9 Healthy Aging Tips for People Living With HIV

Increased Focus Being Placed on Keeping an Aging HIV Population Healthy

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As the early testing and treatment of HIV have increased life expectancy rates to that of the general population, greater emphasis is now being placed on the good health of those aged 50 years and older, who often experience premature frailty and illness as a result of long-term infection.

According to data from the Centers for Disease Control and Prevention (CDC), more than 25% of 1.2 million Americans living with HIV—or approximately 313,000 people—fall into this aging HIV population.

Estimates suggest that, within the course of a few years, that figure could rise to as much as 50%.

Causes of Premature Illness in People with HIV

The chronic inflammation associated with HIV has been implicated in the higher rates of non-HIV-associated diseases (such as cardiovascular disease, cancers, neuro-cognitive disorders and type 2 diabetes), which often appear ten to 15 years earlier than what would be expected in the general, non-infected population.

Even for individuals on successful HIV therapy, who are able sustain undetectable viral loads for years at a time, there remains a significantly high risk for these aging-associated effects.

While the mechanisms for this condition—known as premature senescence—are not fully understood, it is widely accepted that chronic inflammation can diminish a person's immune function in a way that is not dissimilar to that of older adults, wherein the body simply "ages before its time."

And it appears to affect many, if not all organ systems to some degree. Even a person's T-cells, central to the immune response, become less and less capable of identifying and neutralizing foreign agents when under the burden of this persistent, inflammatory reaction.

To complication matters even further, both HIV and a number of antiretroviral drugs have been linked to increases in visceral (intra-abdominal) fat in people with HIV, which only adds to the burden by secreting pro-inflammatory proteins directly into the bloodstream.

So what can a person do to live healthier with HIV, avoiding the illnesses and conditions associated with long-term infection?

1. Get Tested Today

It may sound obvious, but as many as 20% of Americans living with HIV not been tested for the virus and, according to the World Health Organization, as much as 50% of the world’s HIV population are as of yet untested.

Current guidance from the U.S. Preventive Services Task Force calls for the one-time HIV testing of all Americans aged 15-65 as part of a routine doctor visit. Other higher risk groups, including sexually active men who have sex with men (MSM), are encouraged to test annually. 

Without testing, there is no way to implement the one thing than can best ensure the long-term good health for people living with HIV, and that is…

2. Start HIV Treatment Today

In July 2015, a study presented at the 8th International AIDS Society Conference in Vancouver called for the immediate initiation of antiretroviral therapy (ART) for all people with HIV, irrespective of disease stage or CD4 count.

The study, known as the Strategic Timing of Antiretroviral Therapy (START) trial, confirmed that prescribing ART on diagnosis reduced the likelihood of illness and death by 53%, while slashing the risk of non-HIV-associated conditions like cardiovascular disease (CVD) and some cancers by nearly two-thirds.

By contrast, even those rare individuals able to sustain undetectable viral loads without ART—people known as "elite controllers"—are twice as likely to be hospitalized, three times as likely to be hospitalized for CVD, and four times as likely to be admitted for psychiatric conditions when compared to non-elite controllers on fully suppressive ART.

If there is one "must" to living long and well with HIV, this is it. It is the one and only place to start.

3. Stop Smoking

This is not just another public service announcement. The startling truth today is that people living with HIV are twice as likely to be smokers as non-infected people (42% vs 21%, respectively), resulting in nearly double the risk of acute heart disease, twice the likelihood of death from respiratory illnesses, and a 14-fold increase in the risk of lung cancer.

In fact, multiple studies have concluded that smoking remains the single greatest risk factor in the development of morbidity and mortality in people living with HIV, reducing life expectancy by a startling 12.3 years compared to HIV-infected non-smokers.

While smoking cessation programs are not always easy—requiring an average of eight attempts before successfully quitting— access to treatment has been far simpler under the Affordable Care Act, with two annual quit attempts allowed by Medicare and a variety of treatment programs offered through Medicaid in all 50 states.

4. Get Your Shots

It's surprising the number of people with HIV who either avoid, ignore or are simply unaware of type of shots or oral vaccinations they may need. These include such immunization series as those for hepatitis B, human papillomavirus (HPV), pneumococcal pneumonia, and (yes) the annual quadrivalent flu shot.

An ounce of prevention takes on a whole, new meaning when, for example, the risk of anal cancer, strongly associated with HPV infection, is known to be 25 times greater in people with HIV, while cervical cancer carries a striking, five-fold increase. A simple, three-dose HPV vaccine is all it would take to cut the risk of these cancers by as much as 56%.

Before embarking on any immunization series, be sure to meet with your doctor to discuss options and risk. While many will significantly reduce the risk of HIV-associated comorbidities, others can actually hurt you, particularly if your immune system is severely compromised.

5. Discuss Statins with Your Doctor

According to a study from the Johns Hopkins University School of Medicine, the use of cholesterol-lowering statin drugs, combined with ART, can reduce the risk death in people with HIV by 67%. The investigators reported that, in addition to lowering harmful cholesterol levels, statins also appear to significantly reduce chronic inflammation.

