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The Aging HIV Patient: Sharpening Skills, Grasping Guidelines (Article)

INTRODUCTION

In June 1981, the U.S. Centers for Disease Control and Prevention (CDC) announced a mystery: they had fielded reports of a cluster of cases of rare Pneumocystis pneumonia—an infection usually confined to people with failing or impaired immune systems—among homosexual men. In the many cases that followed—and this infection spread aggressively—approximately half of affected individuals were heterosexual. Many developed Kaposi's Sarcoma, a very rare cancer. Within a year, the syndrome had a name: acquired immune deficiency syndrome (AIDS). Patients who developed AIDS were plagued with opportunistic infections usually seen only in the immunocompromised, yet they had none of the usual risk factors associated with immunodeficiency (e.g., they were not taking corticosteroids, being treated for cancer, elderly, pregnant, compromised by chronic conditions). Hence, the mystery.¹

This mystery began almost 40 years ago and galvanized by perhaps the strongest advocacy movement from a constituency with a specific disease ever experienced in the United States, medical researchers have changed the human immunodeficiency virus (HIV)-infected individual's prospects. The likely prognosis of impending death in the 1980s has improved to decades of life for most People Living with HIV (PLWH) today. Under 3 conditions—early diagnosis, early treatment with antiretroviral therapy (ART), and excellent adherence—PLWH can expect to live almost as long as others.^2,3 For these reasons, health care providers need to understand and appreciate the intricacies of care for the aging individual who has HIV over decades.

This continuing education activity focuses on older people infected with HIV, specifically the individual who has had the infection for many years. The U.S. Department of Health and Human Services (DHHS) Adult and Adolescent HIV Treatment Guidelines now address older individuals because the majority of PLWH are now older than 50.^4,5 It is also important to remember that older individuals are at elevated risk for HIV transmission or acquisition.⁴ Table 1 lists reasons why this population presents unique concerns for health care providers.

People who achieve and maintain viral suppression are less likely to acquire AIDS-defining conditions; AIDS-defining conditions (discussed below) include opportunistic infections, HIV wasting syndrome, HIV encephalopathy, Kaposi's sarcoma and similar conditions. Consequently, they are experiencing a widening spectrum of non-AIDS diseases.^7-9 Life expectancy among PLWH on antiretroviral therapy (ART) is almost identical to the general population,¹⁰ and by 2020, 70% of PLWH will be 50 years of age or older.^2,3 Of note, these patients develop more non-AIDS conditions unrelated to HIV infection than others.¹¹

It's time to start managing HIV as a chronic disease. Pharmacists need to integrate themselves into the treatment team. Pharmacists can help move the traditional multidisciplinary team (teams with representation from multiple disciplines) or interdisciplinary team (teams with representation from several disciplines that encourage conversation among the disciplines) to transdisciplinary status. This newer transdisciplinary approach to care is eminently applicable to HIV and other chronic conditions. In transdisciplinary teams, shared team mission, role overlap, and integrated responsibilities, training, and leadership are emphasized and pivotal.^12,13 In the HIV setting, transdisciplinary team members collaborate to provide overlapping counseling, monitoring, and adherence advocacy.

Multimorbidity in the Older Adult with HIV

When aging and HIV intersect, the risk for comorbidities associated with aging is elevated. With most PLWH now between the ages of 50 and 65 years, health care providers see a population experiencing high rates of comorbid illnesses.^14-16 Liver disease—which is sometimes related to infection with hepatitis—cancers, cardiovascular disease, frailty, kidney impairment, neurocognitive decline, and osteoporosis all seem to have different profiles in PLWH. In PLWH, non-HIV issues related to immunocompetence and lifelong treatment with antivirals also create some unique situations. Compared with people who do not have HIV, PLWH are ^14,17-24:

• 4 times more likely to develop type 2 diabetes mellitus.
• At significantly elevated risk of cardiac disease.
• At risk of HIV–hepatitis C virus (HCV) coinfection. Coinfection is common because of similar risk factors and shared routes of acquisition. It is also linked to earlier HCV- induced fibrosis and lower odds of successful treatment outcome with interferon-based therapy.
• At high risk for lymphoma and cancer.
• Likely to harbor misconceptions about smoking. Approximately half of HIV-infected people smoke or continue injection drug use (IDU).

