In 2011, the HIV and Aging Consensus Project’s Recommended Treatment Strategies for Clinicians Managing Older Patients with HIV was released. It recommends:
- Initiation of ART for all patients older than 50, with a CD4 cell count below 500 cells/mm3
- Initiation of ART at any CD4 cell count for patients with AIDS-defining illness, HIVAN, or chronic HBV infection.
- Consideration of ART initiation for patients over age 50 with a CD4 count greater than 500 cells/mm3; factors favoring treatment initiation include plasma HIV RNA levels greater than 50,000 copies/ml, greater than 100-point decline in CD4 count in prior 12 months, or risk factors for cardiovascular disease.59
Polypharmacy—the use of multiple medications—is common among PLWHA on ART, especially those over 50 years of age.60 Clinicians can minimize the risk of drug–drug interactions from polypharmacy by carefully selecting antiretroviral agents. Clinically significant drug–drug interactions—requiring close monitoring or dose adjustment—are more likely to occur with protease inhibitor-based regimens than non-nucleoside inhibitor- or raltegravir-based regimens, and in people who are taking less than 5 medications in addition to antiretroviral therapy.61,62 In addition, drug–drug interactions between antiretroviral agents, drugs used to prevent or treat opportunistic infections, insulin and insulin sensitizing medications for diabetes, antihypertensive agents, lipid lowering drugs, methadone, and recreational or psychotropic drugs—many of which share a metabolic pathway—may occur.63,64,65,66,67
Cardiovascular disease (CVD) has become a leading cause of death among HIV-positive people; family history, lifestyle, and inflammation from HIV itself contribute to the risk. Smoking and low levels of high-density lipoprotein cholesterol (HDL-C), which are risk factors for CVD, are more prevalent among PLWHA than the general population.68,69,70,71 Although benefits of ART outweigh the risks, certain antiretroviral agents cause metabolic changes, such as lipid elevation, insulin resistance, visceral adiposity, and subcutaneous fat loss.72,73
Ryan White HIV primary care providers play a life-saving role in prevention and management of CVD among PLWHA. Strategies for CVD risk management do not differ by HIV status (see Box “ABCs of CVD Risk Management”). Clinicians can work with patients to reduce the risk of CVD through changes in diet, regular exercise, and pharmacologic therapy. Smoking cessation is especially important, since HIV increases the risk for chronic obstructive pulmonary disease and lung cancer.74,75,76 Quitting smoking has been shown to decrease the risk of heart attack and stroke among people with HIV/AIDS.77 Providers can play an important role in helping patients to quit: When trained clinicians provide smoking cessation plus counseling and pharmacotherapy, patients are more likely to stop smoking and less likely to relapse.78