Wednesday 29 June, 2016 13.00 EDT
Managing your health: a guide for people living with HIV
18. HIV and aging
It’s very good news that people with HIV are paying attention to issues around aging. It means we are surviving and getting older like the rest of the population! Sometimes it’s hard to tell whether a symptom is due to HIV or aging. We need to take good care of ourselves, be proactive and pay attention to changes in our bodies as we age.
This information is just for you, but also see other chapters of Managing your health that apply to all people with HIV.
The challenge of HIV in an aging population
Thanks to advances in treatment, people with HIV are living much longer than ever before. It is estimated that up to 12 per cent of HIV-positive people in Canada are older than 50 years of age; this number is expected to increase by as much as 20 per cent over the next decade.
Unfortunately, the number of people older than 50 who are newly diagnosed with HIV is also growing. In many cases, the person has been living with HIV for some time without knowing it, giving the disease a chance to advance significantly and making it more challenging to find effective treatment. This trend towards a late diagnosis in older people signals the need for better understanding of sexual activity and injection drug use in the over-50 population and the need for better prevention education for this age group.
Clearly, early diagnosis of HIV infection is important no matter what your age. Early diagnosis becomes even more critical the older you are, however, as HIV progresses more quickly with age. The good news is that anti-HIV drugs appear to work just as well whether you are 52 years old or 25. And studies show that age and better control of HIV seem to go hand in hand. Those who are HIV-positive later in life tend to achieve and maintain an undetectable viral load more often than do younger people with HIV, possibly because they are better at following treatment instructions. An undetectable viral load means that the number of viral particles in the blood is lower than can be detected by tests.
Overall, the issues associated with treatment of HIV become more complex with age. This is because the chances of having other diseases that also require treatment, including high blood pressure, arthritis or even cancer, also increase with age. Taking several different drugs at the same time can raise your risk of drug interactions, side effects and toxicities. And while careful monitoring of all drugs is essential, this is especially true when you are 50 or older.
The side effects of anti-HIV drugs, discussed in Chapter 11, Side effects and symptoms, don’t appear to occur more often in people with HIV as they get older, but they can be made worse by the side effects of other non-HIV drugs. Decreases in kidney and liver function that come naturally with age also increase the potential for higher drug toxicity, as can changes in hormone levels and metabolism, as well as weight loss associated with aging.
Is it HIV or is it age?
Many of the health changes that occur with aging can be similar to the symptoms of HIV as well as to the side effects of HIV treatment. Let’s take a look at some of the health conditions associated with both age and HIV.
Overall immune system decline
As you age, your immune system becomes less effective at protecting your body from infection and disease. This is why HIV progresses more quickly in people who are older and why early diagnosis of HIV is so important.
Cardiovascular disease is a broad term that includes coronary heart disease, heart attack and stroke. It is often referred to as heart disease. As you age, the risk of developing heart disease increases, whether you are HIV-positive or not. Women older than 55 and men older than 45 are at higher risk of developing heart disease. If you have other members in your family who have heart disease—a father, a mother, an uncle or a sibling, for instance—your risk of developing heart disease will be higher than the person who doesn’t have a family history.
While you can’t control risk factors for heart disease such as your age and family history, there are many lifestyle risk factors you can control. These include:
- being overweight;
- lack of exercise;
- poor diet;
- excessive alcohol intake;
- high blood cholesterol and blood lipids or fats;
- high blood pressure or hypertension.
The relationship between HIV and heart problems is not fully understood but is being studied. However, some studies show that anti-HIV drugs such as some protease inhibitors can increase the risk of heart problems by raising the level of cholesterol and triglycerides in the blood (see Chapter 11, Side effects and symptoms). Other research suggests it may be HIV itself that causes heart problems. In either case, it is clear that the benefits of anti-HIV treatment far outweigh the risks of heart disease.
For most women, menopause occurs between the ages of 45 and 55. During this time, the production of female hormones (estrogen and progesterone) declines, eventually causing menstruation (periods) to stop completely.
Although the impact of menopause on women with HIV has not been well studied, menopause does appear to occur earlier in some women with HIV. Just why is not clear, but there are many possible factors in addition to treatment. They include:
- a low red blood cell count or anemia;
- decreased production of the hormones estrogen and progesterone;
- weight loss;
- reduced CD4+ cell count;
- use of street drugs, such as heroin and methadone.
