When you have HIV, getting older means getting wiser about new health challenges.
Tim Van Nattan is a classic example of an HIV “Lazarus.” In 1995, he was on the brink of dying from AIDS. Thanks to the arrival of HAART, like the biblical character, Van Nattan regained his life. Today, he is a vibrant 60-year-old who runs a small AIDS service organization in Arizona, takes care of his home and two dogs—and rides a motorcycle in his spare time. “The fact that I’m turning 60 is a surprise,” he says. “To be doing it in relatively good physical health is amazing.”
There are more people in Van Nattan’s demographic than you might think. The Centers for Disease Control estimates that in 2004, 15% of those living with the virus were over 50, and many experts say that’s too low. (Some docs don’t realize this is an at-risk group; see “Middle Age, High Risk). Fortunately, scientists like Johns Hopkins University investigator Kelly Gebo, MD, are looking at the impact of older age on HIV disease progression. “As this population ages, it’s going to be a bigger and bigger problem,” she says.
According to Gebo and others, people with HIV need to be especially prepared to face typical age-related illnesses, such as heart disease, cancer, diabetes and osteoporosis. Some HIV medications can accelerate their onset or worsen their severity; in all cases, your HIV meds must be compatible with life-extending drugs for other maladies. “The greatest challenge for older people with HIV is managing the virus in the context of other medical conditions,” says Amy Justice, MD, of the VA Connecticut Healthcare system. “The fact that these issues are present is a testament to the success of HIV treatment.”
This POZ Focus provides you with information about treating your HIV while preventing or managing age-related health problems—and fills you in on treatments that are HIV-friendly or unfriendly. Whatever the latter years of life bring—a second career, grandchildren, motorcycle joyrides—you should be in the best health to enjoy it.
Multiplying Meds: Treating HIV and other illnesses When you’re over 50 and HIV positive it can sometimes be hard to distinguish normal signs of aging from HIV infection itself or HIV med side effects. One study, for example, found that older people on HAART were twice as likely to report lipodystrophy—but, says Justice, this could also be related to “getting older and heavier.” As you age, you and your doc need to keep tabs not just on your HIV but your whole health picture. That includes being aware of risk factors, such as your family history (a major predictor of age-related illnesses) and behaviors such as smoking and drinking alcohol.
Your HIV meds play a role too. They work about the same in people over and under 50 (though we don’t have enough data on this). But as people age, their kidney and liver function declines, slowing the breakdown of drugs in the body and potentially worsening side effects. What’s more, HIV meds can hasten or worsen diseases for which we’re naturally at greater risk as we age.
Van Nattan, for example, says he has “ridiculous cholesterol levels.” Niacin (vitamin B-3) keeps them under control, but he also struggles with peripheral neuropathy—a holdover from an early flawed drug regimen—and sometimes feels mentally confused, what he calls a “brain fog.” He and his doc are starting a complete workup to find the problem’s source.
As you and your doc monitor your health, be aware of any possible interactions between your HIV meds and meds you take for age-related conditions. The older you are the more susceptible you may be to drug interactions. When it comes to older people on HIV meds in particular, “this is really virgin territory—more research needs to be done,” says Stephen Karpiak, PhD, associate director of the treatment group ACRIA, who has written about aging and HIV.
The following is a list of major illnesses over-50 folks should know about—and how HIV affects their treatment. Remember, always consult your doctor about new meds or changing doses.
Cardiovascular disease: As we age, cholesterol builds up in our arteries, so our risk of a heart attack or stroke rises. Protease inhibitors can further raise cholesterol, and the over-50 crowd on HIV meds has to be extra careful.
While there are a lot of ways to reduce the risk of heart attack—exercise, quitting smoking, a healthy diet—lipid-lowering meds can help too. Government HIV treatment guidelines say that among the statins—the most common cholesterol drugs—Pravachol and Lescol are least likely to interact with protease inhibitors. They advise avoiding Mevacor and Zocor, since some protease inhibitors can boost their levels sky-high, possibly causing liver and muscle damage. For the same reason, starting with a low dose of Lipitor is recommended.
High blood pressure: More than half of people over 60 have high blood pressure. It’s not clear whether HIV or HIV drugs increase the risk, but lifestyle changes—quitting smoking, eating less salt and fat, losing weight, reducing stress—and blood pressure medications are effective solutions. Several different drugs treat high blood pressure, including diuretics, ACE inhibitors, beta blockers and calcium channel blockers. While most appear to have few interactions with HIV meds, Richard Havlik, MD, who consults on HIV in older folks, cautions against calcium channel blockers.
