Marie Dorsey, Pharm.D., AAHIVP OSPA Annual Meeting November 8,
2014
Slide 2
I do not have any conflicts of interest or financial
disclosures
Slide 3
Case Study Medication List: Lopinavir/ritonavir (Kaletra)
tenofovir, emtricitabine (Truvada) Sulfamethoxazole/trimethoprim
(Bactrim) Pantoprazole (Protonix) Paroxetine (Paxil) Mirtazapine
(Remeron) Gabapentin (Neurontin) Lisinopril (Zestril) Simvastatin
(Zocor) Insulin glargine (Lantus) Insulin apart (Novolog) *Bob is a
57 yr WM *Dx HIV 1994, AIDS 2000 *CrCl ~ 50ml/min, Scr -1.2 *VL-Non
detectable *Diabetes, hypertension, * CD4-196 depression, cognitive
delay
Slide 4
Objectives Explore the management of non-AIDS co-morbidities in
aging HIV patients Identify useful information for HIV medication
management Discuss age-related factors that impact adherence and
solutions for improved medication adherence List at least three
quick HIV medication resources
Slide 5
Viral Load and CD4 VL -An indicator of how well the medication
is working -Drops to non- detectable in 12 weeks if on HIV
medication CD4 -An indicator of the immune system response
-Increases 50- 100cells/mm 2 per year if on HIV medication
Slide 6
Anti-Retroviral Therapy (ART) Review Five ART Classes:
Nucleoside Reverse Transcriptase Inhibitor (NRTI) Protease
Inhibitor (PI) Non-nucleoside Reverse Transcriptase Inhibitor
(NNRTI) Entry Inhibitor (EI) Integrase Strand Transfer Inhibitor
(INSTI)
Slide 7
HIV Life Cycle and ART Targets Protease Inhibitor Entry
Inhibitor NRTI NNRTI Integrase Inhibitor
Slide 8
DHHS Antiretroviral Therapy Guidelines: May 1, 2014 Recommended
Regimens Regardless of Baseline HIV RNA or CD4 Count Source: 2014
HHS Antiretroviral Therapy Guidelines. AIDS Info
(www.aidsinfo.nih.gov).www.aidsinfo.nih.gov
^Elvitegravir-Cobicistat-Tenofovir-Emtricitabine: only for patients
with pre-ART CrCl 70 ml/min *Abacavir recommended only if HLA-B5701
negative Slide created by Dr. Brian Wood and Dr. David Spach
Slide 9
The Eras of the HIV Epidemic The HIV/AIDS epidemic: major
clinical themes over 3 distinct eras, 19812011 Chu C, Selwyn P. J
Urban Health 2011:556-566.
Slide 10
HIV and AIDS Current Cases, Diagnoses and Deaths United States
1981-2008 Centers for Disease Control and Prevention. Morbidity and
Mortality Weekly Report. HIV Surveillance United States
1981-2008
Slide 11
HIV Statistics as of 2012 What is the average age of an HIV
positive Oregonian? How many Oregonians are diagnosed with HIV each
year? How many Oregonians are living with HIV? What percent of
people living in the U.S. are >50yrs old? What percentage of
people will be over the age of 50 in 2015? CDC HIV Surveillance
Report 2011, Oregon Health Authority Epi Profile 2013
Slide 12
Issues Unique to the Aging HIV Positive Patient Late Testing
and Diagnosis Diagnosis made later in course of illness Higher
transmission risk ART started later Polypharmacy Organ dysfunction
Girardi E. J Acquir Imm Def Syndr 2000;25:71
Slide 13
The Factors that Contribute to Increased Morbidity and
Mortality in HIV Positive Patients HOST Lifestyle Genetic Aging
HOST Lifestyle Genetic Aging HIV Compromised immunity Inflammation
despite ART HIV Compromised immunity Inflammation despite ART ART
Toxicity ART Toxicity Systems of Chronic Morbidity Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Systems of Chronic
Morbidity Renal Hepatic Cardiovascular Endocrine Skeletal
Neurologic Morbity and Mortality Co-morbidities Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Co-morbidities Renal
