Predictions of geriatric HIV in 2030
Authors: David E Vance, Shameka L Cody
Journal: The Lancet Infectious Diseases (2015)

In 2010, we used our HIV clinic database located in the southern USA to develop a clinical profile of what HIV infection means at each decade of life, focusing specifically on adults older than 50 years.1Vance DE Mugavero M Willig J Raper JL Saag MS Aging with HIV: a cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life.J Assoc Nurses AIDS Care. 2011; 22: 17-25Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar Several of our findings were quite revealing. First, the prevalence of depression and anxiety is largely constant across the lifespan at roughly 40% and 20%, respectively. Second, the average number of prescribed drugs for individuals in their 50s was 12·48, which increased to 14·82 for those aged 60 years or older. Third, although the average CD4 lymphocyte count ranged from 420 to 479 in each decade of life, ANOVA analysis showed that older adults generally had significantly (p=0·018) lower viraemia than did adults in younger decades of life. Older adults were also more likely (p=0·001) to have an undetectable viral load (<50 RNA copies per ml) than were younger adults, with a prevalence of undetectable viral load of 65·4% for those in their 50s and 76·7% for those aged 60 years or older, compared with 36·2% for those in their 20s and 39·4% for those in their 30s. Finally, we noted that various distributions of comorbidities emerged across the lifespan (eg, condyloma was more common in younger adults while alcohol misuse peaked in midlife [40–59 years]). However, the comorbidities that were most prevalent in our group of individuals aged 60 years or older were insomnia (17·8%), coronary artery disease (20·5%), hypertension (67·1%), hypercholesterolaemia (65·8%), diabetes (28·8%), peripheral neuropathy (24·7%), hepatitis C (12·7%), and renal disease (23·3%). Mikaela Smit and colleagues' study2Smit M Brinkman K Geerlings S et al.on behalf of the ATHENA observational cohortFuture challenges for clinical care of an ageing population infected with HIV: a modelling study.Lancet Infect Dis. 2015; (published online June 10.)http://dx.doi.org/10.1016/S1473-3099(15)00056-0PubMed Google Scholar far extends what we and others know about ageing with HIV infection and provides a statistical projection of what the clinical features of ageing with HIV will look like in 15 years. Theirs is the first study to provide such an advanced individual-based model to estimate clinical trends of ageing with HIV. Based on data from the national Dutch ATHENA cohort for more than 10 000 patients infected with HIV, they predicted that by 2030, 73% of individuals infected with HIV will be aged 50 years or older. By 2030, in this older group, 84% of individuals will have at least one additional comorbidity and 28% will have at least three, compared with 19% of HIV-negative adults. The comorbidities underlying this increased prevalence will be malignancies (predicted for 17% of individuals), diabetes (predicted for 17% of individuals), and cardiovascular disease (predicted for 78% of individuals). This prediction supports the findings of several studies3High KP Brennan-Ing M Clifford DB et al.HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group.J Acquir Immune Defic Syndr. 2012; 60: S1-18Crossref PubMed Scopus (429) Google Scholar, 4Vance DE Randazza J Fogger S Slater LZ Humphrey SC Keltner NL An overview of the biological and psychosocial context surrounding neurocognition in HIV.J Am Psychiatr Nurses Assoc. 2014; 20: 117-124Crossref PubMed Scopus (6) Google Scholar that suggest that such comorbidities will be of increasing importance, especially because these comorbidities might be partly caused by HIV-related inflammation and increased stress in this population.3High KP Brennan-Ing M Clifford DB et al.HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group.J Acquir Immune Defic Syndr. 2012; 60: S1-18Crossref PubMed Scopus (429) Google Scholar, 4Vance DE Randazza J Fogger S Slater LZ Humphrey SC Keltner NL An overview of the biological and psychosocial context surrounding neurocognition in HIV.J Am Psychiatr Nurses Assoc. 2014; 20: 117-124Crossref PubMed Scopus (6) Google Scholar With treatments for such comorbidities, pharmacological burden will increase with respect to both the number of drugs needed and possible drug–drug interactions and contraindications with the first-line HIV regimens. Worryingly, Smit and colleagues2Smit M Brinkman K Geerlings S et al.on behalf of the ATHENA observational cohortFuture challenges for clinical care of an ageing population infected with HIV: a modelling study.Lancet Infect Dis. 2015; (published online June 10.)http://dx.doi.org/10.1016/S1473-3099(15)00056-0PubMed Google Scholar predict that as many as 53% of individuals infected with HIV will have such drug–drug interactions in 2030. Further contributing to these interactions will be reductions in renal and hepatic functioning1Vance DE Mugavero M Willig J Raper JL Saag MS Aging with HIV: a cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life.J Assoc Nurses AIDS Care. 2011; 22: 17-25Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar and decreases in patients' adipose tissue, which will affect pharmacokinetics and pharmacodynamics.3High KP Brennan-Ing M Clifford DB et al.HIV and aging: state of knowledge and areas of critical need for research. A report to the NIH Office of AIDS Research by the HIV and Aging Working Group.J Acquir Immune Defic Syndr. 2012; 60: S1-18Crossref PubMed Scopus (429) Google Scholar Adults infected with HIV are expected to have close to normal lifespans5Lewden C Bouteloup V et al.Collaboration of Observational HIV Epidemiological Research Europe (COHERE) in EuroCoordAll-cause mortality in treated HIV-infected adults with CD4 ≥500/mm3 compared with the general population: evidence from a large European observational cohort collaboration.Int J Epidemiol. 