Older adults with well-controlled HIV may have a higher prevalence of certain eye conditions, particularly dry eye, compared to similar adults without HIV, according to a novel study led by a University of Colorado Anschutz Department of Ophthalmology faculty member.
The study is the first to comprehensively describe eye health in adults aged 60 and older who are living with durably suppressed HIV (meaning a person’s viral load is low and they cannot sexually transmit HIV to others) compared to similarly aged adults who do not have HIV, explains Alison Abraham, PhD, MS, MHS, the lead author.
Abraham is the vice chair of education and a professor in the Department of Epidemiology at the Colorado School of Public Health, with a secondary appointment in the ophthalmology department at CU Anschutz. She has spent decades researching issues related to HIV, healthy aging, and sensory loss.
“Vision is a primary sense we rely on,” Abraham says. “Many concerning eye conditions are age-related, and changes in vision can have a big impact on a person’s quality of life. People aging with HIV have a higher burden of several age-associated chronic conditions, and some conditions may occur at younger ages than in people without HIV.”
The research, also known as the HIV Vision Study, is a supplemental study of an ongoing national collaborative research effort through the National Institutes of Health to understand and reduce the impact of chronic health conditions that affect people living with HIV.
Researchers compared 74 older adults living with HIV to 65 patients without HIV. Between 2021 and 2023, each participant completed a series of vision and eye-related evaluations at the Johns Hopkins Wilmer Eye Institute in Maryland.
When comparing the two groups, 15% of people with HIV had uncorrected refractive error (meaning the shape of the eyeball makes it difficult to see clearly) compared to a 5% prevalence in those without HIV. About half of the participants with HIV met the study’s definition of having a cataract (a common condition where the lens of the eye becomes cloudy) or had previous cataract surgery compared to 20% of people who did not have HIV.
The vision-threatening eye diseases of macular degeneration and diabetic retinopathy were rare in both groups.
“Overall, adults aging with HIV who are well-treated are doing fairly well in many ways, including their vision,” Abraham says. “The big surprise for us was the dry eye data.”
Abraham was shocked at how common dry eye was in both groups. Roughly 63% of people living with HIV and 51% of people without HIV had clinical signs of dry eye disease. She notes that moderate-to-severe tear insufficiency was almost identical between groups: 34% versus 33%. The larger difference in the composite measure of dry eye appeared partly related to other signs, including meibomian gland dysfunction (20% versus 8%).
“That isn’t at all what we expected,” Abraham says. “The findings raise the possibility that HIV or HIV-associated factors may contribute to dry eye, but larger studies are needed to determine what might be behind the observation.”
It is unknown why this happens, but Abraham suspects persistent immune activation and inflammation associated with chronic HIV infection may play a role.
“HIV can affect ocular tissues, and persistent immune activation may occur even with systemic viral suppression. One possibility is that local inflammatory processes contribute to ocular surface disease, although this study was not designed to determine the mechanism,” she says. “Overall, it seems that if there is an eye issue among adults aging with well-controlled HIV, it appears to be dry eye.”
During the HIV and AIDS epidemic in the 1980s and early 1990s, much of the research focused on people who were immunocompromised, Abraham explains. Some people with HIV developed “HIV retinopathy,” a noninfectious disease that can damage the retina, a layer of tissue near the back of the eyeball that detects light and transmits visual information from the eye to the brain.
However, as better treatments for HIV were developed over the years and more people were able to successfully suppress HIV, there was less research focused on how the eyes may still be impacted by this virus, she notes.
“Many people with HIV are living long, healthy lives — but even with good treatments, they are still experiencing persistent low levels of chronic inflammation,” Abraham says. “This inflammation is why we think people with HIV tend to get cardiovascular disease, kidney disease, and other conditions earlier in life.
“There are also a lot of eye diseases that have an inflammatory component,” she adds. “It didn’t seem like a lot of researchers had looked at eye disease in the modern antiretroviral therapy era with the context of well-controlled HIV, which sparked the idea for this research.”
Given the study’s findings, Abraham explains further research is needed on dry eye, which she describes as a “very complicated disease syndrome.” One of the challenges of dry eye is that the symptoms a person experiences do not always correlate with the clinical signs of dry eye.
“Symptoms can include the eyes feeling itchy and almost like sandpaper, making it difficult and painful to open the eyes. It can be debilitating,” she says. “Sometimes, a patient will experience these symptoms, but they don’t have clinical evidence of dry eye, and vice versa.”
“We suspect part of the reason this happens is because of corneal pain sensitivity. A future research question is whether HIV is affecting this pain sensitivity, in addition to studying whether inflammation from HIV may play a role in why we saw a higher prevalence of dry eye in people with HIV,” she adds. “If we can understand what is happening, we might be able to build treatments.”
In the study, Abraham and her co-authors say their research shows it is important that routine ophthalmic examination is part of integrated HIV and aging care.
“Whether you’re living with HIV or not, we all should be attentive to our vision health, because vision and quality of life are tightly woven,” she says.
As part of her research, Abraham aims to uncover ways to improve the health care system so that accessing eye care is easier for all people, including those living in areas where there is a lack of eye specialists. She says that developing more integrated models of care is critical given the projected ophthalmology workforce shortage amid a growing aging population and rising need for ophthalmic services across the nation.
“My passion is helping people get access to care,” Abraham says. “I want to help develop community models of integrated care where we can offer people vision, HIV, and aging-related services all at one place, in a way that is both accessible and affordable.”