Hepatic Cardiovascular Endocrine Skeletal Neurologic
Slide 14
The Factors that Contribute to Increased Morbidity and
Mortality in HIV Positive Patients HOST Lifestyle Genetic Aging
HOST Lifestyle Genetic Aging HIV Compromised immunity Inflammation
despite ART HIV Compromised immunity Inflammation despite ART ART
Toxicity ART Toxicity Systems of Chronic Morbidity Renal Hepatic
Cardiovascular Endocrine Skeletal Neurocologic Systems of Chronic
Morbidity Renal Hepatic Cardiovascular Endocrine Skeletal
Neurocologic Morbity and Mortality Co-morbidities Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Co-morbidities Renal
Hepatic Cardiovascular Endocrine Skeletal Neurologic
Slide 15
Compromised immunity Decline in CD4 T cells predict higher risk
of morbidity and mortality Immune dysfunction in HIV similar to
aging Inflammation despite ART HIV results in low level
inflammation Chronic inflammation also occurs in aging ART
associated with increase in visceral fat, causing inflammation Are
non-AIDS co-morbidities more likely with immune dysfunction and
chronic inflammation? Living with HIV = accelerated aging? Phillips
AN. AIDS 2008, Casau N. CID 2005;41:855-863 The Contribution of HIV
to aging and non-AIDS Co-morbidities
Slide 16
The Factors that Contribute to Increased Morbidity and
Mortality in HIV Positive Patients HOST Lifestyle Genetic Aging
HOST Lifestyle Genetic Aging HIV Compromised immunity Inflammation
despite ART HIV Compromised immunity Inflammation despite ART ART
Toxicity ART Toxicity Systems of Chronic Morbidity Renal Hepatic
Cardiovascular Endocrine Skeletal Neurocognitive Systems of Chronic
Morbidity Renal Hepatic Cardiovascular Endocrine Skeletal
Neurocognitive Morbity and Mortality Co-morbidities Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Co-morbidities Renal
Hepatic Cardiovascular Endocrine Skeletal Neurologic
Slide 17
Host Factors that Contribute to Increased Risk of Co-Morbidity
Lifestyle Smoking, alcohol Diet, exercise Genetic Family history
Aging Renal, hepatic function Neurocognitive function Immune system
Co-infections Hepatitis B Hepatitis C HOST Lifestyle Genetic Aging
Co-infections HOST Lifestyle Genetic Aging Co-infections Helleberg
M. Clin Infect Dis. 2013;56:727-734
Slide 18
The Factors that Contribute to Increased Morbidity and
Mortality in HIV Positive Patients HOST Lifestyle Genetic Aging
HOST Lifestyle Genetic Aging HIV Compromised immunity Inflammation
despite ART HIV Compromised immunity Inflammation despite ART ART
Toxicity ART Toxicity Systems of Chronic Morbidity Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Systems of Chronic
Morbidity Renal Hepatic Cardiovascular Endocrine Skeletal
Neurologic Morbity and Mortality Co-morbidities Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Co-morbidities Renal
Hepatic Cardiovascular Endocrine Skeletal Neurologic
Slide 19
ART Toxicity Is anti-retroviral therapy toxic to the body? Most
studies exclude patients >50 or those with co-morbid conditions
Most studies do not compare ages ART Toxicity ART Toxicity *The
newer ART medications have less toxicity *The toxicity from the
virus is greater than the toxicity from the medication El-Sadir WM.
N Engl J Med 355;22:2283-2296.
Slide 20
Pharmacokinetics in Aging Patients Pharmacokinetics: Absorption
- body fat changes Distribution - body fat changes Metabolism -
decreased CYP function Elimination - decreased creatinine clearance
(ClCr) Dumond JB. HIV Medicine 2013; 12(7):401-409, Wooten JM.
