Age is the great equalizer and one of the greatest gifts modern biomedical innovations have provided to people with HIV. Originally a diagnosis that came with great fear and the tragic reality that life would now be counted in months, weeks or even days, HIV swept through communities taking the young and vibrant far too early in their life stories. But with the advent of AZT and later antiretroviral therapy, a diagnosis of HIV infection has become — for those with adequate access to care, treatment and support — a conversation about chronic illness and management more than mortality.
Over four decades after the virus was first identified, over 50% of people with HIV in developed nations are over 50, a point of pride for all those who worked together to make it a reality. (1) There is no longer a decline in life expectancy for those diagnosed with HIV because of great accomplishments in medication, systems of case management and clinician expertise.
But we now sit at a precipice: How do we care for elders with HIV?
Identifying the challenges
Aging is a complex occurrence in health care, requiring a multitude of interventions, pharmacological acumen and specialist care, as well as extra time interfacing with a clinician. Aging erodes general comprehension, hearing and/or sight, strength and ambulation abilities, all while chronic conditions related to the general wear and tear of living a longer productive life may develop. Many researchers and clinicians are now trying to answer key questions regarding aging with HIV:
- What are the effects of decades of varying ART use?
- What chronic conditions do people with HIV have a greater chance of developing, and how does this affect their viral load and overall health?
- How does HIV contribute to the biological effects of aging, like increasing frailty that occurs at a younger age?
The answers to these questions should guide the next generation of HIV care providers’ practices, going beyond getting patients to simply live longer but also to actively improve their quality of health over the course of their lifetime.
Multiple factors and questions to explore
Much of the current discussion about aging with HIV focuses on biology, how the body experiences aging simultaneously with the chronic condition of HIV infection, even if undetectable. But the real challenges lie in the sociological, particularly the exacerbation of the barriers experienced by many marginalized people who are overrepresented amongst people with HIV. In making biomedical intervention and management accessible over the decades to many communities, not just the well-connected and wealthy, groups who exist in the socioeconomic and racial margins now face the compounding limitations that come with aging stacked on top of these social determinants of health.
There are many important questions to consider, including:
- How is case management being redesigned or expanded to include a client’s shrinking capacity to use or access transportation?
- Are primary clinicians creating consistent processes to monitor the symptoms of polypharmacy and prescription cascade in patients as they start to require several specialists to manage their shifting state of health?
- What happens when a client’s most pressing challenge is the erosion of their cognition, vision or hearing while having little to no social support network?
- What resources can be provided to individuals struggling to live on a newly reduced fixed income that threatens to destabilize their housing, and how can that impact consistency in their undetectable status?
- Are providers educated on identifying a multitude of signs that indicate interpersonal abuses are occurring to a patient (physical, financial, psychological/emotional)?
- What choices and sacrifices are patients quietly making to continue to remain independent, and what effect do these short-term decisions have on nutritional health, medication adherence, or frailty?
- In what ways can clients be asked about their inconsistent hygiene that is endangering their health while still centering their dignity and autonomy?
These are just some examples of the questions that must be brought to the forefront and made a primary part of how HIV care is practiced in the immediate future. In doing what was once unthinkable (extending the life of those with HIV well into their elder years), HIV practitioners have tumbled into a new care matrix challenge, one that needs innovation, compassion and a commitment to health equity best practices as a central component. Do all HIV professionals become gerontologists too? Should all geriatricians be trained in providing HIV care?
These novel complexities demand our attention. In looking at the precipice before the HIV health care community, our tremendous success in developing lifesaving treatment requires it. The ability for people with HIV to continue to independently thrive demands it.
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