7. HIV across the life course

There has been an increase in the number and proportion of people over 50 years being diagnosed with HIV and these are more likely to be late diagnoses. The exposure profile of older people being diagnosed with HIV also differs from that of younger populations, including, for example, higher proportions of heterosexually identified people. Promotion of testing opportunities should include recognition of these aspects of the HIV epidemiology in the UK.

Prevention programmes are often targeted at younger populations and attention needs to be paid to opportunities to include older age groups in prevention campaigns, and the optimal approaches for ensuring older people have equitable access to prevention technologies.

It is important to recognise the differences in both the requirements and access to resources necessary for optimum self-management for those in an older age group. The intersection between issues of HIV and ageing may be critical in understanding barriers and enablers for access to quality health and social care, for example, access to residential care or menopause support services, or the geographical provision of HIV-specific services.

Peer support may be particularly important for those diagnosed in older age, as many people will have had no previous exposure to people living with HIV or HIV-related issues. This may be crucial for engagement and retention in care. Peer support needs for those living long term and ageing with HIV will differ from other groups, as issues such as historic stigma and discrimination, community-level loss and survivor guilt may play out quite differently.

It is important to ensure that provision of sources of support and information are relevant and acceptable – not all older adults will be as familiar with online resources as younger people.

There is considerable complexity around comorbidities and their relationship to ageing, particularly in the areas of cardiovascular disease, osteoporosis, menopause and dementia. This is an area where there is significant emerging knowledge.

Where possible the involvement of a geriatrician with HIV knowledge will strengthen service provision for this population. This may be achieved through co-specialty clinics, mentoring schemes or identified experts for the provision of advice and guidance.

There may be more need for multidisciplinary services involving other specialties and primary care to reduce the number of clinic visits and lessen potential for harm, such as HIV pharmacists, older age pharmacists, physiotherapy and occupational therapy. Supplementary tailored health programmes, for example around exercise, may be of increased importance for this population.

In direct clinical terms, attention needs to be paid to drug–drug interactions as we learn more about the possible co-effects of HIV medications and medications used in ageingrelated health conditions. It may be important to tailor ART to co-medications including menopause hormone therapy where possible. There may be a need to actively encourage early ART uptake among those diagnosed with HIV in older age, as this may be crucial in reducing morbidity and mortality.

Among those living long term and ageing with HIV, there is a need to recognise that long and complex treatment history may have significant consequences for both health and well-being. In particular, the experience of suboptimal treatment may be implicated in both higher levels of treatment optimism and treatment scepticism. Concerns about remaining treatment options may have implications for treatment switching.

In addition, consideration should be made for the use of designated care coordinators where possible for those experiencing complex care issues, particularly where care is across multiple health and social care service provision.

It is important to take opportunities to discuss sexual activity and health in older people. This is particularly so in primary care, since older adults may be less willing to access sexual health services. Older adults are less likely to use condoms where there are no concerns about pregnancy and may have come out of a long-term relationship in which condoms were not used. However, perimenopausal women may still be at risk of pregnancy so adequate contraception is important for this group.

As with other groups, all sexually active older people should be made aware of, and have access to, a tailored and comprehensive package of HIV prevention options.

The core issues discussed in the psychological care standard apply equally to populations of older people living with HIV. There are particularities for the two broad groups identified – those ageing with HIV and those diagnosed in older age – that should be considered when identifying best practice in the provision of psychological care. Considerations for those living long term with HIV may include the experience of multiple loss over many years, the cumulative effects of community-level stigma and discrimination, differing reference points for self-assessment of health and well-being (e.g. having been near to death), and a history of activist engagement with HIV. Issues for those diagnosed in older age may include familiarity with HIV issues, terminology and services, differences in peer and family understandings of HIV, and the primacy of other health concerns.

Issues associated with palliative care may be particularly acute for both those ageing with HIV and those diagnosed at an older age. For those living long term and ageing with HIV, there may be particular sensitivities around death and dying arising from experiences of profound ill health and from community-level loss. Services referring to and offering palliative care services need to be cognisant of the complex pathways people may have in relation to their health and life expectancy.

There is an ongoing need to offer training and professional development in management of comorbidities (HIV, primary and secondary care providers), particularly as they relate to ageing with HIV.