The burden of growing old with HIV
This article has been commissioned and funded by ViiV Healthcare
Author: Dr Mike Youle, Royal Free Hospital, London
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The high rates of polypharmacy, likelihood of co-morbid conditions and greater potential for antiretroviral-related toxicities create special challenges in the care of older PLHIV. In addition to selecting appropriate combination antiretroviral therapy (cART), encouraging an active, healthy and social lifestyle can help PLHIV stay well.
Research suggests that nearly three-quarters of PLHIV are concerned about future toxicity-related complications, and that most are open to reducing the number of antiretrovirals they take, provided their viral load remains suppressed.3
Ethnicity: White British
Age: 59 years old
- Diagnosed with HIV in 2013, aged 52 years, after developing shingles
- Viral load 194,306 copies/mL and CD4 cell count 230 cells/mm3 at diagnosis
- Started on darunavir/ritonavir 800 mg/100 mg plus TDF/FTC once daily
- Viraemia was undetectable at 12 weeks, and has remained so ever since
- Within the last six months, he has been diagnosed with hypercholesterolaemia, gout and osteoporosis, and is now receiving atorvastatin, allopurinol, a calcium/vitamin D supplement and alendronate
- Recently, he has developed symptoms consistent with angina and is currently awaiting a cardiology appointment for further investigation
- He is concerned about the long-term risks associated with taking multiple medications, how his other conditions will affect his HIV and vice versa and how he will keep track of his medication
What would you do?
- Undertake an assessment of the risk of drug-drug interactions?
- Refer to an HIV pharmacist for help with managing polypharmacy and optimising adherence?
- Simplify his cART regimen?
- Adopt a watch-and-wait approach?
- He now has three co-morbidities in addition to HIV and these will require medication for a prolonged period. In addition, a diagnosis of ischaemic heart disease, if confirmed, would likely add to the medication burden and potentially require intervention
- It would be sensible to reduce the risk of current or future drug-drug interactions by switching away from a boosted protease inhibitor, and from TDF, which should not be used in people with osteoporosis14
- He has no history of virological failure
- As an older PLHIV, one option could be to reduce the number of antiretroviral medications taken – for example, by switching to an evidence-based two-drug regimen where appropriate. This would achieve his objectives of taking fewer drugs, and may reduce drug-drug interactions15
- The patient’s cART regimen was switched to DTG plus 3TC, with follow-up planned in three months’ time
- He was advised to take his calcium supplement and DTG at opposite ends of the day; taking them at the same time reduces DTG exposure16
- He was also referred to the hospital’s clinical pharmacy team, for practical help with managing his medicines
As an HIV care provider, there is a lot you can do to help older PLHIV live well for many years to come. Every time you see them, ask yourself: how I can make their life simpler and safer, considering their future health and well-being?
Fewer drugs could mean fewer potential interactions. In this regard, avoiding cART regimens that contain boosting agents is paramount – and, furthermore, this is achievable in most individuals by using unboosted regimens, including a dolutegravir-based two-drug regimen.
About the author
Dr. Mike Youle is an HIV physician at the Royal Free Hospital, London, UK. In addition to caring for patients, he runs JUSTRI, a not-for-profit organisation that educates and produces resources. Coming of Age, a guide for those ageing with HIV, and The Right Time, a resource for those looking after ageing PLHIV, can be downloaded from www.justri.org. (This link will take you to a non-ViiV Healthcare website. ViiV Healthcare does not recommend, endorse or accept liability for sites controlled by third-parties.)
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PM-GB-DLM-WCNT-190001 | October 2019