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HIV, Aging, and the Immune System

Premature aging among HIV-positive people is actually related to premature aging of the immune system, which leads to a condition called immunosenescence. Premature aging of the immune system begins with immune activation, a short-term process that stops when wounds heal, or when recovery from an infection is complete. After decades of exposure and response to a variety of infections, a tired immune system works harder, but is less effective, causing a state of chronic inflammation. Researchers have linked chronic inflammation with age-associated conditions in the general population, including frailty, cardiovascular disease, bone loss, and cancer.49,50,51

Some chronic viral infections, such as Epstein-Barr, cytomegalovirus and HIV cause ongoing immune activation.52,53 In PLWHA, immune activation and inflammation do not fully resolve with use of ART.54,55 Immune activation and inflammation cause immune dysregulation—an immune response that is too strong, or too weak—and immunosenescence, which is “an impairment in immunity as a result of age-associated changes in function in a variety of cells; it is a phenomenon of decreased function, involving changes to both innate and adaptive immunity and a dysbalance between the two arms.”53 Immunosenescence is seen in the elderly and in people with HIV.56,57

The risk for polypathology (the presence of at least two age-associated conditions, such as cardiovascular and kidney disease, hypertension, diabetes, and bone fracture) is similar for an HIV-positive person who is 40 years old and a 55-year-old HIV-negative person.44 As the incidence of AIDS-related malignancies has dropped due to the immunological benefits of antiretroviral therapy, the incidence of non-AIDS-related malignancies has increased among the aging population of PLWHA.46,47,48 As Telzak explains,

One of the most recent and important contributions of HIV medicine is how it has informed all of medicine about the negative outcomes associated with ongoing inflammation, such as diabetes, liver, kidney, and cardiovascular disease. Though still very much in the early stages of study, this might have very broad implications; it could revolutionize how people think about early intervention for diseases, and that there may be unifying risks for many seemingly different kinds of diseases. In many ways, the field of HIV may really be onto something that could have a great impact on medicine.

Photo of older man.

Researchers are working to determine the contributions of HIV itself, long-term use of antiretroviral therapy, family history, and lifestyle to premature aging. At the same time, clinicians are working with their patients to prevent and manage these conditions. The good news is that ART is effective in suppressing HIV, regardless of a person’s age. However, immune recovery is known to be slower in older people, leaving older patients who are diagnosed with a low CD4 cell count especially vulnerable to a blunted CD4 response.

HIV Treatment Guidelines: Recommendations for Older Patients

The March 2012 Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents now includes a section on key considerations when caring for older HIV-infected patients. It recommends initiation of ART in all patients over 50 years of age regardless of CD4 cell count, due to a greater risk for non-AIDS related complications and potentially blunted immunological response to ART.58

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