People with HIV are at greater risk of comorbidities including heart disease, cancers, osteoporosis, and neurocognitive impairment, often manifested at younger ages.  It is thought that HIV contributes to more rapid ageing due to prolonged immunodeficiency, chronic inflammation, and immune activation.  Side effects of treatments are also believed to contribute to earlier ageing in those with HIV (26). 

One large international case-control study showed that, compared with HIV–negative controls, HIV–positive people have a higher rate of comorbidities at all ages; however, the most significant rate was among those over 60 years, where the rate of comorbidities in people with HIV was 63% compared with 12% for HIV–negative controls (27).  In addition, comorbidities may appear from 10 to 20 years earlier than they do among HIV-negative people (28, 29). Non–acquired immune deficiency syndrome (AIDS)-related conditions or comorbidities that disproportionately affect people with HIV include cardiovascular disease, diabetes, osteoporosis, liver and kidney disease, mental health issues, cognitive problems, drug, and alcohol problems (30).  Cardiovascular disease can be related to untreated HIV infection and certain antiretroviral therapies that can cause metabolic changes (31). 

The nursing literature on ageing people with HIV also emphasises comorbidities, long–term medication toxicities and drug interactions, erectile dysfunction, diabetes, peripheral neuropathy, hepatitis C and renal disease (30, 32).  Concerns about medicines for older people include polypharmacy, treatment burden, the need for adherence support and stigma, highlighting the need to develop medicine optimisation strategies (33). 

Frailty affects a significant minority of older PLHIV, and can have an impact on their mobility, overall health, and quality of life (34).  Screening for frailty is an important component of the nursing assessment of older PLHIV, informing appropriate nursing interventions, referral, and support. 

Cancers 

People with HIV are at a higher risk of some types of cancers. This is believed to be due to several factors, including immune deficiency, co-infection with other viruses such as human papillomavirus (HPV) or hepatitis viruses (35) and higher rates of smoking (36-38). 

Certain cancers – Kaposi sarcoma, non-Hodgkin’s lymphoma, and invasive cervical cancer are classified as AIDS-defining illnesses.  HIV-associated cancers that are mostly infection-related occur at relatively high rates in people with HIV – anal cancer, vulvovaginal cancer, penile cancer, and liver cancers (35).   

Many cancers can be prevented.  Nurses’ roles in preventing both HIV-related and other cancers focus on health promotion and client education (advice and referrals for smoking cessation, safety in the sun to minimise the risk of skin cancers, vaccination against Human Papillomavirus or hepatitis viruses as required), promotion of cancer screening (39), and antiretroviral adherence support to maintain optimal immune health.  The START study results indicate that the risk of some cancers is reduced with early treatment initiation (40). 

While AIDS-defining cancers remain the most common cancers in people with HIV, both HIV–related and non-AIDS-defining cancers are increasing and are more prevalent among people with HIV than within the general population.  Hospitalisation rates for people with HIV have been reported as 50–300% higher in a cohort of HIV patients in Australia than in comparable groups (by age and sex) in the general population, with age being significantly associated with hospitalisation. Mortality rates among people with HIV are still around 10–fold higher than in the general population (41). 

As can be seen, as people with HIV live longer, the prevalence of comorbidities increases significantly and can affect health-related quality of life.  This can mean that older people with HIV require enhanced community and social supports (42). 

Sars-CoV-2 infection – COVID-19 

While evidence does not suggest higher rates of COVID-19 infections amongst people living with HIV, once they contract COVID-19, PLHIV can be at greater risk of severe illness and poorer outcomes (43).  Risk factors for severe COVID-19 amongst PLHIV include older age, comorbidities such as diabetes and chronic renal failure, but also HIV-specific factors such as immunosuppression, high viral load (44) and other opportunistic infections (44). Those who are on ART, have normal CD4 counts and are virally suppressed have a lower risk of poor outcomes (44), but a large WHO study found that HIV infection remained an independent risk factor for severe disease and mortality regardless of viral load suppression and use of ART (46). 

Nurses need to consider that immunosuppressed PLHIV will not respond as effectively to vaccination against COVID-19 (47) and seek expert advice on targeted vaccination for this group (48). Check the latest edition of the Australian Immunisation Handbook for current recommendations.