Early initiation of ART is still of utmost importance in older people with HIV infection and is probably of more significance, compared with younger people, due to the potential for poorer immune recovery on ART and a higher risk of serious non-AIDS events in older people with HIV infection. ^[28-30] This approach is supported by data from observational cohort studies and a post-hoc analysis of data from the START study. ^{[28, 31-33]}  Education should be provided that suppression of HIV replication (HIV viral load < 200 copies/mL) improves overall health, as well as prevents transmission of HIV infection, including from people ageing with HIV infection. ^[28]

A change in ART regimen (cessation, switch or dose adjustment) may be required to minimise toxicity and/or drug-drug interactions, when older people with HIV infection develop non-AIDS co-morbidities, such as bone disease, CKD, CVD, or frailty. ^{[4, 28]} For example, Tenofovir Disoproxil Fumarate (TDF) has been associated with an increased risk of CKD ^[34] and a higher prevalence of osteopenia and osteoporosis ^[35], and it is now expert recommendation to switch TDF or boosted protease inhibitors (PIs) to another antiretroviral drug in those at high risk for fragility fractures. ^{[28, 36]}  Similarly, in people with declining renal function, a drug regimen that avoids TDF or atazanavir should be considered. ^{[28, 37]}

Given that multiple treatment options now exist, the ART regimen that is prescribed should take into consideration not only the individual and provider preference but also be informed by the patient’s co-morbidities. ^[4] Clinicians should be aware that hepatic metabolism and renal elimination of some drugs decline with age and may result in increased drug exposure and risk of adverse drug reactions. ^[28] Most clinical trials have included only a small proportion of participants over the age of 50 years and current ART dosing recommendations are based on younger persons with normal renal and hepatic function. ^[28] Close monitoring for adverse effects is recommended.

The significant increase of age-related co-morbidities in people with HIV infection has led to increased healthcare utilization and associated higher costs. ^[28] Out-of-pocket expenses and loss of employment related to the burden of chronic disease can lead to financial strain/insecurity, and possible inability to pay for ART medication – this should be avoided whenever possible. Increasing life expectancy and multi-morbidity can place greater demand on HIV services – thus an approach where modifiable health-related problems are prioritized should be employed. ^[28]

Even in people with a severe, debilitating non-AIDS related condition, the general consensus is to continue ART if there is no overt harm or negative impact on quality of life.^[28]  If the ART is contributing to harm or diminished quality of life, the decision for ART cessation should be made in conjunction with the patient and partner/family. ^[28]

Key recommendations

1. Early ART initiation in older persons with HIV infection is of utmost importance.
2. The optimal ART regimen should be tailored to the individual – their preferences, co-morbidities and non-AIDS associated complications should all be considered.
3. ART regimens may need to be changed on the basis of the risk, or confirmation, of non-AIDS co-morbidities, such as bone disease, CVD and CKD.
4. The metabolism of medications may be altered or impaired in the ageing individual and adverse drug reactions should be closely monitored for.
5. People ageing with HIV infection who have multiple co-morbidities will incur increased healthcare expenditure and medication costs and may encounter financial strain. The HIV clinician should screen for this, and where possible, resources and support be offered in order to avoid ART treatment interruption.
6. The decision to continue ART in an older person with HIV infection, in the context of a severe, debilitating non-AIDS associated condition, is a risk versus benefit decision that takes into account individual and partner/family preferences.