While this doesn't mean that statin drugs are indicated for all people living with HIV, it does strongly suggest the benefits of regular lipid monitor and other indicators of cardiovascular disease—particularly in older patients or in those with associated risk factors (e.g., family history, smoking, etc.).

6. Vitamin D and Calcium Supplementation

Low bone mineral density (BMD) is regularly noted in people with HIV, resulting in higher rates of bone and hip fractures, as well as the premature development of osteoporosis. BMD losses of between 2% and 6% are commonly seen within the first two years of starting ART, a rate similar to that of women during the first two years of menopause.

As a result of these and other statistics, it is currently recommended that all post-menopausal women with HIV be provided DEXA (dual-energy x-ray absorptiometry) scanning to assess for possible bone loss, as well as all HIV-positive men over the age of 50 .

In terms of maintenance, a number of studies have suggested that co-administration of a daily vitamin B and calcium supplement may help reduce the risk of bone fractures. While the research remains far from conclusive, current U.S. guidelines recommend between 800-1000mg of oral vitamin D per day and 1000-2000mg of oral calcium per day. 

Patients with osteoporosis may benefit from such first-line drugs as alendronate (Fosomax) and zoledronic acid (Zometa), which may help prevent osteoporotic fragility fractures.

7. Diet and Exercise

Perhaps even more than smoking, the words "diet" and "exercise" tend to elicit indulgent grins (and even the occasional rolling of the eyes) from patients, as if they were  somehow down-home homilies rather than the actual medical advice that they are.

But consider this: people living with HIV are prone to often-profound increases in body fat, due not only to HIV itself but to the drugs used to treat the disease. And even for those on fully suppressive ART, it is not uncommon to see 40% gains in limb fat and 35% gainss in abdominal fat, with an associative increase in both CVD and type-2 diabetes risk.

In addition to a provision for statin drugs, the daily management of HIV should include a balanced, reduced-fat diet and an informed combination of aerobic and resistance training, irrespective of age, CD4 count or disease stage.

Before starting ART, both lipids and blood glucose levels should be tested, with the regular monitoring thereafter to track the potential development of CVD and/or diabetes.

Bottom line: don't rely on tablets or diet alone to address weight issues, or take an aerobics-only approach to redressing lean muscle loss.  Work with your doctor and ask for referrals to qualified nutritionists and fitness experts in your area—,particularly if you are overweight, in poor health, have a cardiovascular or diabetes concern, or are in simply need of guidance.

8. Get Regular Pap Tests and Mammograms

Special consideration should be made for women living with HIV, not only to ensure the prevention of cervical cancer and other related comorbidities, but to address issues relating to pregnancy, HIV serodiscordancy (i.e., where one partner is HIV-positive and the other is HIV-negative), and the prevention of mother-to-child HIV transmission.

Women should actively discuss any plans or intentions they may have regarding pregnancy upon initiation of care, while ensuring regular mammogram screening as indicated (annually for women over 50 and individualized for women between the ages of 40 and 49).

HIV-positive women should also be given a cervical Pap smear, again upon initiation of care, with repeat tests performed every six months thereafter.

9. Never Treat HIV in Isolation

One of the misconceptions about HIV management is that it is bounded with a fixed number of lab tests (CD4 count, viral load) and routine screenings (STDs, hepatitis), combined with regularly scheduled visits to your HIV specialist. And that's pretty much it.

With greater focus being placed on the long-term comorbidities, many have begun to call for the normalization of HIV, treating it a facet of primary care rather than as an isolated specialty. This means changing the way that we look at HIV today, both patients and doctors. It means understanding that HIV cannot be treated in isolation but rather an integrated part of our long-term healthcare.

As such, it's important to always advise your HIV doctor about any specialist care you may be receiving, including any hospitalizations or outpatient visits. And don't presume that something is necessarily "unrelated" to HIV, especially since the disease can manifest with any number of associated complications, from eye problems to oral/dental disease to neurologic disorders.

And finally, if your primary care physician is different than your HIV doctor, be sure that they always share results, including lab tests and other reports vital to your long-term care.

Sources:

Centers for Disease Control and Prevention (CDC). "HIV Among People Aged 50 and Older." Atlanta, Georgia; accessed August 3, 2015.

Capeau, J. "Premature Aging and Premature Age-Related Comorbidities in HIV-Infected Patients: Facts and Hypotheses." Clinical Infectious Diseases. October 31, 2011; doi: 10.1093/cid/cir628.

The INSIGHT START Study Group. "Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection." New England Journal of Medicine. July 20, 2015; DOI: 10.1056/NEJMoa1506816.

Mdodo, R.; Frazier, E.; Mattson, C.; et al. "Cigarette smoking among HIV+ adults in care: Medical Monitoring Project, US, 2009." 20th Conference on Retroviruses and Opportunistic Infections (CROI 2013). Atlanta, Georgia; March 3-6, 2013: Abstract 775.

U.S. Department of Health and Human Services (DHHS). "Recommended Immunizations for HIV Positive Adults." Washington, D.C.; issued June 9, 2009; accessed August 3, 2015.

Cannon, J. "Keeping Fit with HIV – ACSM Guidelines Make Exercise Possible for Patients." Today’s Dietician. October 2011; 13(10):86.

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