CATIE News

18 February 2020 

Managing medicines may become more difficult as some HIV-positive people age

  • By taking medication as prescribed, a person with HIV can live a long and healthy life
  • A study of older people found those with HIV had more challenges managing medication
  • They were also less likely to report these challenges to their care providers

In Canada and other high-income countries, the widespread availability of potent HIV treatment (ART) has led to significant and sustained declines in AIDS-related illness and death. The power of ART is so profound that scientists expect that many HIV-positive people will have near-normal life expectancy.

However, as ART users become older, their risk for developing age-related issues—cardiovascular disease, diabetes and so on—increases. As a result, middle-aged and older HIV-positive people will very likely be taking other medicines along with ART.

In the past 15 years, entire treatments for HIV have been put inside a pill or a few pills that can be taken once daily. When pills for conditions other than HIV are added to a person’s regimen, it may be difficult to remember to take them, particularly if some pills need to be taken at different times and/or have food requirements.

Scientists in St. Louis, Missouri, who specialize in studying brain health have compared the ability of older people with and without HIV infection to manage medications and plan and schedule their pill-taking at the right times. Overall, HIV-positive people had more difficulty managing their medication-taking. Among HIV-positive people, factors linked to problems with medication management included having a detectable HIV viral load and co-infection with hepatitis C virus (HCV). The scientists also found that some older HIV-positive people may not be able to “self-describe concerns regarding their ability to manage complex medication regimens.”

Study details

Nurses recruited 146 HIV-positive people and 60 HIV-negative people for this study. The average profile of HIV-positive participants was as follows:

  • age – 58 years
  • 80% men, 20% women
  • years of education – 14
  • current CD4+ cell count – 534 cells/mm3
  • lowest-ever CD4+ cell count – 105 cells/mm3
  • proportion with an undetectable viral load (less than 50 copies/mL) – 87%
  • duration of HIV infection – 18 years
  • duration of time on ART – 16 years
  • HCV co-infection – 12%

Participants with the following issues were not enrolled:

  • a history of head injury with prolonged loss of consciousness
  • major mental health conditions – severe depression, bipolar disorder, schizophrenia
  • active brain infections
  • use of street drugs other than marijuana

The HIV-negative people were of similar age to the HIV-positive people.

All participants underwent the following:

  • extensive neuropsychological assessment
  • objective assessment of medication management – this involved validated questionnaires about a simulated regimen consisting of prescribed and over-the-counter medicines. As part of this assessment, participants were required to “manipulate a pill organizer designed for a one-week supply of medications”
  • surveys about their medication-taking and any related problems

Results

On average, HIV-positive people were more likely (42%) to have significant problems managing their medications than HIV-negative people (17%).

The scientists found that the following factors were significantly associated with problems managing medications:

  • having a lower reading level
  • having difficulty planning and organizing complex tasks

When the scientists analysed bio-medical factors, they found that the following were associated with significant problems managing medications:

  • a detectable HIV viral load
  • being co-infected with hepatitis C virus

Also, HIV-positive people with a detectable viral load tended to have a higher average pill burden (11 pills) than HIV-positive people with an undetectable viral load (eight pills).

In reviewing the different tests and survey results, the scientists concluded that older HIV-positive people “are not likely to accurately describe their ability to manage their prescribed medications.” The scientists therefore made the following statement: “It is important for clinicians to recognize that [older HIV-positive people] may require additional attention and time to ensure that they can adequately manage their own medication regimen.”

The scientists encouraged clinicians to make use of recent information from the American Geriatrics Society about the potential unnecessary prescribing of medicines to some older people. The scientists stated that “a careful review and application of such information by clinicians may help reduce the number of potentially inappropriate medications older individuals are prescribed, thereby reducing daily pill burden.”

Limitations

The present study was done with people at one time point. Longer and larger studies of medication management by older HIV-positive people may be more useful to see how problems develop and if they change over time. The scientists did not assess participants’ ability to take their own medicines. Some people may have grown used to taking their medicines and managing them in a certain way at home. When faced with the study’s test regimen, they may have found it unfamiliar and perhaps even confusing.

There are additional measures that could have been done, such as assessing the timeliness of refilling prescriptions at a pharmacy. However, the present study provides data that could be incorporated into a grant proposal for a larger and more comprehensive study of the complexity of medication management by older HIV-positive people.

Not mentioned by the scientists is that some pharmacies can, on request, package a person’s medicines into blister packs. These packages can be divided into days of the week and even further subdivided into morning and afternoon or other intervals. Blister packs and related interventions can take a lot of the hassle out of medication management.

Resources

2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older AdultsAmerican Geriatrics Society

Exploring the impact of aging on the brains of HIV-positive and HIV-negative peopleCATIE News

Problems with movement and muscle coordination found in some HIV-positive peopleCATIE News

Brain fitness leads to improvement for some HIV-positive peopleCATIE News

Exercise found to improve memoryTreatmentUpdate 186

Exercise and the brainTreatmentUpdate 203

Good for the brain—advice from neuroscientistsTreatmentUpdate 203

Menopause and HIV—their impact on cognitionTreatmentUpdate 203

High rates of frailty seen among middle-aged and older HIV-positive people in AlbertaCATIE News

—Sean R. Hosein

REFERENCES:

  1. Cooley SA, Paul RH, Ances BM. Medication management abilities are reduced in older persons living with HIV compared with healthy older HIV- controls. Journal of NeuroVirology. 2020; in press.
  2. Patton DE, Woods SP, Franklin D Jr, et al. Relationship of Medication Management Test-Revised (MMT-R) performance to neuropsychological functioning and antiretroviral adherence in adults with HIV. AIDS and Behavior. 2012;16(8):2286–2296.