Check out our blog post on HIV and Ageing from November 2016 for more simple and up to date information.
This article has been reprinted from Volume 9, No. 4 of HIV Australia, published by the Australian Federation of AIDS Organisations.
By Mia Dawson
Thirty years on from the first reports of HIV and AIDS, and following the advent of antiretroviral therapies, HIV is now considered to be a chronic, manageable disease rather than a critical illness.
Today, people living with HIV receiving treatment can expect a near normal lifespan – something that many of us could not imagine living to see! With the focus now on maximising longevity and quality of life, growing old and navigating all that the ageing process entails is now a reality for many HIV-positive people.
In addition to the health issues experienced by the ageing population as a whole, women living with HIV face some specific challenges as they age.
While much has been written on the social and cultural differences that affect how women manage HIV, from a research perspective little is understood about the long-term effects of the antiretroviral drugs (ART) on women’s physiology, or the physical and emotional effects of ageing specific to HIV-positive women.
This article will focus on the physical and emotional aspects and consequences of living longer with HIV as experienced by women.
Women are under-represented in the majority of clinical studies, such that effective gender comparisons are not possible. Of all clinical trials between 2000 and 2008, only 20% of participants were women.
Historically, drug regimens were tested on men, and due to biological differences between women and men - such as weight and fat distribution - women may in effect receive a higher dose of a drug in their blood level because they generally weigh less.
There are also biological differences between men and women in how medicines affect the body and the way in which it metabolises these.
This is also important where women are living longer with HIV and need to take other medications which may alter the metabolic action of some drugs, such as hormone replacement therapy. There is a need for more women-specific and comparative studies to explore and address some of these issues.
Physical challenges of ageing in women with HIV
There is a growing body of evidence that suggests that women living with HIV have an earlier onset of menopause than their HIV-negative counterparts. This has implications for other health issues affecting women as a result of entering menopause at a younger age.
The onset of menopause is associated with an increased risk of cardiovascular disease (CVD), high blood cholesterol levels, diabetes and osteopenia and osteoporosis. The early onset menopause (before 46 years) is associated with an increased risk of these diseases and may be linked to increased mortality.
Although women living with HIV were 73% more likely to experience an early onset of menopause when compared with HIV-negative women, there is a distinct data gap between the research on the early onset of menopause and HIV.
There are a number of factors that can contribute to the early onset of menopause; potential contributors to the early onset of menopause in women with HIV are: immunosuppression (a lower CD4 count); smoking (menopause can occur up to 1–2 years earlier in smokers, compared with non-smokers); and socioeconomic status (markers of low socioeconomic status such as a lower level of education, unemployment and/or poverty have been associated with early menopause onset).
Many of the symptoms associated with menopause such as hot flushes, fatigue or insomnia can also be associated with HIV, so women need to monitor these changes in consultation with their health professional. In addition, women have complications with drug interactions between ART and hormone replacement therapy (HRT) prescribed to relieve the symptoms of menopause.
Antiretroviral medications have been shown to reduce the effectiveness of HRT (oestrogen and progesterone), and oestrogen can also cause decreased levels of ART resulting in an increased viral load and resistance issues.
There is an increased risk of osteoporosis in women living with HIV. Recent studies have shown that people living with HIV have a lower bone mineral density and this is compounded in women, particularly around the onset of menopause. However, the causes of this decrease in bone mineral density are unclear and may be due to HIV itself or to antiretroviral drugs.
Additionally, vitamin D deficiency is common in women living with HIV and may be exacerbated by the onset of menopause. It is recommended that women have a DEXA scan (‘dual energy X-ray absorptiometry’ used to measure bone mineral density) every two to five years. There are also FRAX (Fracture Risk Assessment) calculation tools that assess bone health available; many are available online.
Women with HIV – particularly those on ART – may be at an increased risk of cardiovascular disease (CVD). Studies suggest that antiretroviral medications such as some protease inhibitors (PI) and non-nucleoside reverse-transcriptase inhibitors (NNRTI) can increase the risk of heart problems by raising the levels of cholesterol and triglycerides in the blood. Researchers have also noted that there is a higher CVD incidence with interruption versus continuous highly active antiretroviral therapy (HAART).
However, other research suggests that it may be HIV itself that causes heart problems. Historically, health professionals have tended to focus on cardiovascular disease amongst men, but given that CVD ‘is the main killer of older women’ worldwide there needs to be an increased focus on women’s health in this respect.