Diabetes: Diabetes is a condition in which your body can’t properly process sugar. That can increase the chances of heart disease, and a recent study linked diabetes to impaired cognition in people with HIV. Studies also suggest that HIV drugs worsen blood sugar problems—the risk clearly rises with age. While lifestyle changes play a role in controlling diabetes, the drugs Avandia and Glucophage appear safe for people with HIV. Note: Glucophage may raise lactic acidosis risk if used with some nukes.
Liver disease: Some HIV drugs can cause liver problems, which may be worse for older positive people. Another problem is hepatitis C: 30% of HIV positive folks are coinfected with the virus. Because it usually takes a while for hepatitis C (and hepatitis B) to cause severe liver damage, people often develop symptoms in their forties or fifties. Be aware that the hep C drug ribavirin doesn’t mix well with Videx (ddI) or Zerit (d4T) and, in some cases, Retrovir (AZT).
Kidney disease: With age, the kidneys often become less efficient at filtering the blood. High blood pressure and diabetes are major culprits behind kidney disease, but some HIV drugs also carry renal risks, especially in older people. Talk to your doc about which HIV meds could potentially mean kidney trouble, and have your kidney function checked regularly.
Cancer: Here’s some good news. Most studies show that prostate, breast and colon cancer are not more common in HIV positive people. Having HIV increases the risk of some cancers caused by viruses, including Kaposi’s sarcoma (caused by HHV-8), non-Hodgkin’s lymphoma (EBV) and cervical or anal neoplasia (HPV). It may also increase the risk of a few other cancers, including lung cancer and head and neck cancer. However, none of these cancers are common occurrences. Just be sure to get recommended screenings. Treatment note: Chemotherapy for cancer is complex and often involves multiple drugs, making it difficult to generalize about HIV med interactions.
Osteopenia and osteoporosis: Bone loss—common among women after menopause, but also affecting men—can increase the risk of fractures. The jury is out on whether HAART or HIV raise the risk of osteopenia (reduced bone mineral density) or osteoporosis (more severe bone loss), although some studies have implicated meds like Viread (tenofovir) and the PIs. Many docs recommend vitamin D and calcium supplements. The drug Fosamax safely boosts bone density in people with HIV. Plus, “Older women in particular should get DEXA bone scans,” says Gebo. Quitting smoking, cutting down on alcohol and exercising also help slow bone loss.
Arthritis: Joint pain and stiffness have various causes, from autoimmune reactions to normal wear and tear. Research hasn’t linked arthritis to HIV or its treatment. Commonly used anti-inflammatory drugs don’t appear to interact with HIV meds. Vision problems: It’s not unusual for vision to decline with age, but if you notice any sudden changes—especially if your CD4 count is low—get checked for CMV retinitis.
Cognitive problems: Mental function, including memory and concentration, normally declines as we age, but cognitive impairment can also be due to HIV medication side effects. There’s a long list of drugs to treat cognitive problems that should be avoided or used with caution in patients over 65, so talk to your doctor.
Depression: There are many treatment options for depression, including exercise, therapy, support groups, antidepressants, adjusting your HIV meds or a combination of these. Potential interactions exist between some antidepressants and HIV drugs, but common SSRIs (like Zoloft) can be safely used at the usual doses. Some believe that certain meds—like Sustiva (efavirenz) and interferon used to treat hepatitis C—can complicate depression. Skip the St. John’s Wort; it can interact with protease inhibitors.
Erectile Dysfunction: Blood levels of Viagra, Levitra and Cialis may rise when combined with PIs and some non-nukes. Talk to your doctor about using a lower dose of ED drugs to reduce the risk of side effects.
Making It Count With improvements in HIV therapy, positive people can live long, active lives. The more aware you are of conditions linked to aging, the better you’ll be able to prevent or manage them along with HIV. Always ask your doctor about symptoms as well as possible drug interactions.
While much remains to be learned about HIV in people over 50, one thing is clear: Healthy habits and regular health maintenance can lead to better quality of life. It’s a lesson Van Nattan, who now has a nearly undetectable viral load, learned years ago. He quit smoking, eats a healthy diet and exercises every day. The VA’s Justice approves: “Those are things I’m pushing on my patients. They’re clear wins.” But Van Nattan knows that life is about more than just healthy habits. “No matter what the day brings,” he says. “I try to do something either fun or gratifying.” Now that’s aging gracefully.