As the population of patients living with HIV ages, even those who have been taking antiretroviral therapy (ART) for decades may benefit from changes in their overall drug regimen, said speakers at the Dec. 9 session Aging Well with HIV: Making the Golden Years Shine at the 2025 Midyear Clinical Meeting & Exhibition in Las Vegas, Nevada.
“We can still improve ART for older people with HIV. We can improve tolerability and drug interactions. We can really improve convenience,” said session presenter Elizabeth Sherman, associate professor at Nova Southeastern University in Fort Lauderdale, Florida.
In some cases, it’s imperative to take these actions with an older person, as illustrated by 74-year-old “Mr. MG,” a patient case that was threaded through the educational session.
Mr. MG started ART in 1990 and his viral load has been undetectable since 2011. His physician recently asked for a medication review because Mr. MG “is on a lot of drugs,” said session presenter Alice Tseng, HIV pharmacotherapy specialist at Toronto General Hospital in Ontario, Canada. Mr. MG’s daily medication regimen featured 26 oral pills, two oral liquids, two inhalers, and a rectal medication.
Tseng said the medication review revealed 29 potentially significant drug–drug interactions, 12 involving ART and 17 involving medications for the treatment of comorbid conditions. She emphasized that accurately identifying all of Mr. MG’s significant drug–drug interactions required sifting through multiple drug interaction databases.
That’s because an HIV-specific database is likely to have up-to-date information about antiretrovirals, and a general drug–drug interaction database will complete the picture by capturing interactions between medications other than ART.
“We always recommend that people use both an HIV-specific ... and a general drug interaction checker,” Tseng said.
Inappropriate prescribing is also a concern in older patients, as is the use of anticholinergic and sedating drugs. At the time of Mr. MG’s medication review, he was taking triazolam despite a history of hip fracture from a fall and a diagnosis of Parkinson’s disease with mild cognitive impairment. Other potentially problematic medications included trazodone, codeine, omeprazole, and bisacodyl — making Mr. MG a good candidate for deprescribing.
Tseng said one study of pharmacist-led deprescribing in older people with HIV found that 69% of participants were able to discontinue at least one medication. Forty-one percent required immediate intervention to halt the use of one or more medications identified as inappropriate for older people, and 37% needed at least one medication change to correct their therapy.
Deprescribing decisions should involve patients, and Tseng recommended applying “the five E’s” to the deprescribing plan. That strategy emphasizes engaging the patient in the conversation, exploring what the patient wants, educating the patient, empowering the patient to make informed choices, and enabling behavioral changes to help patients achieve their goals.
Sherman said deprescribing in older patients requires closely examining the indication of each drug in the context of comorbidity, function, quality of life, and patient preferences. This process is also essential when making changes to the ART regimen.
“First and foremost, where I spend most of my time is carefully reviewing the patient’s ART history,” Sherman said. “We have to remember that the goal of any regimen change is to maintain virologic suppression without jeopardizing future treatment options.”
She said it’s critical to obtain the details of every antiretroviral medication the patient has taken, the response to therapy, including treatment failures that may indicate the development of resistance, and the results of all viral resistance, genotype, and phenotype tests.
“It’s worth it to contact prior providers to get all of those virus resistance tests,” Sherman said.
She said that for virologically suppressed patients like Mr. MG, switching from a complex ART regimen to an optimized 2- or 3-drug regimen can reduce drug interactions, pill burden, toxicity, food requirements, and medication costs. For older patients on legacy regimens dating from the early days of ART, switching to a modern regimen can reduce the risk of antiviral resistance.
Mr. MG’s ART regimen did present an opportunity to simplify his therapy. He went from a four-pill daily regimen (abacavir/lamivudine, dolutegravir, darunavir, and ritonavir) to a two-pill regimen (bictegravir/emtricitabine/tenofovir and darunavir/cobicistat).
“That’s a win,” Sherman said.
Mr. MG required another ART change a year later when he was hospitalized for new-onset atrial fibrillation and started on apixaban, which interacted with the proteinase inhibitor portion of the ART regimen. Sherman said a change to bictegravir/emtricitabine/tenofovir alafenamide and fostemsavir factored in Mr. MG’s past ART history and met his treatment needs while minimizing potentially significant drug interactions and cost concerns and maximizing convenience.
Ultimately, said session presenter Jerika T. Lam, professor at the Chapman University School of Pharmacy in Irvine, California, successfully caring for older patients who are living with HIV requires regular medication reviews, ongoing optimization and simplification of therapy, and accounting for new needs related to changes in health and circumstances.