There is an increased risk of non-AIDS defining cancers in women living with HIV, such as cancers of the lung, oesophagus, multiple myeloma, oral cavity and pharynx, Hodgkin’s disease, leukemia, and rectal/anal cancers.
There is also an increased risk of human papillomavirus ( HPV) tumours and cervical cancer. However, researchers have not discerned an increased risk of breast cancer in women living with HIV.
It would also appear that HAART regimens significantly reduce the risk of AIDS-defining cancers, and drug‒drug interactions between cancer drugs and ART can be predicted and managed.
Age is one of the major risk factors for renal disease in women aged 45 years and over, and women living with HIV may be at an increased risk for acute renal failure or chronic kidney disease.
In order ‘to define frailty as an independent syndrome (or phenotype), three of the following criteria need to be present: unintentional weight loss; self-reported exhaustion; low physical activity; slowness measured by time taken to walk three metres; and weakness measured by grip strength.
For women living with HIV, severe CD4 cell depletion is an independent predictor of slowness, weakness, and frailty. Women who have a CD4 count <100 cells/mm3 have a 2.7 times higher prevalence of frailty … Hospitalisation rates are greater for frail persons, with a five-fold longer duration of inpatient stay’.
Neurocognitive changes associated with HIV consist of cognitive, behavioural and motor dysfunctions, and have a tendency to increase with age in people living with HIV. While neurological impairment is present in over 50% of HIV-positive people, neurological dysfunction, including memory impairment and psychomotor function, has been shown to be increased in women with HIV.
A recent study of HIV-positive women just entering middle age, ‘has found an association between carotid artery disease and neurocognitive impairment. Among HIV-negative people, such impairment does not usually appear until at least 15 years later.’
There is much debate over the association of HIV with the increased incidence of early onset dementia and an increased risk of Alzheimer’s disease. However HIV-associated dementia is known to increase with age.
Depression and anxiety
In findings released in January 2012 at the 2nd International Workshop on HIV and Women, researchers concluded that ‘women living with HIV are more likely to suffer from depression than HIV-positive men.’
The study’s findings included that ‘the percentage of women who met the criteria for depression did not differ significantly between those who were taking antiretrovirals and those who were not. However there was a significant difference in depression rates, antiretroviral use and gender: 10.6 percent of the men living with HIV who were not on AIDS meds met the criteria for depression versus 20.8 percent of the women living with HIV who were not on treatment.
[Furthermore], a higher proportion of women than men screened positive for anxiety, and more women than men suffered from both depression and anxiety.’
Family and parenting issues
Research has suggested that older women may not perceive themselves to be at risk from HIV and therefore often present as a late diagnosis. In addition to the health complications that a late diagnosis often entails, older women face many different social and cultural challenges surrounding living with HIV.
Older women often have a dual role of caring for their own health while also caring for children, grandchildren or elderly parents, and are more likely to have issues around disclosure to their children. Many may have delayed starting a family due to HIV only to find subsequent complications affecting parenthood due to the early onset of menopause.
A recent article published in the Medical Journal of Australia has suggested that Australians with a chronic illness or disability face serious levels of economic hardship.
The authors state that ‘the available evidence indicates that the out-of-pocket costs of treatment and self-management and loss of income from chronic illness and disability are associated with economic hardship, catastrophic health care spending and non-compliance with medical treatment.’ It would not take much to extrapolate this research to older women living with HIV.
Gender-related barriers including social and economic determinants have long affected women living with HIV. ‘Women may face barriers due to their lack of access to and control over resources, child-care responsibilities, restricted mobility and limited decision-making power.’
Healthcare professionals and community advocates have suggested that ‘older women living with HIV may require more healthcare and emotional support than those without HIV. [They point to] financial circumstances and support from a partner may be decreased with older women with HIV, [and that women have a] double role of caring for ailing parents or coping with parental loss.
Feelings of stigma and isolation are still common among ageing women with HIV, and information available to women with HIV about ageing is limited with regard to what is due to the disease and what is due to the normal ageing process.’
Women living with HIV face many potential physical and emotional health issues as they age. However, it has been suggested that with the appropriate interventions, lifestyle choices and integrated support from health care professionals and community groups, the impact of these challenges can be effectively managed.
The question is whether there is the political and collective will to ensure that older women’s physical and emotional wellbeing is adequately supported through their journey with HIV.