Better drugs and treatments mean that people with HIV now have near normal lifespans.
But aging with HIV is still fraught with difficulties.
A study published earlier this year in the journal The Lancet HIV concluded that “Between 1996-99 and 2008-10, life expectancy in people living with HIV starting [antiretroviral therapy] increased by around 10 years for both sexes, in Europe and North America.”
A 20-year-old person with HIV who began antiretroviral therapy (ART) after 2008 could be expected to live to 78 years of age, almost the same as the average population.
Researchers said these dramatic changes can be attributed to less toxic drugs and better management of the disease.
They also noted that increased life expectancy could inspire people with HIV to take other steps to improve their overall health as well, such as stopping smoking.
Aging with HIV
The longevity is welcome news for people with the infectious disease, but what it means to grow old with HIV is significantly more complicated.
“This is the first generation of people that have survived [the AIDS epidemic],” said Vincent Crisostomo, program manager for the Elizabeth Taylor 50-Plus Network in San Francisco, a social support network for people with HIV.
“A lot of stuff that’s happening we are learning as we go along,” he told Healthline.
For HIV individuals who are young with immediate access to ART — those who are expected to live to be 78 — things will be different.
The current population of people with HIV now entering middle or old age will most likely struggle with a host of health and psychological complications.
“This is probably the only generation that will have special needs around aging with HIV that medical, aging, and benefits providers will need to address. If you are testing positive now regardless of age, the chances of you getting a disabling HIV diagnosis are slim,” said Crisostomo.
He is concerned, and acutely aware of the knowledge gap between members of the medical field who specialize in HIV care and those who study gerontology and the needs of an aging population.
“Aging providers understand health issues around aging, but they may not fully know or understand the HIV piece,” said Crisostomo. “The HIV providers get the HIV piece, but they don’t really know a lot about the issues related to aging. So, there are quite a few moving parts.”
Common health issues … and then some
For older HIV individuals, all of the medical problems associated with growing old in the United States — heart disease, diabetes, cognitive issues, cancer, and metabolic problems — are more likely.
Mobility issues including frailty and osteoporosis are also more common, particularly for women.
The presence of HIV plus one or more of these other conditions are called comorbidities.
“All those aging comorbidities are more serious and occur younger than they do if you don’t have HIV,” Dr. Renslow Sherer, director of the International AIDS Training Center at the University of Chicago, told Healthline. “If you’re on antiretroviral therapy, that mitigates those problems, but it doesn’t reduce the risk back to normal.”
HIV patients are also susceptible to HIV-associated neurocognitive disorders (HAND), a form of dementia. However, now that some people with HIV are living long enough to develop Alzheimer's, HAND can be misdiagnosed and vice versa.
From a treatment perspective this can be problematic because drugs used to treat Alzheimer’s are not the same as those used to treat HAND.
Both aging and HIV are individually associated with chronic inflammation and immunosenescence (deterioration of the immune system). Together, the effects are amplified.
A condition known as inflammaging is used to describe a state of premature aging due to chronic inflammation. It is prevalent in older individuals who are HIV positive.
A study from the journal Clinical & Translational Immunology from 2017 concluded, “A persistent, low-grade chronic inflammation that typically characterizes immunological aging is an essential contributor to several comorbidities in the setting of HIV infection.”
Getting proper treatment
ART is effective at treating many of these comorbidities, but the therapy itself also presents problems for healthcare providers.
“Our biggest challenge actually is not only to diagnose everybody but to [have them] seen in care and remain in care,” says Sherer. “Almost half the patients who have ever been found to have HIV in this country aren’t stably seeing doctors and remaining in care.”
The key to successful HIV treatment does not end in diagnosis. Nor does it end with therapy.
Only through continual, consistent treatment can HIV be managed effectively. When that is done, comorbidities will also be reduced.
Beyond health risks, Crisostomo cautioned that people with HIV entering old age also have to deal with a psychological dilemma:
“Now, just about the time that they talk about finding a cure, we’re starting to lose our friends to old age,” he said.
And the complexity of care needed for some — managing daily doses of ART in addition to the ubiquitous aches and pains of age — can be tricky.
“A lot of people throughout the country who are living with HIV and who aged through this, who say they still have needs, they are told that, you know, ‘You lived, isn’t that enough?’” said Crisostomo.
Sherer also suggested that the headlines touting increased life expectancy should also be tempered in a different way.
Treatment on a national level, let alone global, still has a way to go before the disease is completely controlled.
“It’s a good news/bad news [situation], but I do worry that we might lose some of the sense of what a dreadful disease this still is,” Sherer said.
The disease still remains prevalent among marginalized sections of the population, including African-Americans, men who have sex with me, those who use injectable drugs, and young people.
“They are all increasingly vulnerable populations where it’s much harder to access healthcare, not to mention housing, good nutrition, and regular primary care for all kinds of medical problems,” said Sherer.
“I worry that we’re not promoting this enough because of the sense of complacency that, ‘Oh well, most people could live a normal life expectancy,’” he said. “I think it’s true that it would be misleading to say. ‘Oh it’s a normal life expectancy, so the problem is over.’ It’s not.”