In this downloadable slideset, Eric S. Daar, MD, and David A. Wohl, MD, provide expert recommendations for older patients with HIV, both in terms of ART selection and general management. Format: Microsoft PowerPoint (.ppt) File size: 545 KB Date posted: 2/12/2018

1. HIV Alert: ART Considerations for
Aging Patients
This program is supported by an educational grant from
ViiV Healthcare

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About These Slides

3. Faculty
Eric S. Daar, MD
Chief, Division of HIV Medicine
Harbor-UCLA Medical Center
Professor of Medicine
David Geffen School of Medicine
at UCLA
Los Angeles, California
David A. Wohl, MD
Professor of Medicine
School of Medicine
Site Leader, AIDS Clinical Trials
Unit-Chapel Hill
University of North Carolina at
Chapel Hill
Director, North Carolina AIDS
Training and Education Center
Chapel Hill, North Carolina
Co-Director, HIV Services
North Carolina Department of
Correction
Raleigh, North Carolina

4. Faculty Disclosure Information
Eric S. Daar, MD, has disclosed that he has received consulting
fees from Gilead Sciences, Merck, and Theratechnologies and
funds for research support from Gilead Sciences, Merck, and ViiV.
David A. Wohl, MD, has disclosed that he has received consulting
fees from Gilead Sciences, Janssen, and ViiV and funds for
research support from Gilead Sciences and ViiV.

5. Program Overview
 HIV and Aging
 ART Considerations for Older Pts
 General Management Recommendations for Older Pts With HIV

6. HIV and Aging

7.  Modeling study with data from 2982 HIV-
infected pts in Italy[2]
Older Pts Becoming More Prevalent in the HIV-
Infected Population
 ATHENA[1]: modeling study with data from
10,278 HIV-infected pts in the Netherlands
1. Smit M, et al. Lancet Infect Dis. 2015;15:810-818.
2. Guaraldi G, et al. 18th Intl Workshop on Comorbidities & Adverse Drug Reactions in HIV. Abstract P06.
ProportionofHIV-PositivePts
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2010 2015 2020 20302025
Slide credit: clinicaloptions.com
> 70
60-70
50-60
40-50
30-40< 30
100
75
50
25
0
People(%)
Age < 35 35-49 50-64 65-74 > 75
Age(yrs)

8. Older HIV-Infected Pts at Increased Risk for
Multiple Comorbidities
 AGEhIV: prospective cohort study of HIV-infected pts (n = 540) vs
controls (n = 524) 45 yrs of age or older
Schouten J, et al. Clin Infect Dis. 2014;59:1787-1797. Slide credit: clinicaloptions.com
0
20
40
60
80
100
45-49 50-54 55-59 60-64 ≥ 65
Pts(%)
HIV Infected
45-49 50-54 55-59 60-64 ≥ 65
HIV Uninfected
3+
2
1
0
Age (Yrs)
Comorbidities, n

9. Older HIV-Infected Pts at Increased Risk for
Multiple Comorbidities
 Compared with HIV-uninfected persons, people with HIV at increased
risk for
– Impaired renal function[1]
– HTN, MI, PAD, CVD mortality[1,2]
– Frailty[3]
– Osteoporosis, decreased BMD, increased fracture[4,5]
– Cognitive issues[6]
– T2DM[7]
– Cancer[8]
References in slidenotes Slide credit: clinicaloptions.com

10. Polypharmacy Among HIV-Infected Pts on ART
 Predicts that 20% of pts will be receiving
≥ 3 meds other than ART in 2030
Slide credit: clinicaloptions.com1. Hasse B, et al. Clin Infect Dis. 2011:53;1130-1139. 2. Smit M, et al. Lancet Infect Dis. 2015;15:810-818.
ATHENA Modeling Study[2]
16,000
14,000
12,000
10,000
8000
6000
4000
2000
0
People(n)
3+ comedications
2 comedications
1 comedication
No comedication
2010 2015 2020 2025 2030
Swiss HIV Cohort Study (N = 8444)[1]
Prospective Observational Study
< 50 50-64 ≥ 65
100
80
60
40
20
0
Participants(%)
n = 5761 n = 2233 n = 450
No comedication
1 comedication
2 comedications
3 comedications
4+ comedications
Age (Yrs)