South Med J. 2012;105(8):437-445
Slide 21
Side Effects Metabolic (diabetes, lipodystrophy) - PI, NNRTI
Osteoporosis Tenofovir (Viread) Cardiac - PI, Abacavir (Ziagen)
Renal Tenofovir (Viread) Hepatic - older PIs Central Nervous System
efavirenz (Sustiva), dolutegravir (Tivicay) Gastrointestinal - PI
Peripheral neuropathy - older NRTIs NNRTI-Non-nucleoside Reverse
Transcriptase Inhibitor, PI-Protease Inhibitor NRTI-Nucleoside
Reverse Transcriptase Inhibitor
Slide 22
Drug Interactions MedicationPredicted EffectManagement Acid
Reducers (Calcium, H2RA, PPI) PI, INSTI, rilpivirineAtazanavir
-timing and max dosing requirements, some contraindicated
INSTI-separate antacids by 2hr Rilpivirine-omeprazole
contraindicated StatinsPI StatinsSimvastatin, lovastatin
contraindicated Start with low dose statin Use pravastatin,
rosuvastatin Herbals or any medMany unknowns Counsel about
necessity St. Johns Wort, Garlic DHHS Guidelines Drug Interaction
Charts HIV-druginteractions.org Micromedex or LexiComp
INSTI-Integrase Strand Transfer Inhibitor, PI-Protease Inhibitor,
H2RA-Histamine-2 Receptor Antagonist, PPI-Proton Pump Inhibitor
DHHS Antiretroviral Guidelines 2014
Slide 23
Drug Interactions MedicationPredicted EffectManagement
SteroidsPI SteroidUse Beclomethasone Check for adrenal suppression
(Cushings Syndrome) NarcoticsPI, NNRTI or NarcoticIncrease or
decrease narcotic Methadone PDEIPI PDEISildenafil, Tadalafil,
Vardenafil -Start with lowest dose Boosting *Therapeutically
necessary Ritonavir PI Cobicistat Elvitegravir Ritonavir given with
most PI Cobicistat always given with elvitegravir
NNRTI-Non-nucleoside Reverse Transcriptase Inhibitor, PI-Protease
Inhibitor PDEI Phosphodiesterase Inhibitor DHHS Antiretroviral
Guidelines 2014
Slide 24
Case Study *Bob is a 57 yr WM *Dx HIV 1994, AIDS 2000 *CrCl ~
50ml/min, Scr -1.2 *VL-Non detectable *Diabetes, hypertension, *
CD4-196 depression, cognitive delay Bob states he has been having
muscle fatigue and pain. What do you suggest for him? 1. Quit
lifting weights and rest 2. Change his ART 3. Discontinue
simvastatin and replace it with pravastatin Medication List:
Lopinavir/ritonavir (Kaletra) Tenofovir, emtricitabine (Truvada)
Sulfamethoxazole/ Trimethoprim (Bactrim) Pantoprazole (Protonix)
Paroxetine (Paxil) Mirtazapine (Remeron) Gabapentin (Neurontin)
Lisinopril (Zestril) Simvastatin (Zocor) Insulin glargine (Lantus)
Insulin apart (Novolog)
Slide 25
The Factors that Contribute to Increased Morbidity and
Mortality in HIV Positive Patients HOST Lifestyle Genetic Aging
HOST Lifestyle Genetic Aging HIV Compromised immunity Inflammation
despite ART HIV Compromised immunity Inflammation despite ART HAART
Toxicity HAART Toxicity Co-morbidities Renal Hepatic Cardiovascular
Endocrine Skeletal Neurologic Co-morbidities Renal Hepatic
Cardiovascular Endocrine Skeletal Neurologic Morbity and
Mortality
Slide 26
Renal Function HIV Associated Nephropathy, IgA nephropathy,
glomerulonephritis Chronic kidney disease associated with higher
mortality ART effects Tenofovir (Viread)-Fanconi Syndrome Tenofovir
Alefenamide Phase III trials, improved efficacy, less SE Atazanavir
(Reyataz) renal stones Scherzer R. AIDS 2012 April
24;26(7):867-875, Lucas GM. CID 2014:59(9):e96-e138 Prevalence of
abnormal renal function: 30%
Slide 27
Renal Dose Adjustments Drug ClassAdjustments Needed? NRTIYes
-except abacavir (Ziagen) PIAtazanavir (Reyataz) and Lopinavir (in
Kaletra) in hemodialsis Fusion InhibitorMaraviroc (Selzentry)
INSTICobicistat (booster in Stribild) NNRTINo DHHS Antiretroviral
Guidelines 2014 NRTI-Nucleoside Reverse Transcriptase Inhibitor,
PI-Protease Inhibitor, INSTI-Integrase Strand Transfer Inhibitor,
NNRTI-Non Nucleoside Reverse Transcriptase Inhibitor
Slide 28
Case Study * Bob is a 57 yr WM * Dx HIV 1994, AIDS 2000 * CrCl
~ 50ml/min, Scr -1.2 * VL-Non detectable * Diabetes, hypertension,
* CD4-196 depression, cognitive delay Medication List:
Lopinavir/ritonavir (Kaletra) Tenofovir, emtricitabine (Truvada)
Sulfamethoxazole/ Trimethoprim (Bactrim) Pantoprazole (Protonix)
Paroxetine (Paxil) Mirtazapine (Remeron) Gabapentin (Neurontin)
Lisinopril (Zestril) Pravastatin (Pravachol) Insulin glargine
(Lantus) Insulin apart (Novolog) Bobs creatinine clearance
decreases to 40 ml/min. What do you suggest For him? 1. Change
tenofovir to abacavir 2. Decrease frequency of Truvada 3. Change
Bactrim to atovaquone (Mepron) 4. Answers #2 and #3
Slide 29
Liver disease is the most common non- AIDS related cause of
death - Up to 18% of all deaths Hepatitis C co-infection (30%)
Hepatitis B co-infection (10%) Alcohol abuse Hepatotoxicity from
medication- discontinue meds if >10x upper limit of normal
Atazanavir (Reyataz) Smith C. AIDS 2010; Price JC Clin Gast Hepat.