Menopause brings with it an increased risk of many health problems, including:
- cancer of the breast, lung or ovaries;
- emphysema and other lung diseases;
- cardiovascular (heart) disease.
Many of the symptoms of menopause and HIV overlap. This can result in a missed or late diagnosis of HIV or difficulty determining the cause of symptoms. They include:
- hot flashes;
- night sweats;
- skin and hair changes;
- trouble sleeping;
- emotional changes/mild depression.
Talk to your doctor if you have a family history or concerns about any of these health conditions or menopause symptoms (see Chapter 15, Women and HIV).
Your bones are living and growing. The strength of your bones, or bone density, is determined by the amount of calcium, phosphorous and other minerals they contain.
When you have HIV, your risk of some bone disorders increases, whether or not you are on treatment. Research suggests that up to one-third of people with HIV may have early-stage bone loss or osteopenia.
Age is also a risk factor for bone problems, as is gender. Women, for instance, have a higher risk than men of osteoporosis, a bone disease that causes bones to become thin and fragile and to break easily, particularly at the hip, spine and wrist. This is partly because women have 30 per cent less bone mass than men. But women are also particularly vulnerable to osteoporosis after menopause, when the hormone estrogen—a key factor in maintaining bone strength in women—is no longer produced by the ovaries. On the other hand, HIV appears to cause more bone loss in men than in women, cancelling out or even reversing the advantage that men usually have.
Other risk factors for both men and women include a family history of osteoporosis, smoking and a sedentary lifestyle. See Chapter 11, Side effects and symptoms, for more information on bone disorders.
Before HAART was introduced in the mid-1990s, the most common cancers in people with HIV were the HIV-related cancers, including Kaposi’s sarcoma, non-Hodgkin’s lymphoma and cervical cancer (see Chapter 12, HIV-related infections and cancers). Now, thanks to more effective HIV treatment, these cancers are less likely to occur when you have HIV.
On the other hand, the chances of developing both HIV-related and non-HIV-related cancers increases as you age. Both men and women older than 50 are at an increased risk of developing colon and/or rectal (colorectal) cancer, for instance. In fact, some research indicates that age-related cancers are more common than HIV-related cancers among persons on HIV treatment.
Other non-HIV-related cancers seen in people with HIV 50 years of age and older include:
- skin cancer;
- lung cancer;
- prostate cancer;
- anal cancer;
- liver cancer (mostly in those who are co-infected with hepatitis C).
Insulin is a hormone produced by the pancreas to control the amount of sugar or glucose in the blood. Diabetes occurs when your pancreas cannot make enough insulin.
There appears to be a link between treatment with anti-HIV drugs and a rise in blood sugar levels leading to diabetes (see Chapter 11, Side effects and symptoms). There are numerous lifestyle measures that can help you keep your blood sugar levels within the range of normal.
- Limit the amount of sugar and starchy foods in your diet, such as desserts, soft drinks, white rice or potatoes.
- Choose whole grains and unprocessed foods that contain fibre, such as barley, brown rice and oats as healthy grain choices.
- Eat smaller amounts.
- Eat a balanced diet, including healthy protein sources such as lean meats and at least two servings of fish per week.
- Exercise as often as possible, ideally every day (see Chapter 4, healthy living).
Dementia is a brain disorder that can affect your memory and ability to think clearly. It can have a serious impact on your daily activities, quality of life and even your ability to live independently. Fortunately, the rate of HIV-associated dementia has greatly declined since more effective anti-HIV drugs became available in the mid-1990s. Nevertheless, as you age, you may be at increased risk of developing dementia not associated with HIV (non-HIV-associated dementia). It’s important to speak to your doctor as soon as possible if you become aware of early signs of dementia, such as difficulty remembering, concentrating or completing basic tasks.
Depression is quite common in people with HIV of all ages. If you are experiencing symptoms of depression, such as fatigue, sleep problems or feeling hopeless, talk to your doctor. Some of these health problems can be caused by HIV and treatment as well as other conditions that can occur as you age.
Depression can also be a side effect of some anti-HIV drugs as well as other medications, such as those used to treat hepatitis C. It’s very important to see your doctor and get treatment and support.