11. ART Considerations for Older Pts

12. START: Outcomes With Immediate vs Deferred
ART by Age
 Subgroup analysis of START, in which HIV-infected, ART-naive adults with CD4+ cell count
> 500 cells/mm3 randomized to immediate or deferred* ART (N = 4685)
Molina JM, et al. IAC 2016. Abstract THAB0201. Slide credit: clinicaloptions.com
*Until CD4+ cell count ≤ 350 cells/mm3, AIDS-related event, or event requiring ART.
Mos
Aged < 30 Yrs
PtsWithSeriousAIDSor
Non-AIDS–RelatedEvent(%)
16
14
12
10
8
6
4
2
0
600 12 24 36 48
2.6
1.3
Immediate ART
Deferred ART
Aged 30-49 Yrs
16
14
12
10
8
6
4
2
0
600 12 24 36 48
3.3
1.3
Aged ≥ 50 Yrs
16
14
12
10
8
6
4
2
0
600 12 24 36 48
11.7
2.9

13. DHHS Guidelines: ART Considerations for
Older Pts
 ART is recommended for all pts regardless of CD4+ cell count
 Adverse drug events from ART and concomitant drugs may occur more
frequently in older pts with HIV
– Bone, kidney, metabolic, cardiovascular, and liver health should be monitored
closely
 Polypharmacy is common in older pts with HIV, with an associated
increased risk of drug–drug interactions
 HIV experts should collaborate with primary care providers and other
specialists to optimize the medical care of older pts with HIV and complex
comorbidities
Slide credit: clinicaloptions.comDHHS Guidelines. October 2017.

14. DHHS Guidelines: Starting ART
Slide credit: clinicaloptions.com
Regimen
STR
?
DHHS First-Line Recommendation
Most people Certain situations
DTG/ABC/3TC  
DTG + FTC/(TAF or TDF) 
EVG/COBI/FTC/(TAF or TDF)  
RAL + FTC/(TAF or TDF) 
RAL + ABC/3TC 
EFV/FTC/TDF or + FTC/TAF  
RPV/FTC/(TAF or TDF)  
Boosted PI + 2 NRTIs 
DHHS Guidelines. October 2017.

15. Selecting ART Components for Pts With
Comorbidities or Polypharmacy
Slide credit: clinicaloptions.com
Component May Be Suboptimal for Pts With: Key DDIs*
NRTI Backbone
ABC/3TC
CKD Not for use when CrCl < 50 mL/min
CVD Possible increased CVD risk
FTC/TAF CKD Not for use when CrCl < 30 mL/min Rifamycins
FTC/TDF
CKD Not for use when CrCl < 50 mL/min
Osteoporosis Smaller BMD declines with TAF and ABC
Additional Agents
Boosted PIs Hyperlipidemia Other agents have lower lipid effects Statins, steroids
DTG Antacids†, metformin
EVG/COBI Hyperlipidemia Other agents have lower lipid effects Statins, steroids, antacids
RAL Antacids†
RPV PPIs
References in slidenotes.
*Consider www.hiv-druginteractions.org to assist with identifying potential interactions for all regimens.
†Polyvalent cation–containing antacids.

16. What About NRTI-Limiting Regimens?
Slide credit: clinicaloptions.com
Scenario
DHHS Options When
NRTIs Not Desirable[1] Comments
Starting
 DRV/RTV + RAL  Suboptimal efficacy in pts with high HIV-1 RNA
(≥ 100,000 copies/mL), low CD4+ cell counts
(< 200 cells/mm3)[2]
Switching in
suppressed
pts
 DTG + RPV  STR now FDA approved for pts in this setting
with no history of treatment failure or
component resistance[3]
 No restrictions for pts with renal impairment
 SWORD studies: similar virologic efficacy vs
continued suppressive ART[4]
 PI/RTV + 3TC  Several studies suggest similar virologic efficacy vs
suppressive ART with boosted PI + 2 NRTIs[5,6]
References in slidenotes.