2010 Hepatic Function
Slide 30
Cardiovascular Disease (CVD) HIV infected and older adults at
increased risk for CVD Higher rates of CVD risk factors in HIV
infected: -smoking, dyslipidemia ART improves CVD markers Lower CD4
associated with increased CVD risk SMART Study versus D:A:D Study-
conflicting results CVD: -1/3 of serious non-AIDS conditions ~10%
of deaths El-Sadir WM. N Engl J Med 355;22:2283-2296,Theibaut R, et
al. AIDS. 2010 Jun 19;24(10):1537-48
Slide 31
Cardiovascular Illness and Dyslipidemia Guidelines from HIV
Medical Association and AIDS Clinical Trials Group Protease
Inhibitors most significant effect Atazanavir (Reyataz) and
Darunavir (Prezista) improved impact on lipids Efavirenz (Sustiva)
mostly Statins: Use pravastatin (Pravachol), rosuvastatin (Crestor)
Start low and titrate up Avoid simvastatin (Zocor), lovastatin
(Mevacor) Fibrates: Use fenofibrate (Tricor) Dube MP. Eval of
dyslipidemia in HIV. CID 2003
Slide 32
Endocrine Function Diabetes Mellitus Multiple factors
contribute to diabetes PI, NNRTI most likely culprits HbA1c in HIV
underestimates blood sugar Testosterone Older men often need
androgen replacement Menopause Occurs earlier in HIV positive women
Hormone replacement may interact with ART Kim, PS, et al. Diabetes
Care. 2009
Slide 33
Case Study * Bob is a 57 yr WM * Dx HIV 1994, AIDS 2000 * CrCl
~ 50ml/min, Scr -1.2 * VL-Non detectable * Diabetes, hypertension,
* CD4-196 depression, cognitive delay Medication List:
Lopinavir/ritonavir (Kaletra) Tenofovir, emtricitabine (Truvada)
Atovaquone (Mepron) Pantoprazole (Protonix) Paroxetine (Paxil)
Mirtazapine (Remeron) Gabapentin (Neurontin) Lisinopril (Zestril)
Pravastatin (Pravachol) Insulin glargine (Lantus) Insulin apart
(Novolog) You notice Bob is at increased risk for cardiovascular
illness. What do you suggest for him? 1. Discontinue ritonavir
(Novir) 2. Change tenofovir to abacavir (Ziagen) 3. Change Kaletra
to raltegravir (Isentress)
Slide 34
Skeletal Function: Osteoporosis HIV and aging increases risk
Declines in bone mineral density have been observed with the start
of most ART Tenofovir main culprit Interventions: Bisphosphonates
Vitamin D and calcium Change ART: tenofovir abacavir or raltegravir
Brown T Top Antiv Med 2013, Stellbrink HJ. Clin Infect Dis. 2010
Osteopenia and osteoporosis may be 3x higher
Slide 35
Neurologic Function and HIV HIV replicates in the Central
Nervous System HIV Associated Neurocognitive Disorders (HAND) ART
effect on the Brain: CNS Drug Penetration Effectiveness Score (CPE)
Better CPE score = improved CNS viral load Studies non conclusive
of clinical effect of CPE scores Efavirenz-high CNS penetration
Letendre S. Top Antiviral Med 2011 >50% of HIV patients have
some form of HAND >50% of HIV patients have some form of
HAND
Slide 36
Neurologic Function and HIV Antiretroviral Therapeutic
Threshold Neurotoxicity Threshold Antiretroviral Drug Concentration
in the CNS Risk of Neurocognitive Impairment _____________ >
______ > Damage from: -Uncontrolled HIV Replication -Immune
activation Letendre S. Top Antiviral Med 2011 Clinical Cognitive
Threshold
Slide 37
Neurologic Function and HIV Mental health illness Great risk of
morbidity and mortality Depression up to 40% Antidepressant therapy
partially reverses medication non-adherence AIDS Survivors Syndrome
