6.10 HIV in Older People
In this episode we will be looking at the diagnosis of HIV and its impact on older people.
To make the episode we have had the help of some wonderful friends of ours, they are:
Guest Faculty:
Dr Tom Levett – Consultant Geriatrician Royal Sussex Hospital – Brighton
Heather Leake-Date – Pharmacist, Elaney Yousseff – Health Services Researcher and Eileen Nixon, HIV Nurse Consultant
Broadcast Date: 11th December 2018
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Iain:
Jo:
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Learning Objectives
Knowledge:
- To understand the demographics of HIV infection in UK
- To understand barriers to HIV diagnosis in older adults
- To understand the challenges facing older adults with HIV
Skills:
- To feel empowered and able to discuss HIV testing with older adults
Attitudes:
- To understand how stigma is still impacting on the life and care of people living with HIV
- To see HIV as a chronic disease that older adults may live with
Show Notes
Click here and follow the link for a pdf of the show notes
Definitions:
The human immunodeficiency virus (HIV) is a virus which infects cells of the immune system, destroying or impairing their function. Infection with the virus results in progressive deterioration of the immune system, leading to “immune deficiency.”
The immune system is considered deficient when it can no longer fulfil its role of fighting infection and disease. Infections associated with severe immunodeficiency are known as “opportunistic infections”, because they take advantage of a weakened immune system.
Acquired immunodeficiency syndrome (AIDS) is a term which applies to the most advanced stages of HIV infection. It is defined by the occurrence of any of more than 20 opportunistic infections or HIV-related cancers.
Important to note that individuals are consider older with HIV when they reach 50. This is historical based on data collection methods primarily used by the Centre for Disease Control (CDC) in the US. It aligns with previous definitions of older age used by the WHO. This cut off is still used across the research literature and by Public Health England (PHE) in their data outputs.
Key Points from Discussion
Demographics
As of 2016:
- 91,987 individuals diagnosed with HIV and accessing services
- An estimated 10,400 with undiagnosed HIV (this is a decrease)
- HIV prevalence is 1.6/1000 people (0.16%)
- There were 5164 new diagnoses in 2016, which is a decrease from previous years
- Decreases seen in diagnoses among gay and bisexual men (PrEP), black Africans (changes to migration patterns)
- Static in white heterosexuals but low numbers
- 38% of those with HIV accessing services were aged over 50 years, which has increased from 17% in 2007.
- 19% of all new HIV diagnoses were in people aged over 50 years, up from 9.6% in 2007
And Elaney Youssef has done some research in this area (to record but replace with interview if possible)
There has been a decline in the number of new HIV diagnoses in the UK, mainly among MSM. Newest data from Public Health England suggests a 31% decrease in new diagnoses among MSM between 2015 and 2017. However, the number and proportion of new diagnoses in people aged 50 and above is increasing. Although the numbers aren’t huge (around 900 (873) were diagnosed in 2017), this suggests that there may be unique barriers to testing in the older group. We need to better understand this before we can design interventions to increase testing in this group.
So why are we seeing an increase in older adults with HIV?
- The success of Anti-Retroviral Therapy (drugs) in prolonging lifespan of those on treatment
- Acquisition of new disease later in life
- Decreasing HIV incidence in younger individuals shifts burden of disease to older ages
- Tavoschi et al looked at notifications of new HIV diagnoses made to surveillance reporting systems across Europe. The UK, along with Norway were the only countries to see a decreasing trend on new diagnoses in younger adults and increasing in older adults.
Tavoschi et al. Lancet HIV 2017
Why are adults acquiring HIV later in life?
- Later life divorce
- Access to sex- The internet, ‘sex tourism’, people are less risk conscious on holiday
- Treatments for erectile dysfunction
- Lack of safe sex messages or need for condoms – less likely to use
- Difficulties negotiating safer-sex
- Increased biological susceptibility to infection
Does age matter?
- In older adults
- Increased risk of late diagnosis and advanced immunosuppression
- Late diagnosis defined as CD4 count <350 within 91 days of diagnosis
- In 2016 31% of those aged 15-24 were diagnosed at this stage compared to 57% of those aged 50-64 and 63% if >65.
- Those diagnosed late have a 10-fold increase in experiencing an AIDS defining illness within a year of HIV-diagnosis
- Late diagnosis and diagnosis at older age associated with:
- Faster rate of HIV progression (CD4 count decline)
- Increased occurrence, and decreased time to, AIDS defining events
- Higher risk of death
- Those aged 50 years and over had a much higher risk of death in the year following diagnosis than those under 50, which increased further for those over 65 irrespective of CD4 count.
- But worse if late diagnosis (so CD4<350) and over 50 where 1/14 died within the year of diagnosis.
