Susan Herrmann1, Matthew Skinner2
- Institute for Immunology and Infectious Diseases, Murdoch University WA
- Sir Charles Gairdner Hospital, WA
Last reviewed: April 2016
Next review due: February 2020
While a cure remains elusive, longevity in the context of human immunodeficiency virus (HIV) infection is attainable for those with access to primary health care and antiretroviral therapy (ART). In Australia, between the years 1996 and 2006 the number of people with HIV infection over the age of 65 years grew tenfold. By 2012 about 10% of new diagnoses were in people aged 50-59, reflecting a global trend of prolonged survival and late acquisition among older adults. However, despite the positive outcomes of effective and tolerable treatments, it is becoming increasingly evident that independent factors related to HIV infection are complicating the ageing process for people living with HIV.
As a matter of definition the Australian Government considers age chronologically and, accordingly, people aged 65 years and older are classified as 'older'. Coupled with this definition is the notion of 'biological' ageing and the general perception of deficit-associated changes even in the absence of identifiable pathology  This concept creates a boundary between so-called 'normal' ageing and 'abnormal' ageing. and these boundaries, constructed in a Western context, influence the practice of medicine as it relates to older individuals in society.
Biological ageing per se is characterised by substantial heterogeneity between individuals modified by genetic, epigenetic and psychological factors. It is increasingly recognised that many of the physiological changes and diseases associated with ageing, such as cardiovascular disease and osteoporosis, are modifiable or preventable. However, HIV infection in the absence of a cure, is not inherently modifiable and evidence suggests that HIV infection augments biological ageing directly by way of prolonged immunodeficiency, chronic immune activation and side effects of treatment; and indirectly via anxiety and depression.
In addition to conditions commonly associated with ageing in the general population, HIV-associated immunopathology and the diverse pathways that have led to the HIV seropositive status, such as injecting drug use, sex work and men who have sex with men, represent additional risk factors influencing health in later life. High rates of anxiety and depression, substance use and comorbidities together with cumulative unresolved side effects of earlier therapies, e.g. peripheral neuropathy and lipoatrophy, are additional stressors on physiological and psychological systems, which affect health-related quality of life. Consequently, addressing potentially modifiable stressors is a hallmark of quality HIV care. It is becoming evident that people with HIV infection, especially those with a history of prolonged immunodeficiency, have complex care needs at the end of life.
While HIV management in Australia can be framed within chronic disease models, there is a need to consider HIV-related influences on ageing including taking a 'life course perspective', and to integrate geriatric principles into care that maximises mental and physical function, minimises frailty and directly addresses factors that affect quality of life. Rowe and Kahn proposed deflecting focus from a pathological vs non-pathological definition of ageing by articulating three components of 'successful' ageing: low risk of disease and disease-related disability; maintenance of high mental and physical function; and continued engagement with lifestyle. These components provide a goal-oriented framework for HIV management in older Australians. In this section we will explore some of the issues associated with HIV and ageing and provide guidance for practitioners.