Lets Kick ASS (AIDS Survivors Syndrome) Re-focusing on living
instead of dying Celebrating survival
Slide 38
Medication Adherence Older HIV positive adults may have better
adherence than younger Concerns: Neurocognitive function Vision
loss, hearing loss Polypharmacy Physical impairment Consequences:
Viral resistance Opportunistic Infections Drug toxicity Shortened
life-span Becker BW, et al. AIDS Behav. 2011 Nov: 15(8):1888-94,
Suarez S, et al. AIDS 2001:15:195-200, Silverberg MJ, et al. Arch
Intern Med 2007;167:684-691
Slide 39
Medication Adherence Tools Pharmacist-led medication adherence
counseling Pill boxes, alarms, calendars On-line applications
mymedschedule.com adultmeducation.com Support from family, friends
Referrals to psychiatry or substance use rehabilitation
Transportation assistance Prescription mailings
Slide 40
Case Study * Bob is a 57 yr WM * Dx HIV 1994, AIDS 2000 * CrCl
~ 50ml/min, Scr -1.2 * VL-Non detectable * Diabetes, hypertension,
* CD4-196 depression, cognitive delay Medication List: Raltegravir
(Isentress) Tenofovir, emtricitabine (Truvada) Atovaquone (Mepron)
Pantoprazole (Protonix) Paroxetine (Paxil) Mirtazapine (Remeron)
Gabapentin (Neurontin) Lisinopril (Zestril) Pravastatin (Pravachol)
Insulin glargine (Lantus) Insulin apart (Novolog) Bob is having a
difficult time with medication adherence. what do you suggest? 1. A
new pillbox 2. Refer to psychiatry 3. Set an alarm for dosing times
4. All of the above
Slide 41
Medication Adherence: Food and Absorption DrugDrug exposure
with food Requirement Daruvavir (Prezista) 30%acid Atazanavir
(Reyataz) 35-70%Acid/fat Ritonavir (Norvir) 20%acid Etravirine
(Intelence) 50%acid Rilpivirine, tenofovir emtricitabine (Complera)
40%Acid/fat Elvitegravir, cobicistat, Emtricitabine, tenofovir
(Stribild) 34-87%Fat *Efavirenz (in Atripla)-take before bed and on
an empty stomach *Forgetting food may lead to viral resistance and
more side effects
Slide 42
Immunizations for HIV+ Adults VaccineDose/FrequencyNotes
Influenza0.5ml annuallyInactivated only. Never use live attenuated
(intranasal) PneumococcalPCV-13 (Prenvar) x 1 then Pnvax 23 x1, 5yr
a part If CD4>200 Hep BRecombivax HB 40ug x 3 or Engerix B
2-20ug doses x 4 If sAG neg and sAB60 and CD4>200 CDC Adult
Immunization Schedule U.S. 2014.
Slide 43
Resources Guidelines for the Use of Antiretroviral Agents in
HIV-1 Infected Adults and Adolescents, Department of Health and
Human Services 2014. Http://www. http://aidsinfo.nih.gov/guidelines
North West AIDS Education and Training Center. Http://www.
http://depts.washington.edu/nwaetc/ HIV-druginteractions.org
HIVinsite.ucsf.edu The HIV and Aging Consensus Project. Recommended
Treatment Strategies for Clinicians Managing Older Patients with
HIV. American Academy of HIV Medicine. 2013.
www.aahivm.org/hivandagingforumwww.aahivm.org/hivandagingforum
Marie Dorsey, Pharm.D., AAHIVP: [email protected]
Slide 44
Conclusions Diagnosing and starting ART early will prolong life
Consider recommendations for HIV patients according to
co-morbidities Check for drug interactions Assist patients with
medication adherence The interplay between HIV, aging, drug effects
and co- morbidities is not well understood and more studies are
needed
Slide 45
Do not regret growing older. It is a privilege denied to many.