- Also implications for onward transmission and higher healthcare costs if diagnosed late.
- Increased risk of late diagnosis and advanced immunosuppression
Being diagnosed late with HIV means an individual has likely been living with undiagnosed infection for up to 5 years, which has significant implications for onward transmission, especially since the majority of individuals are estimated to have been infected by an undiagnosed source.
Older individuals are also more complex to treat, they likely have pre-existing comorbidity and poly-pharmacy issues. As a result of this and increased morbidity, the cost to healthcare services is higher.
It has been estimated that for heterosexual individuals, earlier HIV diagnosis would reduce short term mortality (death within one year of diagnosis) by 56% and all morality by 32% (Chadborn et al 2006)
How does having HIV affect older adults?
- 58% were defined as being on or below the poverty line
- Social care not meeting the needs of older adults with HIV
- Co-ordinated long-term condition management, with support to self-manage, is essential for people living with HIV aged 50 and over
- GPs need to step up to the mark in supporting people living with HIV aged 50 and over
- Many people living with HIV aged 50 and over face social isolation and loneliness
- People living with HIV aged 50 and over experience HIV self-stigma
- Older women are also affected by HIV – one third, ‘invisible face of HIV in UK’, less likely to report high levels of wellbeing and were on average on lower incomes.
Uncharted Territory A report into the first generation growing older with HIV January 2017
HIV testing – who and when should we be testing?
- Anyone with an Indicator diseases – this is a broad spectrum of conditions known to be associated with HIV or may be AIDS defining, which when seen should prompt HIV testing. A lot of overlap with conditions/symptoms/signs/blood abnormalities that we see in older adults so this can be difficult to implement.
- e.g. pneumonia, thrombocytopenia
- Enhanced screening where young people and adults (defined as over 18) present to hospital or newly register with GP are offered an HIV test in areas of high/extremely high HIV prevalence (nb: UK prevalence 1.6/1000 (aged 15-59)).
- High prevalence 2-5/1000 = 79/325 local authorities (PHE document gives areas)
- Extremely high prevalence >5/1000 = 20/325 local authorities, 18 in London (Lambeth highest) and outside Brighton and Hove (8/1000) and Manchester (6.4/1000)
- Not sure how many areas are offering this however.
- NICE quality standard, HIV testing: encouraging uptake.
Why might older adults be diagnosed late? i.e. barriers to testing.l
- Barriers to testing for HIV in older age is complex but I will talk about some of the big issues I found…
- Sexual lifestyles and behaviours have changed over time. An increase in life expectancy and successful ageing means that older individuals increasingly value sexual fulfilment into older age. Sexuality is now considered a factor contributing to successful ageing and remains important to quality of life. The latest National Survey of Sexual Attitudes and Lifestyles (NATSAL) analysis indicated that although the frequency of sexual activity and the range of sexual practices decrease with age, the majority of adults, regardless of age, are sexually active.
- Despite this, there is the perception of asexuality in older age; that older people don’t engage in sexual activity. This is a stigma placed on older people and often results in HCP perceiving them not to be at risk of HIV which may have an impact on whether they offer older individuals an HIV test
- Many people have a stereotype of the kind of person at risk of HIV and my research has suggested that a lot of this was informed by the early HIV/AIDS campaigns (MSM, young people, IVDU, “promiscuous”)– and as a result, older people don’t feel at risk of HIV either. No perception of risk often means no motivation to seek a test
- Some HCP perceive older individuals would be offended or uncomfortable discussing SH and sexuality, and some feel that the patient should bring this up. My study indicated that actually older individuals are not offended!-often they are unwell and want to get better, and also they trust the HCP to do whatever testing is necessary and if they feel that HIV testing is necessary then they are happy to do it! This is in agreement with a systematic review we did which indicated that one of the biggest facilitators to undergoing HIV testing in older age was being offered a test by a HCP.
- HCP in the study indicated that it was easier to offer testing to older individuals if it was routinely offered to everyone, or if they could say that ‘when a patient presents with X condition, they are routinely offered an HIV test’
- Attribution of symptoms is another big factor associated with testing. Often patients and HCP misattribute symptoms which may be related to HIV, to ageing. Patients often feel that illness is related to “getting older” and because illness is expected in older age, other underlying causes are not always explored.
Explore how older adults respond to being offered a HIV test…
- How to approach it
- Counselling required?
- Guidance available
When to test?
- Current UK HIV testing guidelines recommend the universal offer of HIV testing in certain healthcare settings including sexual health or termination of pregnancy services, to individuals reporting risk, and to individuals presenting with symptoms which may indicate HIV, or where HIV may be part of the differential diagnosis.
