Where Are the DHHS HIV Treatment Guidelines for Clients Over 50 Years Old?
As I just celebrated another birthday and relocated to Houston, Texas, to a nice home with lots and lots of stairs, I couldn't help but think about aging. My knees and back are aching. I'm just plain tired! I know that in the clinical setting you are hearing similar complaints among your older clients. We can be an achy mess as we age! For our clients, is it the untreated/inadequately treated HIV, aging, or both?
In the news, we have heard a lot of buzz terms, such as immunosenescence, persistent high levels of inflammation and chronic T-lymphocyte activation. We know that with all of this drama and older age there is an increased risk of AIDS-related and non-AIDS-related death.
So why is it that the U.S. Department of Health and Human Services (DHHS) has not specifically addressed or recommended treatment for those older adults at any CD4 count? Just stating in the guidelines that we should use our clinical judgment is not enough, in my humble experience.
The International AIDS Society (IAS) addressed this in its guidelines as of July 21, 2010: Antiretroviral therapy is recommended for clients aged 60 years and older, regardless of CD4 count. Well!
Aren't the goals of antiretroviral therapy the same for older adults who are living with a tired (i.e., decreased optimal function) immune system? The goals of therapy, according to the DHHS guidelines, are to:
- Reduce HIV-associated morbidity with a longer and nicer survival;
- Restore and preserve what immunologic function is left;
- Maximally and durably suppress the plasma viral load; and
- Prevent HIV transmission.
Persons over 60 years of age deserve the same as everyone else: to live as long as possible and prosper. Yes, and be sexually active, too!
Many studies (NA-ACCORD, etc.) have shown that there is emerging biologic evidence regarding end-stage organ damage from inflammation associated with untreated HIV replication. When you are already starting with that "tired" immune system, older clients need some consideration.
DHHS experts: Are you treating your patients over 60 regardless of CD4 count? Are other providers considering patient age in addition to other co-morbidities? Inquiring minds want to know.
Stay tuned for more in my "older adult" series.
- Caruso C, Buffa S, Candore G, et al. Mechanisms of immunosenescence. Immun Ageing. July 22, 2009;6:10. Available at: www.immunityageing.com/content/6/1/10. Accessed July 29, 2011.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. January 10, 2011; 1-174. Available at: www.thebodypro.com/content/art35709.html. Accessed July 29, 2011.
- Thompson MA, Aberg JA, Cahn P, et al. Antiretroviral treatment of adult HIV infection -- 2010 recommendations of the International AIDS Society-USA Panel. JAMA. July 21, 2010;304(3):321-333. Available at: http://jama.ama-assn.org/content/304/3/321.full.pdf. Accessed July 29, 2011.