Clinical update: HIV and growing older

People with HIV are living beyond the age of 50. Health services must be ready to support them, says Darren Brown.

HIV – human immunodeficiency virus – damages the immune system, weakening the ability to fight infections and diseases. Globally, 36.7 million people live with HIV, 101,200 of them in the UK. Antiretroviral therapy has changed the HIV prognosis from unpreventable death into a chronic condition and, with prompt diagnosis and effective treatment, people can have a normal life expectancy. In addition, if the virus cannot be detected, HIV cannot be passed on to sexual partners; Undetectable = Untransmittable (U=U) is an international campaign to end stigma by empowering people living with HIV via accurate health information.

It is estimated that by 2028, more than half of those in Britain under HIV care will be aged 50-plus, so health services must prepare for a sudden growth in the ageing population of people living with HIV, largely uncharted territory.

Points to note

Prompt diagnosis and treatment means HIV is a chronic condition with normal life expectancy
With effective treatment, when HIV is undetectable, the virus cannot be passed on to sexual partners
The Episodic Disability Framework describes disability experienced by people living with HIV as multidimensional and episodic
People living with HIV can experience frailty and physical functional decline at a younger age than the general population
Exercise is safe and effective for people living with HIV
Physiotherapy and rehabilitation is recommended to support older adults living with HIV

HIV and disability

As people with HIV grow older, they may be susceptible to developing conditions arising from HIV, adverse effects of antiretroviral therapy or ageing, resulting in increasingly more prevalent multi-morbidity, such as bone and joint disorders, mental health conditions, cardiovascular disease, cancer and neurocognitive decline. This can create physical, mental, cognitive and social health-related challenges that could be conceptualised as disability, and many people living with HIV now face new or worsening experiences of disability.

The Episodic Disability Framework (O’Brien KK et al 2008) conceptualises disability experienced by people living with HIV as multidimensional and episodic, where people living with HIV experience unpredictable periods of wellness and illness. The Episodic Disability Framework describes disability domains similar to the International Classification of Functioning, Disability and Health, but also describes contextual factors that influence disability and acknowledges uncertainty as a new disability domain experienced by people living with HIV.

As people live longer, HIV-related disabilities will proliferate globally, so HIV and disability is increasingly recognised as an important underexplored concern. Existing literature identifies that people living with HIV experience a higher prevalence of disability than general populations in Canada and South Africa. However, no data exists on disability experienced by people living with HIV in the UK. This research is under way in the UK.

HIV and physical function

Measures of functional performance used to assess frailty and disability in older HIV-negative populations, have identified that people living with HIV present with functional impairments at an earlier age. Because functional performance is impaired sooner, functional assessments including gait speed and the Short Physical Performance Battery may provide benefit when assessing people living with HIV, and may identify early opportunities to intervene and prevent disability progression.

HIV, physiotherapy and rehabilitation

Physiotherapy is recommended to support older adults living with HIV (O’Brien KK et al 2014) and the strongest evidence focuses on exercise interventions. Exercise is safe and effective for people living with HIV (O’Brien KK et al 2016). Performing aerobic, or a combination of aerobic and resistive exercise, three times a week for at least five to six weeks results in improvements in cardiorespiratory fitness, strength, body composition, weight and quality of life. However, evidence suggests that people living with HIV are less physically active compared to other health populations. They present as the most sedentary population and have the lowest cardiorespiratory fitness levels in comparison to other vulnerable populations. Consequently, it has been proposed that specialists in exercise and health, such as physios, should be included in the multidisciplinary teams that support people living with HIV. In the UK, HIV physiotherapy services are proven to be effective (Brown DA et al 2016), improving strength, physical function and quality of life. fl

Darren Brown is a specialist HIV physio at Chelsea and Westminster Hospital NHS Trust, vice chair of the UK Rehabilitation in HIV Association and HIV/AIDS co-ordinator of the WCPT Network International Physical Therapists for HIV/AIDS, Oncology, Hospice and Palliative Care.

HIV and frailty

HIV seems to be linked to frailty. Key factors include:

increased falls risk
bone fractures
unemployment
social isolation

Frailty measures

As the number of older adults living with HIV increases, more people are experiencing multiple comorbidities, more than age-matched controls. A causal relationship has been described between comorbidities, disability and frailty, whereby comorbidity is a risk factor and disability an outcome of frailty. Frailty, characterised by decreased functional capacity and reduced ability to perform activities of daily living, represents both a manifestation of and contributor to the complications of an ageing HIV epidemic.

The mechanisms believed to result in the increasing burden of frailty among people ageing with HIV are multi-factorial, such as mitochondrial dysfunction, chronic inflammation and oxidative stress.

But there is no consensus on a universally accepted tool to measure frailty. The Fried phenotypic model of frailty is the most commonly used frailty measurement among people living with HIV, demonstrating higher rates of frailty occurring at younger ages among people living with HIV in the US and Europe. The Veterans Aging Cohort Study (VACS) Index, developed to assess physiologic frailty, including routine clinical HIV and organ system biomarkers, is accepted as an effective frailty measure, predicting morbidity such as hospitalisation, intensive care admission and fragility fractures. The presence of frailty and HIV can predict mortality, and so measuring frailty is important to identify the most vulnerable and help target resources.

07 March 2018

07 Mar 2018