~Unknown
Slide 46
References Becker BW, Thames AD, Woo E, et al. Longitudinal
change in cognitive function and medication adherence in
HIV-infected adults. AIDS Behav. 2011 Nov;15(8):1888-94 Brown T.
Challenges in the Management of Osteoporosis and Vitamin D
Deficiency in HIV Infection. Topics in Antiviral Medicine 2013;
21(3); 115-118 Casau N. Perspective on HIV Infection and Aging:
Emerging Research on the Horizon. CID 2005; 41:855-863 Center for
Disease Control and Prevention. Morbidity and Mortality Weekly
Report. HIV Surveillance United States 1981-2008. June 3, 2011
60(21);689-693.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6021a2.htm. Accessed
October 2014 Center for Disease Control and Prevention. Recommended
Adult Immunization Schedule United States 2014.
http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-schedule.pdf.
Accessed September 15, 2014 Dumond JB, Adams JL, Prince HA, et al.
Pharmacokinetics of Two Common Antiretroviral Regimens in Older
HIV-Infected Patients. HIV Medicine 2013 14(7):401- 409 El-Sadir
WM, Lundgren JD, Neaton JD, et al. CD4+ Count-Guided Interruption
of Antiretroviral Treatment. The strategies for Management of
Antiretroviral Therapy (SMART) Study Group. N Engl J Med
355;22:2283-2296. Girardi E. Increasing proportion of late
diagnosis of HIV infection among patients with AIDS in Italy
following introduction of combination antiretroviral therapy. J
Acquir Immune Defi Syndr 2000;25:71 Helleberg M et al. Clin Infect
Dis. 2013;56:727-734 Kim PS, Woods C, Georgoff P, et al. A1C
underestimates glycemia in HIV infection. Diabetes Care.
2009;32:1591-1593
Slide 47
References Letendre S. Central Nervous System Complications in
HIV Diseasae: HIV-Associated Neurocognitive Disorder 2011. Top
Antiviral Med 19(4):137-142 Lucas GM, Ross MJ, Stock PG, et al.
Clinical Practice Guideline for the Management of Chronic Kidney
Disease in Patients Infected with HIV: 2014 Update by the HIV
Medicine Association of the Infectious Diseases Society of America.
Clin Infect Dis 2014; 59(9):e96-e138. Oregon Health Authority,
Public Health Division, HIV/STD/TB Program, HIV Data and Analysis.
Epidemiologic Profile of HIV/AIDS in Oregon. 2013.
https://public.health.oregon.gov/DiseasesConditions/CommunicableDisease/DiseaseSurveillanceData/HIV
Data/Documents/EpiProfile.pdf. Accessed September 12, 2014. Panel
on Antiretroviral Guidelines for Adults and Adolescents. Guidelines
for the use of antiretroviral agents in HIV-1-infected adults and
adolescents. Department of Health and Human Services. May 1, 2014.
Available at
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf.
Accessed September
2014http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
Phillips AN, Neaton J, Lundgren JD. The role of HIV in serious
diseases other than AIDS. AIDS. 2008;22:2409-2418h, C, Lundgren JD,
Thiebaut R, et al. Factors associated with specific causes of death
amongst HIV-positvie individuals in the D:A:D Study. AIDS. 2010 Jun
19;24(10):1537-48 Silverberg MJ, Leyden W, Horberg MA, et al. Older
age and the response to and tolerability of antiretroviral therapy.
Arch Intern Med. 2007;167:684-691.) Stellbrink HJ, Orkin C, Arribas
JR et al. Comparison of changes in bone density and turnover with
abacavir-lamivudine versus tenofovir-emtricitabine in HIV-infected
adults:48 week results from the ASSERT study. Clin Infect Dis.
2010;51(8):963 Suarez S. Baril L, Stankoff B. et al. Outcome of
patients with HIV-1 related cognitive impairment on highly active
antiretroviral therapy. AIDS 2001;15:195-200 Virus (HIV)-Infected
Adults Receiving Antiretroviral Therapy: Recommendations of the HIV
Medicine Association of the Infectious Disease Society of America
and the Adult AIDS Clinical Trials Group.Clin Infect Dis. 2003;37
(5):613-627 Wooten JM. Pharmacotherapy Considerations in Elderly
Adults. South Med J. 2012;105(8):437-445