascular dementia instead of HAND.
 
Neither the CDC nor the IDSA offers guidelines on HIV-associated neurocognitive impairment, although the European AIDS Clinical Society guideline provides an algorithm for its diagnosis and management.[41] For symptomatic persons without obvious confounding conditions, depression should be evaluated and treated. If problems persist, brain magnetic resonance imaging and cerebrospinal fluid (CSF) examination should be performed to exclude other causes of cognitive impairment. Individuals diagnosed with HAND should start ART if they are not already on a regimen or have ART optimized if CSF viral escape is detected.
 
Age is also a risk factor for peripheral neuropathy. As a result, pain should be considered the fifth vital sign and should be assessed at every visit. Trials of symptomatic and disease-modifying treatments for HIV-associated distal symmetric polyneuropathy have had limited success, and the Food and Drug Administration has not approved any treatments at this time.
 
Polypharmacy
 
Older adults with HIV are at greater risk of polypharmacy,[42] defined as taking medications that are inappropriate for the individual's medical condition, using medications that cause adverse drug events, or using incorrect dosing for the condition. Polypharmacy in older adults with HIV is more prevalent because of greater multimorbidity, multiple HIV-related factors affecting cytochrome P450 isoenzymes and renal function, and underrepresentation of older adults with HIV in pharmacokinetic studies. Polypharmacy in individuals with HIV may contribute to medication fatigue, nonadherence to ART, falls, and poor medication quality prescribing.[42]
 
To avoid polypharmacy, a medication review is recommended at every visit and a medication reconciliation annually.[38] Routine use of an up-to-date electronic resource such as Epocrates, Lexi-Comp, and www.hiv-druginteractions.org will help clinicians monitor the array of drug-drug interactions and needed dose modifications based on renal or hepatic function,[43] although changes to ART can be complex, and only providers with adequate expertise should make them. Although the Chronic Kidney Disease Epidemiology Collaboration glomerular filtration rate estimate is the most accurate for use in individuals with HIV on stable ART,[44] the Cockcroft-Gault calculated creatinine clearance remains the standard of care for medication dosing. Last, individuals should be encouraged to use a single pharmacy, preferably specializing in HIV with an integrated computer network.
 
Alcohol and Substance Abuse
 
Substance use disorders are more common in individuals with HIV, in younger and older populations alike.[45] Consequently, providers should routinely screen for alcohol and substance use in older adults with HIV,[30] because risk perception is often inaccurate in this population. Although specific research on the effects of substance use in elderly adults with HIV is limited, evidence in younger cohorts suggests deleterious outcomes including poor medication adherence, end-organ damage, risky sexual activity, psychiatric comorbidities, adverse social consequences such as criminal activity or homelessness, malignancy, cognitive impairment with resulting injuries such as falls and fractures, and overall mortality.
 
Special considerations may be given to the increasing legalization of marijuana in the United States, because it is likely that this will present challenges to HIV providers. Beneficial effects of marijuana in individuals with HIV may include better mood, less anxiety, improved appetite, less nausea, and less pain,[46] although smoking marijuana may cause cough, phlegm production, wheezing, and airflow obstruction.[47] Of particular concern in older adults with HIV, smoking marijuana may also lead to greater risk of lung cancer[48] and impaired cognition.[49] Researchers and policy-makers must therefore provide clear evidence and guidelines, especially in elderly individuals with HIV, before legalization causes unintended adverse effects in this vulnerable population. Despite limited evidence of effective interventions for substance abuse disorders in elderly adults with HIV, providers may explore brief, targeted counseling combined with pharmacotherapy, because most medication options are deemed safe in the setting of ART.[45]
 
Advance Care Planning
 
With greater risk of neurocognitive impairment and debility from multimorbidity, advance care planning is essential in older adults with HIV. Without appropriate documentation of a surrogate decision-maker for health care and finances, decisions regarding emergence or end-of-life care may be legally deferred to estranged family members who are unaware of the individual's preferences or HIV status.[50] Although there are no specific guidelines for individuals with HIV, the U.S. Department of Health and Human Services recommends advance care planning in all individuals with chronic life-limiting illness or anyone aged 55 and older regardless of health status.
 
Conclusion
 
An increasing proportion of older adults is living with HIV, and these adults differ from their younger counterparts in many ways, including risk of late or underdiagnosis, impaired immunological recovery, differing antiretroviral toxicities, and greater multimorbidity. Each older adult with HIV is a unique and complex individual, and disease-centric guidelines should not be applied the same way in every individual. The geriatrics approach of caring for the whole person should guide management of diseases in older adults with HIV, incorporating aging phenotypes, interactions with multimorbidity, and individual preferences into person-centered care plans. The VACS Index may be used to identify aging phenotypes and can provide useful prognostic information to help providers prioritize interventions and guide shared decision-making with individuals and caregivers.