Therefore, older PLWH may have several serious health conditions that cannot be cured, but only managed. Debilitating conditions, when superimposed on normal aging, are synergistic and lead to more morbidity and mortality than otherwise expected. Multimorbidity is not unique to PLWH, but the presence of 2 or more chronic diseases in PLWH creates a complex chronic disease constellation. Polypharmacy (use of 5 or more medications) adds an additional layer of complexity. Multimorbidity requires provider expertise and a transdisciplinary approach for best outcomes.^25-27

Health care providers also need to consider geriatric syndromes, e.g., sarcopenia (loss of skeletal mass normally seen in association with aging), falls, urinary incontinence, and other conditions that often lead to nursing home admission.²⁸ These interrelated medical conditions generally occur in older adults, especially frailer adults. Consider this:

• PLWH who were infected early in the HIV epidemic often developed frailty, profound and unexplained wasting, and fatigue. (Experts have yet to agree on a definition for frailty.) Risk factors for frailty in the HIV-infected person are similar to those in the uninfected individual: medication toxicities, greater immune system dysfunction, and chronic inflammation. In PLWH, however, their complex medical and socioeconomic situations complicate the frailty picture. At this time, it appears that frailty in HIV- infected patients is more closely related to the development of AIDS than just HIV infection.²⁸
• The HIV clinical community considers sarcopenia an emerging issue in PLWH. Both HIV infection itself and certain ART have been associated with myopathy. PLWH appear to be at significantly elevated risk of sarcopenia, which can increase the risk of frailty and falls in aging individuals.²⁸
• HIV-infected individuals tend to experience falls at rates similar to uninfected individuals. They begin to experience falls at an earlier age, however (around middle age). Approximately one third of PLWH report falls between ages 45 and 65 years.²⁸

Researchers are studying the underlying causes of multimorbidity in the aging HIV population. Research suggests that microbial translocation (translocation of microbial products from the gastrointestinal tract to portal and systemic circulation), chronic inflammation, oxidative stress, and immune senescence account for some of the increased morbidity, with chronic inflammation cited most often as a primary contributor.^29,30 At infection, HIV prompts an inflammatory cascade that continues even after patients start ART. Other sources of inflammation include significantly higher levels of alcohol and tobacco use among PLWH,^31,32 past and current illicit substance use, and HCV coinfection.^33,34 Depression, anxiety, HIV-related stigma, ageism, and social isolation are probable influences,^35,36 as are stress, poor nutrition, and sedentary lifestyle.^37,38 Cumulatively, these factors seem to explain the high rates of multimorbidity in PLWH.

Tailoring Care

Treating aging HIV-infected individuals means applying geriatric principles in concert with clinical HIV treatment guidance. Rather than focusing on disease, these principles focus on implementing interventions that address and improve function.

When providing care for older PLWH, clinicians should first identify modifiable risks and develop achievable goals.^39,40 To do this, clinicians should examine the patient's entire health picture, and might give more weight to the HIV diagnosis and treatment, which adds additional areas of concerns, e.g., adherence, drug-drug, drug-disease, and disease-disease interactions. Next, the transdisciplinary team must appreciate syndromes underlying affected organ systems and disease severity more than specific diagnoses.⁴⁰ Some diseases may remain asymptomatic, but organ system failure always creates symptomatic morbidity and mortality. Finally, the team needs to consider mental health, social vulnerability, and barriers to care delivery; these tend to increase as health declines.⁴¹

HIV Treatment

Cohort studies indicate that, without treatment, older PLWH have a more rapid progression to AIDS and shortened survival than younger PLWH.^42,43,44 Unfortunately, most randomized, controlled ART therapy clinical trials exclude PLWH who are older than 50 or 60 years. Retrospective studies confirm that ART improves survival rates,⁴⁵ but starting ART late in life is associated with delayed and diminished CD4 cell recovery.^{46-49 T}this is due in part to later diagnosis of HIV, which is associated with more severe HIV.⁴ Virologic response rates, however, appear to be good, and similar to those experienced by younger PLWH.^47,48

In the past, medical professionals used the patient's CD4 count to determine when to start antiretroviral therapy. Today, treatment guidelines recommend that clinicians urge patients to begin ART when they are diagnosed with HIV infection.4 Starting ART early lowers the risk of a variety of HIV-related illnesses and dramatically reduces the chance of passing HIV to an HIV- negative sexual partner. In addition, many of the newer HIV medications are more effective, easier to take, and have fewer side effects. Once HIV patients begin ART, they must continue taking antiretrovirals (ARVs) for the remainder of their lives. Patient should only discontinue ART under medical supervision if they experience significant or life-threatening side effects.⁴