- In areas where there local HIV prevalence is high (>2/1000), the offer of an HIV test is additionally recommended to individuals registering at primary care services, to all general medical admissions, to any individual having blood taken for any reason (in primary and secondary care), and opportunistically based on clinical judgement. These recommendations are made despite patient age.
- Indicator diseases- broad spectrum of conditions known to be associated with HIV or may be AIDS defining, which when seen should prompt HIV testing. A lot of overlap with conditions/symptoms/signs/blood abnormalities that we see in older adults.
- Enhanced screening where young people and adults (defined as over 18) present to hospital or newly register with GP are offered an HIV test in areas of high/extremely high HIV prevalence
- UK prevalence 1.6/1000 (aged 15-59)
- High prevalence 2-5/1000 = 79/325 local authorities (PHE document gives areas)
- Extremely high prevalence >5/1000 = 20/325 local authorities, 18 in London (Lambeth highest) and outside Brighton and Hove (8/1000) and Manchester (6.4/1000)
- Not sure how many areas are offering this however.
- NICE quality standard, HIV testing: encouraging uptake. https://www.nice.org.uk/guidance/qs157
- How do older adults respond to being offered an HIV test? – My study suggested that although HCP fear that older patients will be offended, patients are happy to undergo testing if the HCP feels it is necessary and actually, one of the biggest facilitators to undergoing testing is being offered a test by a HCP
- Practically how do we offer a test?
- Counselling required?
- Guidance?
- My study indicated that confusion around what is required in terms of consent for HIV testing potentially acts as a barrier to offering HIV testing (unless that HCP felt it was necessary) – however, British HIV Association (BHIVA) testing guidelines state that “All doctors, nurses and midwives should be able to obtain informed consent for an HIV test in the same way that they currently do for any other medical investigation”.
- There is no need for lengthy pre-test counselling or written consent
- As with other procedures, a pre-test discussion should include a) the benefits of testing and b) details of how the patient will receive the result
- If a patient declines or is unable to consent to a test the NICE guidelines suggest that they are offered information about other local testing services (such as self-sampling)
Next section will explore the specific elements of HIV particular to Ageing Issues
Premature Ageing in Older Adults with HIV – is there a biological explanation?
The ageing process in patients with HIV infection, whether on long-term ART or not, is still poorly understood and much research is underway. Many abnormalities of the immune system associated with HIV infection are like those observed in ageing, including: low CD4 count, high rates of immune activation, reduced activity of the thymus gland and shorter telomeres.
There is a difference between accelerated ageing i.e traditional age-related conditions occurring earlier in the life course as one might expect, or accentuated i.e. conditions occur at the same time but they are just more common in those with HIV. Nicely described by Pathai et al: There is probably a bit of both occurring.
Life expectancy
Data from UK CHIC- population cohort study would say that potential life expectancy is the same for those with and without HIV, with potential for people living with HIV to do better. This survival paradox is thought to be due to engagement with healthcare. Caveat also that a lot of studies based on modelling work rather than recorded numbers. But there are challenges to longer life – HIV control, smoking, alcohol, recreational drugs, comorbidities and co-infections
Comorbidity and multimorbidity
- Most certainly on the rise with accompanied polypharmacy.
- Most studies have shown a difference when looked at HIV vs Non-HIV. Best study is that from AgeHIV as a good control group. Here prevalence of most major comorbidities was higher in those with HIV.
- Some cancers are more prevalent but not breast and prostate (i.e. common ones) leading people to suggest drivers may be more related to other factors.
Geriatric syndromes and frailty
- People HIV (PHIV) are worried about ageing and studies have started to look at what might be considered geriatric syndromes with high prevalence of frailty, falls, functional decline, disability.
- Can expand on this with respect to:
- Frailty- now driven by traditional factors rather than HIV factors now that people are suppressed on therapy.
- Frailty prevalence higher than we might see in general populations but controlled studies haven’t shown a big difference.
- Two controlled studies of falls saw no greater falls frequency in those with and without HIV. But PHIV do have additional falls risk factors namely peripheral neuropathy, potential prior CNS opportunistic infections (rarer now), increased substance misuse, opiates.
Polypharmacy and drug-drug interactions (DDI) in context of Anti-Retroviral Therapies.
- Response of older adults to ART (good viral suppression- adherence, potentially poorer immune reconstitution especially if lower CD4 at start, higher metabolic side effects and toxicities but perhaps better tolerated- therapeutic stoicism.
- Key facts about ART that people working in elderly medicine should know
- Risks of DDI, key interactions to avoid, where to seek info ie Liverpool drugs website
https://www.hiv-druginteractions.org/checker
Psychosocial disadvantage (Elaney & Tom)
- Survivorship
- Ongoing stigma and the added impact of ageism
- Financial disadvantage
- Social networks and isolation
- Worry about future care needs