17. General Management Recommendations

18. Life Expectancy in Older HIV-Positive Adults in
Modern ART Era
 Population-based cohort study of survival in HIV-infected pts (n = 2440) and
uninfected controls matched by age and sex (n = 14,588) in Denmark
HIV-Negative
Controls
1996-2014
2006-2014
2000-2005
1996-1999
HIV-Positive Pts
1.00
0.75
0.50
0.25
0
ProbabilityofSurvival
50 60 70 80
Age (Yrs)
Legarth RA, et al. J Acquir Immune Defic Syndr. 2016;71:213-218. Slide credit: clinicaloptions.com

19. The Facts About Aging With HIV
 People with HIV have a greater risk for conditions that are
associated with getting older
 The reasons why people with HIV suffer more from these
conditions are debated, but all agree that lifestyle plays a role
 Although aging with HIV is inevitable, the course of aging can be
influenced by actions
– eg, healthy diet, exercise
Slide credit: clinicaloptions.com

20. Aging With HIV: Factor Stacking
LIFESTYLE
Normal Aging Process
Low CD4+ Cell CountUntreated HIV
HIV-Mediated
Inflammation
Slide credit: clinicaloptions.com

21. Interventions Contributing to Reductions in CVD
in HIV-Infected Pts
 Modeling study using data from 8791 pts in ATHENA study
van Zoest R, et al. CROI 2017. Abstract 129. Slide credit: clinicaloptions.com
Reductions in CVD by Intervention
20
15
10
5
0
AverageAnnualPercentage
ReductioninCVDCases 25
Earlier HIV
Diagnosis and
Treatment
Avoiding cART
With Increased
CVD Risk
Smoking
Cessation
Monitoring/Tx
of Hypertension
and Dyslipidemia
50%
successful
100%
successful

22. HIV and Aging: Potential Comorbidities and
Recommended Actions
Comorbidity Findings in Pts Infected With HIV Recommendations
Malignancy
 Risk of cancer, heart and lung disease
higher in smokers vs nonsmokers[1,2]
 Risk of multiple cancer types
increased[3]
 Smoking cessation intervention(s)
 Recommended cancer screenings
 Exercise
Cardiovascular
 CVD mortality and risk of
hypertension and myocardial
infarction[4,5]
 Some ART associated with
dyslipidemia[6]
 Assess need for statin, ASA
 ASCVD calculator
 Diet assessment/intervention
 Exercise
 Consider ART that does not raise
lipids/CVD risk
Slide credit: clinicaloptions.comReferences in slidenotes.

23. HIV and Aging: Potential Comorbidities and
Recommended Actions
Comorbidity Findings in Pts Infected With HIV Recommendations
Mental health
 Depression more prevalent[1,2]
 Alcohol use more harmful at lower
thresholds[3]
 Counseling, anti-depressants,
social support
Renal
 Risk of CKD increased[4]
 Some ART associated with declines
in renal function
 Assess CrCl regularly
 Counsel on risks of NSAIDs
 Avoid ART with adverse renal
effects
 Treat HTN to target
Slide credit: clinicaloptions.comReferences in slidenotes.

24. HIV and Aging: Potential Comorbidities and
Recommended Actions
Comorbidity Findings in Pts Infected With HIV Recommendations
Fractures
 Greater risk in for atraumatic
fractures[1,2]
 Some ART associated with increased
bone loss
 Follow guidelines for DXA
screening and management
 Bisphosphonates
 Exercise
 Consider ART associated with
smaller BMD declines
Frailty
 Frailty more prevalent[3]  Consider assessing frailty
phenotype (eg, Fried’s criteria,
which includes weight loss,
weakness, exhaustion)
Slide credit: clinicaloptions.comReferences in slidenotes

25. Conclusions
 For many reasons, people living with HIV have a higher risk for
select age-related health problems
 ART selection should take into account the pt’s comorbidities and
potential for drug interactions and adverse events
 Many comorbid conditions can be prevented or reversed by
actions taken by the pt and the provider
– HIV care must start to incorporate principles of geriatric medicine to
meet needs of older pts
Slide credit: clinicaloptions.com

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