Since January 2016, the DHHS Antiretroviral Therapy guidelines have specifically addressed ART use for persons 50 and older.⁴ Here they emphasize that all PLWH older than 50 years of age should start ART regardless of CD4 cell count. The rationale is clear: compared with younger patients, older HIV-infected individuals are at increased risk for non-AIDS related complications and their CD4 cell count recovery in response to ART is diminished.⁴ The only barrier should be the patient's readiness to start ART and commit to lifelong adherence. Pharmacists are well placed to help patients understand why they need to start ART and how they can remain adherent. Table 2 lists currently available ART.

The goals of managing HIV/AIDS are to slow progression of the infection, reduce opportunistic infections (OIs), prolong survival, improve quality of life, and prevent transmission.⁴ What do pharmacists need to know about ART use in older populations? First, they need to be aware of several challenges^4,44,47:

• Older PLWH, like all older adults, often have non-HIV-related comorbid medical conditions, such as hyperlipidemia, hypertension, diabetes, and coronary artery disease. Elderly patients are treated similarly to younger patients, but disease states that older patients may encounter (osteoporosis, CKD, chronic liver disease with cirrhosis, hyperlipidemia, increased cardiovascular risk) and polypharmacy will drive decisions about appropriate ART regimens. (Interested readers will find more information about these decisions in the DHHS Guidelines.)
• Older adults may have age-related changes in body composition that can alter volume of distribution and influence pharmacokinetics. The DHHS Guideline includes an important table that describes dosing adjustments for specific ARTs in the presence of renal or hepatic insufficiency.
• The likelihood for drug-drug interactions is high because many older adults need medication for comorbidities. Table 3 lists the most common antiviral interactions; readers should note that the DHHS Guideline recently removed its comprehensive drug interaction table, and this table is a general guide only. Pharmacists must check for interaction whenever PLWH have medications added to their regimens. Proton pump inhibitors and products that reduce stomach acid are of particular concern as they may decrease many HIV medications' effectiveness.
• Older HIV-infected patients develop drug-related toxicities (e.g., hyperglycemia, elevated creatinine, and unfavorable lipid profile changes) more often than younger people.

Table 3 also highlights a fact that many pharmacists overlook. PLWH take supplements and over-the-counter medications also interact with antivirals. Recent research indicates 67% of HIV-infected individuals use complementary and alternative medicines (CAM), and dietary supplements are the most common form of CAM consumed.^50,51 So here, too, HIV is like every other chronic disease. Table 4 summarizes potential CAM-ART interactions. Pharmacists must make patients aware not that using these CAM is wrong, but that they need to use CAM carefully and always disclose use to their treatment team.

Opportunistic Infections

HIV's main target is the CD4 lymphocyte cell, also called a T-cell or CD4 cell. As HIV infects more and more T-cells, it gradually disables the immune system. Untreated, HIV eliminates the body's immune defenses entirely and leaves patients susceptible to OIs. People with normal immune defenses generally have CD4 counts of 800 cells/mm³ or more. Once the CD4 count falls below 200 cells/mm³, patients begin to develop OIs. OIs are considered AIDS-defining conditions, which are conditions associated with AIDS that are used to make a diagnosis of AIDS.. As the CD4 count falls, OIs often develop predictably and clinicians use the CD4 count to determine when they should start prophylaxis or increase OI monitoring.⁴ Table 5 shows the relationship between CD4 count and OIs, and lists prophylaxis.⁵⁶

Viral Hepatitis

Viral hepatitis deserves special mention when discussing HIV in older PLWH. Rates of hepatitis B (HBV) and HCV among PLWH in the United States are up to tenfold higher than the rate among HIV-uninfected individuals.^57,58 Chronic HBV infection occurs in 7.1% of American PLWH,⁵⁹ but only in 0.1-2.4% of HIV-negative blood donors. Approximately 73% of PLWH who have HCV indicate they are IDU.⁶⁰ There is a clear need for baseline screening and repeat testing.