2012; 41: 433-445Crossref PubMed Scopus (210) Google Scholar, 6Lewden C Chene G Morlat P et al.HIV-infected adults with a CD4 cell count greater than 500 cells/mm3 on long-term combination antiretroviral therapy reach same mortality rates as the general population.J Acquir Immune Defic Syndr. 2007; 46: 72-77Crossref PubMed Scopus (28) Google Scholar and Smit and colleagues' study provides a glimpse into the many challenges (eg, drug adherence, lifestyle modification, engagement in care) that will need to be addressed, especially in the resource-rich countries in which these findings are most applicable. One topic of particular interest is neurocognitive functioning. At present, the prevalence of HIV-associated neurocognitive disorders range from 52% to 59%.7Bonnet F Amieva H Marquant F et al.Cognitive disorders in HIV-infected patients: are they HIV-related?.AIDS. 2013; 27: 391-400Crossref PubMed Scopus (117) Google Scholar, 8Heaton RK Clifford DB Franklin Jr, DR et al.HIV-associated neurocognitive disorders persist in the era of potent antiretroviral therapy: CHARTER Study.Neurology. 2010; 75: 2087-2096Crossref PubMed Scopus (1703) Google Scholar With increasing age, the prevalence and severity of neurocognitive disorders might increase: Valcour and colleagues9Valcour V Shikuma C Shiramizu B et al.Higher frequency of dementia in older HIV-1 individuals: the Hawaii Aging with HIV-1 Cohort.Neurology. 2004; 63: 822-827Crossref PubMed Scopus (340) Google Scholar reported that older adults with HIV were three times more likely to develop HIV-associated dementia than were younger adults. Malignancies, diabetes, and cardiovascular disease already compromise brain reserve and neurocognitive function,10Vance D Larsen KI Eagerton G Wright MA Comorbidities and cognitive functioning: implications for nursing research and practice.J Neurosci Nurs. 2011; 43: 215-224Crossref PubMed Scopus (39) Google Scholar and could exacerbate HIV-associated neurocognitive disorder.5Lewden C Bouteloup V et al.Collaboration of Observational HIV Epidemiological Research Europe (COHERE) in EuroCoordAll-cause mortality in treated HIV-infected adults with CD4 ≥500/mm3 compared with the general population: evidence from a large European observational cohort collaboration.Int J Epidemiol. 2012; 41: 433-445Crossref PubMed Scopus (210) Google Scholar Although older adults infected with HIV show superior drug adherence and compliance with medical appointments compared with younger adults,11Hinkin CH Hardy DJ Mason KI et al.Medication adherence in HIV-infected adults: effect of patient age, cognitive status, and substance abuse.AIDS. 2004; 18: S19-S25Crossref PubMed Google Scholar which might explain why many older adults are more likely to have suppressed viraemia,1Vance DE Mugavero M Willig J Raper JL Saag MS Aging with HIV: a cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life.J Assoc Nurses AIDS Care. 2011; 22: 17-25Summary Full Text Full Text PDF PubMed Scopus (160) Google Scholar such advantages disappear when these older adults have neurocognitive loss.11Hinkin CH Hardy DJ Mason KI et al.Medication adherence in HIV-infected adults: effect of patient age, cognitive status, and substance abuse.AIDS. 2004; 18: S19-S25Crossref PubMed Google Scholar In the long term, such neurocognitive losses can also reduce ability in driving, financial management, and other everyday tasks, which will disproportionately increase need for formal and informal caregivers among affected individuals.12Thames AD Kim MS Becker BW et al.Medication and finance management among HIV-infected adults: the impact of age and cognition.J Clin Exp Neuropsychol. 2011; 33: 200-209Crossref PubMed Scopus (79) Google Scholar, 13Vance DE Fazeli PL Ball DA Slater LZ Ross LA Cognitive functioning and driving simulator performance in middle-aged and older adults with HIV.J Assoc Nurses AIDS Care. 2014; 25: e11-e26Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar Smit and colleagues' study2Smit M Brinkman K Geerlings S et al.on behalf of the ATHENA observational cohortFuture challenges for clinical care of an ageing population infected with HIV: a modelling study.Lancet Infect Dis. 2015; (published online June 10.)http://dx.doi.org/10.1016/S1473-3099(15)00056-0PubMed Google Scholar contributes to the growing body of research on ageing with HIV and provides solid insights about what to expect for patients as they age. By extrapolation from these findings to other relevant areas, as we have done for neurocognitive functioning (eg, medical management, case management, retirement issues), researchers, clinicians, and policy makers can plan to allocate resources accordingly to provide care to this growing geriatric population. This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on July 27, 2015 This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on July 27, 2015 We declare no competing interests. Future challenges for clinical care of an ageing population infected with HIV: a modelling studyThe profile of patients in the Netherlands infected with HIV is changing, with increasing numbers of older patients with multiple morbidities. These changes mean that, in the near future, HIV care will increasingly need to draw on a wide range of medical disciplines, in addition to evidence-based screening and monitoring protocols to ensure continued high-quality care. These findings are based on a large dataset of HIV-infected patients in the Netherlands, but we believe that the overall patterns will be repeated elsewhere in Europe and North America. Full-Text PDF Open AccessCorrectionsVance DE, Cody SL. Predictions of geriatric HIV in 2030. Lancet Infect Dis 2015; 15: 753–54—This Comment (June 9) should have been published under a Creative Commons CC BY Open Access licence. The correction has been made to the online version as of July 27, 2015. Full-Text PDF