HIV treatment: the challenges for older adults

by Pat Curry

Improved medications have helped many people with HIV live longer, but treating older adults with HIV presents some unique challenges.

The challenges related to diagnosing human immunodeficiency virus (HIV) in older adults have been well documented. In many instances, both doctors and patients are uncomfortable discussing risk factors, such as unprotected sex and intravenous drug use, and the symptoms of HIV can mimic symptoms of other conditions common in older adults.

Once a diagnosis is made, however, there are additional challenges for older adults with HIV and the doctors who treat them, because the most effective combination of drugs can interact with medications these adults frequently take for a host of other conditions, ranging from high blood pressure to osteoporosis.

The protease inhibitors that are a critical part of treating HIV inhibit an enzyme in the liver that metabolizes medications, raising the risk of drug interaction, says Karl Goodkin, MD, PhD, who works with elderly HIV patients at the University of Miami.

HIV drugs also increase the risk of heart disease, high cholesterol, hypoglycemia, bone loss and fracture all of which are already concerns for older adults. Plus, the sheer volume and range of medications they take increases the risk of drug interaction "tremendously," according to Dr. Goodkin.

"Usually, you just avoid prescribing the drugs that interact," says Dr. Goodkin. "You don't have that option here. You have to prescribe the drugs. Substance abuse and diet can also interact with these anti-retroviral medications. We're in a quandary right now. As a result, we're entering a whole new area of research to define what's appropriate to do."

There's also the issue of getting patients to remember to take all their medicine.

"The most common reason HIV patients don't take their meds is 'I forgot,'" says Lori Fantry, MD, PhD, medical director of Baltimore's Evelyn Jordan Center at the Infectious Disease Clinic for the University of Maryland and the Institute of Human Virology. "Think of that with a 20- to 30- year-old and think about it with a 70-year-old. They probably forget to do more things than a younger person."

But forgetting to take medications can be life-threatening for someone with HIV.

"Anti-retroviral therapies are extremely sensitive to lack of adherence," Dr. Goodkin explains. "You need 95% compliance. There are typically three drugs two to three times a day and different drugs at different times a day. With every 5% degradation in adherence, there's an increase in the amount of HIV in the blood."

There is good news, however, on two fronts. Patients who take their medication "have a very good chance of getting a good response," says Dr. Fantry. And older adults experience the same benefits from treatment as do younger patients. Seniors generally have a better acceptance about taking their HIV medication than do younger people, Dr. Fantry explains, because they're already used to a daily routine of taking pills.

"The elderly people in our clinic clearly have a responsible attitude toward their disease," she says. "They may need more support to do it, but once you put the supports in place with the social worker, pill boxes and reminders, they seem to do well."

There have also been significant advances in reducing the number of pills that need to be taken to control the illness.

"We've come a long way from 20 pills a day," says Dr. Fantry. "We have a regimen where we can get good control with just one pill in the morning and one in the evening. You can't do that with everyone one regimen is seven pills a day but it's much better than we had just a few years back. The news is clearly not all negative. Every year, it gets a little easier to take medicine."