PLWH generally experience more virulent HBV and HCV infections than HIV-negative individuals. Active hepatitis also affects HIV disease progression and ART response. Conversely, HIV infection seems to alter the clinical course of hepatitis negatively, accelerating liver disease progression and causing complications. Older individuals co-infected with HIV and HBV or HCV may be at higher risk for liver-related complications than younger co-infected individuals. Predictors of liver-related mortality included recently falling CD4 cell count, older age, IDU, HCV infection, active HBV infection, HIV RNA level, and ART duration.⁶¹

Viral Hepatitis Screening for PLWH

The Infectious Disease Society of America HIV primary care guidelines recommend screening HIV-positive adults for evidence of HBV infection at care initiation and vaccinating those who are susceptible to infection. Pharmacists should note the recommendations also suggest offering vaccination to hepatitis B surface antigen-positive PLWH sexual partners.^4,62 Some clinicians wait until the patient begins ART and has a suppressed HIV RNA and improved CD4 count before vaccinating for hepatitis B. Data indicates response rates are higher then.^63,64

Clinicians who work in HIV care facilities know they must screen all PLWH for HCV at entry into care.⁶² At-risk PLWH should undergo repeat screening at least annually and when laboratory indicators (e.g., elevated AST or ALT levels) that occur sooner imply hepatitis C infection. Screening 3 months after last use or diagnosis is prudent for PLWH with ongoing IDU or a new sexually transmitted infection, respectively.⁶² Approximately 6% of PLWH have seronegative HCV infection; this is chronic infection with detectable HCV RNA but negative HCV antibody. Clinicians who see patients with risk factors and elevated transaminases should order HCV RNA (viral load) testing in conjunction with HCV antibody testing.⁶²

All people with chronic viral hepatitis should avoid alcohol and limit acetaminophen use.⁶²

Treatment of HBV and HCV for Older PLWH

Table 6 outlines treatment for HBV and HCV coinfection, which are now treated similarly in older and younger PLWH.^4,65 With respect to HCV specifically, newer direct-acting antivirals offer significant advantages over the older interferon-based regimens. Treatment courses are much shorter, and the probability of sustained virologic response is very high (90% or greater) for most PLWH. HIV coinfection makes treatment for HCV a high priority because of the elevated risk for liver fibrosis. Some experts believe that older age also creates an urgency, particularly for individuals with decades-old HCV infections and a high likelihood of advanced liver fibrosis at the time of diagnosis.

Changing Mindset, Better Model: Moving from Acute to Chronic Care

Caring for older PLWH requires transdisciplinary care. Again, transdisciplinary care means several transdisciplinary team members collaborate to provide overlapping counseling, monitoring, and adherence advocacy. Pharmacists' bailiwicks—expertise in pharmacology, the ability to prevent drug interactions and adverse events, community-based access, and good communication approaches—are skills that transdisciplinary teams sorely need. Pharmacists can also contribute in 2 areas that need improvement: active case-finding and patient retention in care.⁶⁷ Pharmacist who actively engage PLWH become part of patients' community support services network.

Once patients are diagnosed and begin ART, retaining patients in care (e.g., maintaining access to clinical care and eligibility for ART) becomes a concern. Experts indicate current care retention rates range from 45% to 70% annually, which reflects a variety of studies in different populations (consolidated national data is unavailable).^68-72 Most programs look for ways to ensure PLWH stay connected with care. Motivational interviewing and education, a tool used in the chronic care model, promotes health maintenance rather than just treating HIV. It can also increase engagement with care. Pharmacists are increasingly familiar with motivational interviewing and use it to identify elements that contribute to resistance (e.g. beliefs about treatment, perceived stigma, or poor provider relationships that prevent optimal engagement in HIV care) in many disease states. By virtue of their community accessibility, pharmacists can expand patient access using reminder calls and brief discussion when patients visit the pharmacy. This is especially important during periods of instability and can encourage patients to stay connected.⁶⁷

Cultural Competence with Aging Individuals

In the ideal world, every healthcare provider who sees an older PLWH would have been trained in cultural issues related to aging. That isn't always the case, and miscommunication that emanates from stereotypes or misunderstandings occurs far too frequently. Many older individuals become frustrated and abandon all efforts to retrieve more information, instead making decisions based on limited or incorrect information. Pharmacists who deal with older PLWH need to communicate using common sense and good manners. Most of us adjust our language and behavior to meet the needs of our patients; unfortunately, people who have little exposure to older individuals sometimes adjust inappropriately.⁷³

Any healthcare provider who meets with a patient for the first few times needs to introduce him or herself. It's not enough to just state your name; pharmacists should also state they are pharmacists. The cornerstone of working with the older PLWH is good listening. It means observing the speaker's verbal and nonverbal messages and moderating your own communication style accordingly. Especially with the older individual, it's critical to allow time for the speaker to finish expressing his or her thoughts. Once the older individual provides information or asks questions, pharmacists can provide answers.⁷³