For more information on your emotional and mental health, see Chapter 6, Your emotional health.
It is possible to have a healthy and satisfying sexual life when you are HIV-positive and when you are aging. In fact, sexual health is essential to your well-being.
Sexual problems and low libido (sex drive) can occur in men and women especially as we get older. It’s a sensitive issue that often gets swept under the rug and not addressed. Some possible causes are:
- HIV itself;
- drug side effects;
- hormone imbalances (including low testosterone in women);
- cardiovascular (heart) disease;
- stress and depression.
It’s important to talk to your doctor about sexual problems since, in many cases, they can be treated and you can have a satisfying and happy sex life.
For more information on how to keep your sex life happy and healthy, see Chapter 7, Your sexual health.
For a complete list of all recommended screening tests for people with HIV, see Chapter 9, Monitoring your health.
While HIV is monitored using routine tests, additional tests may be required to monitor your health status as you get older. These tests include:
- Bone density scan A scan of your lower spine and hip measures your bone density and is recommended every two years.
- Fasting blood glucose test A blood test for diabetes is recommended every three to six months.
- Lipid profile test These blood tests check total cholesterol, LDL (bad fats), HDL (good fats) and triglycerides. They are recommended one to two times a year, depending on your risk factors for heart disease.
- Kidney function test Kidney function declines with age, and certain anti-HIV drugs are processed through the kidneys. For both these reasons, a blood and/or urine test is recommended periodically. Speak to your doctor.
- Blood-pressure monitoring A blood-pressure monitor measures the force of blood against the walls of the arteries and indicates your risk of developing heart disease.
- Colorectal cancer screening A few tests can detect cancer of the colon or rectum. Tests can include a digital rectal exam, stool test or a scope inserted into the rectum. Your doctor will advise you on how often you should be screened.
For women only
- Pap test A Pap test collects cells from the cervix for examination under a microscope. It is used to detect changes that indicate the presence of cancer or changes that may lead to cancer. It is recommended that sexually active women with HIV have Pap tests every six months to a year.
- Breast exam In order to detect possible early signs of breast cancer, your doctor will check for lumps or other abnormalities in your breasts, nipples and armpits. A breast exam is recommended once a year, usually combined with your Pap test.
- Mammogram A mammogram uses a low-dose X-ray to examine each breast. It is used to look for different types of tumours and cysts. It is recommended once a year for women over 40.
- Pelvic exam A pelvic exam is a physical examination of the internal and external pelvic organs. It is usually combined with a Pap test every six months to a year.
For men only
- Prostate exam A manual digital exam of the rectum is recommended yearly for men over 40. Your doctor may also order a PSA blood test, which screens for prostate cancer.
Coping with loss
It is wonderful and even miraculous that many people with HIV are now living long enough to experience middle age and beyond. Living with a chronic illness such as HIV can be difficult at the best of times, however, and this can affect your quality of life. Losses you may have experienced as a result of being HIV-positive, such as the loss of health, employment, income, youthful good looks—even the loss of friends who have died because of AIDS—can be devastating.
Here are some ways to combat isolation and improve your overall quality of life:
- get involved in your community;
- create a strong social and support network;
- exercise your mind and keep mentally active;
- manage stress and depression;
- eat a healthy diet;
- sleep well;
- get outdoors and exercise physically;
- cultivate a positive outlook;
- quit smoking;
- avoid excessive alcohol;
- have a spiritual practice;
- have a healthy sexual relationship.
When you reach 65, you may find yourself with a reduced income. Government disability or private insurance benefits may cease and you may need to live on an even stricter budget. This can cause much stress and anxiety. It’s important to seek support and or advocacy from your local AIDS organization or other appropriate supports.
For more information on financial issues related to living with HIV, see Chapter 20, Money matters.
HIV and aging - healthy living tips for people 50 and over living with HIV
The Positive Side– Health and wellness magazine contains articles about aging, such as:
- Growing old gracefully – Recent advances in treatment mean people with HIV are not only living better, they’re living longer. Here’s how to deal with the new reality.
HIV Wisdom for Older Women – Web site dedicated to the prevention of HIV in older women and to life enrichment for those who are living with HIV
Other relevant resources can be accessed through the CATIE Ordering Centre or by calling CATIE at 1-800-263-1638.