Seniors tend to be more conservative than younger individuals, less likely to take risks, respect authority more, and expect to be treated with respect. This means addressing individuals as "Mr." or "Ms." until the patient gives you permission to do otherwise. As patients age, they may have hearing impairment or may become less tolerant of background noise, so finding a quiet place with few distractions is important. If possible, pharmacists should remove physical barriers such as desks and offer comfortable seating to increase the patient's comfort.⁷³

A few tips can improve your discussion with older individuals⁷³:

• Provide paper and pencil and offer the patient a few minutes to jot down questions or topics of concern.
• Remember that most people prefer to say "Yes" and be agreeable. Avoid closed-ended or leading questions and use open-ended questions whenever possible.
• Avoid professional jargon and use language the patient will understand. As you discuss various topics with patients, you'll be able to determine how sophisticated your explanations can be. In short, talk to the person, not the hair color.
• Offer written materials to support what you tell the patient.
• Avoid engaging older patients in parallel cognitive tasks. That is, don't point to a picture or written material while you are verbally explaining. Explain one step, and then point to the area of the written material that covers the topic.
• If older adults do not understand something, pharmacists should not repeat verbatim or repeat using a louder voice. Instead, they should rephrase, using different words.
• Remember that 95% of people aged 55 years of age or older need glasses to improve their vision, and after age 85, more than half of people report that glasses correct vision only partially. In the latter age group, 12% are legally blind. Be familiar with low vision aids that magnify print on curved surfaces so that patients can read prescription bottles. Also, consider using bold color or texture to mark things (e.g., wrapping one rubber band around a medication that is taken in the morning and two around an evening medication). Above all, offer assistance, but let the visually impaired person indicate what type of help he or she needs.

Functional illiteracy is a concern because functionally illiterate adults are more likely to have health problems, to live in poverty, and to have fewer years of education. These literacy problems are twice as common in Americans older than 65 years of age and among inner-city minorities. Regardless, many financially successful people are somewhat or completely illiterate and easy-to-read, well-formatted materials will not close that communication gap. Fortunately, healthcare videos are widely available and patients seem to like them. They can play them over, stop and rewind, and share them with loved ones or caregivers.⁷³

Two situations can present unique challenges for pharmacists: PLWH who develop cognitive impairment or dementia or become agitated must be dealt with carefully.⁷³ The important thing to remember about people with cognitive impairment is that they can communicate in meaningful ways into the later stages of the dementia. Communicating with these individuals requires patience, and the reward is that patient-centered interventions may reduce troublesome dementia-related behaviors. As with all older adults, it's important to reduce background noise from any source. Pharmacists should get the patient's attention before speaking, and repeat the patient's name often throughout the conversation to increase focus. Pharmacists need to maintain eye contact and a friendly expression. They also need to show they are listening and trying to understand what's being said.⁷³

People with dementia need time to concentrate, comprehend, and formulate responses, so pharmacists need to allow adequate time to meet. Simple, positive language, and one-step directions are critical. Pharmacists should ask only one question at a time and avoid pronouns, instead identifying people and things by name. In addition, it's better to tell people who have dementia what they should do, as opposed to telling them what not to do. For instance, instead of saying, "Let's not talk here at the register," it's better to say, "Let's step into this counseling room." Two final points make communicating with the person who has dementia much easier. First, remember that humor is a durable personality trait that often remains intact as dementia progresses; these patients will appreciate appropriate humor. Second, people who have dementia are not oblivious; never discuss the patient with someone else as if the patient is not there.⁷³

Keeping in mind that living with HIV is challenging and often frustrating, some patients become agitated. The pharmacist can use some techniques to de-escalate agitation and negative emotion. Generally speaking, people who are frustrated or fearful will increase their body movement and appear agitated. Once they become angry, they start to grimace, frown, or dart their eyes. They may speak more loudly or at a higher pitch and they may experience rapid breathing, widening of the eyes, dilated pupils, and tightening of muscles. The astute reader will recognize this as fright-or-flight symptoms.⁷³

To de-escalate negative or tense situations, pharmacists need to stay calm and reassuring, and reduce environmental noise. Keeping one's voice low is helpful, as is keeping one's behavior the opposite of the agitated individual's. As the patient's movements increase, the pharmacist's movements should decrease. As the patient's voice increases in volume, the pharmacist should lower his or hers. Disperse crowds or have a coworker disperse crowds, remove dangerous objects from the area, and do not pressure patients or make additional demands when they're frustrated. Sometimes brief pauses or silence are the best way to deal with the agitated patient. Other times, unfortunately, brief pauses or silence simply aggravate them more.⁷³

The How-To of Integrating into a Team

Pharmacists are perhaps the most underutilized of health care professionals. They have a tremendous amount of education, and increasingly, public policy makers are realizing that they have untapped potential. Regardless, many pharmacists wonder how they can introduce themselves to the HIV healthcare team and become valued members.

First, pharmacists need to understand teams, team-building, and team dynamics. Especially in health care, team members have different training, education, scopes of practice, and often vocabularies and methods of presenting patients and their problems.⁷⁴ Pharmacists can't expect teams to seek them out, or even welcome them wholeheartedly if they express interest in working with the team. Finding a place on a team and demonstrating one's worth requires a measured, deliberate approach.⁷⁵

Expanding the pharmacist's role starts with getting involved in HIV-focused events. Professionally, these events include continuing education events, conferences, and volunteer activities that include health care professionals from other disciplines. Pharmacists should also consider social events as ways to meet others with similar interests. At these events, pharmacists should look actively for mentors that can help them understand the local culture related to HIV. Pharmacists should try to absorb information about all aspects HIV care.⁷⁶

With or without a mentor, pharmacists need to reach out to the local HIV team when they have something important or positive to offer. With every contact, pharmacists should be doing 2 things: observing and building relationships. By observing carefully, the interested pharmacist may be able to determine areas when change is needed and offer help in those areas.⁷⁵ It's critical to notice trends or patterns and ensure that the changes address real problems and not rare events with little impact. Pharmacists will tend to work more closely with some team members (usually prescribers and nurses) than others, and should stress interests they have in common. Looking for ways to work with other team members can help highlight skills and demonstrate how pharmacists can help. Working with dieticians to develop a food-drug interaction guide or with case managers to identify solutions to common medication-related problems, for example, builds credibility and support. Being perceived as approachable will build strong relationships, as will taking a few minutes to find common ground with others.^75,76

With every contact with the team or team members, bring solutions framed in a way that works with the team's working style. Learning to do this will rest on observation, but it's also important to read others' responses and body language. Asking colleagues how they want to hear from you is respectful and often time-saving.^75,76

It takes time for teams to adjust to new members, and change can be hard, disruptive, and expensive. For this reason, pharmacists need to ensure the changes they suggest are necessary. The existing team may employ styles or techniques that are different or even uncomfortable for pharmacists. Initially, newcomers must drop preconceived notions and work within established processes. Once they build credibility and show how they add value, pharmacists can suggest new ways of doing thing and have a greater likelihood of success.⁷⁵

Concurrently, pharmacists who are integrating into clinical HIV teams need to build their tool kits, and sometimes, share their tools. Pharmacists have a tremendous amount of technology available to them, and sometimes, they don't use it. A recent study indicated that all pharmacy types collect data that could be helpful in improving ART adherence.⁷⁷ Most pharmacies have software that is capable of tracking patients' failure to fill prescriptions for antiretrovirals on time. They also have tracking systems that can be used to contact patients and promote adherence. Using this data, pharmacists can engage the multidisciplinary team early and increase the likelihood that patients will stay engaged in care.

Conclusion

Conditions that transform from primarily acute to primarily chronic are often difficult to address in real-world settings. This is seen with certain types of cancer, which are similarly transitioning to chronic diseases. When diseases transform from primarily acute conditions to chronic conditions, healthcare practitioners have difficulty putting aside older treatment models. Today's PLWH present similar to patients who have chronic disease—they share many similarities with other chronically infected patients. Yet HIV-infected patients have some unique issues.

Recognizing comorbidities and their unique presentations in the older PLWH can help pharmacists provide the best care possible.

More Information
Organization	Contact
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents U.S. Department of Health & Human Services	https://aidsetc.org/resource/guidelines-use-antiretroviral-agents-hiv-1-infected-adults-and-adolescents
HIV and Aging Consensus Project American Academy of HIV Medicine	www.HIV-AGE.org
HIV.gov U.S. Department of Health & Human Services and supported by the Secretary's Minority AIDS Initiative Fund	https://www.hiv.gov/
The AIDS Education and Training Center (AETC) Program	https://aidsetc.org/

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