HIV/AIDS in Older Americans - PowerPoint Presentation

Slide1

HIV/AIDS in Older AmericansThe graying of the disease Extenuating vs Mitigating Factors

Celia J. Maxwell, M.D., FACP

Associate Dean for Research

Howard University College of MedicineSlide2

CDC Campaign “prevention IS CARE”Risk remains a challenge; 2014 73% diagnosed with HIV in medical care, 58% virally suppressed. Additionally, only 57% retained in care

Early ART initiation and sustained adherence are critically important

Retaining HIV-infected patients in care is essential and can be achieved

Brief discussions about safer sexual behaviors can change behavior

CDC Campaign “Prevention is Care” 2017Slide3

HIV Screening Among Older Adults13% of the US population ≥ 65 years old. Projections 20% by 2030 2015 half of HIV infected persons are 50 years or older

Study reviewed 12,366 adults ≥ 50 with questionnaire

Results:

HIV screening within this population 25.4%

Race had no statistically significant effect

Low risk perception of HIV exposure 84.1%

Routine medical checkup most common reason for HIV screening, 36%

Only 52% of tests were suggested by a HCP

Conclusion:

Increase HCP input critical

PLoS

One. 2012;7(8):e43618. Slide4

New Diagnoses of HIV among Adults Aged 50 Years and OlderAt the end of 2014…….Age Group44% of all new HIV diagnoses were for adults ages 50-54 years old

Race/Ethnicity

African Americans (AA) accounted for 43% of all diagnosed among older adults

The rate for AA (28.4) was

2x

the rate for Hispanics (11.4) and

8x

the rate for whites (3.4)

Transmission

Males: 67% of diagnosed infections were attributed to male-to-male sexual contact, 10% to injection drug use

Females: 85% of diagnosed infections were attributed to heterosexual contact, 15% to injection drug use

CDC HIV Surveillance Report. 2010-2014Slide5

Adults Aged 50 Years and Older Living with HIV InfectionAt the end of 2013….Age GroupAdults aged 50-54 accounted for 41% of older adults living with HIV, followed by those aged 55-59 at 29%

Race/Ethnicity

AA’s accounted for the largest population with 40% of older adults living with HIV

38% were white, 17% were Hispanic/Latino

Transmission

Males: 62% were attributed to male-to-male sexual contact, 17% to injection drug use, 12% to heterosexual contact

Females: 69% were attributed to heterosexual contact, 30% to injection drug use

CDC HIV Surveillance Report. 2010-2014Slide6

Enhance Awareness to Decrease Risk of HIV/AIDSHIV is often assumed to only affect young people, many older people do not recognize that they may be at riskSexual transmission most common way for HIV infection in older adults

Many health care providers (HCP) assume older patients have no sexual desires and are sexually inactive

Reality!!

Sexual behavior is likely to change over time. Meeting the criteria for “successful aging” nonconformance with the stereotype of “sexless elderly.”

Rapid dx and treatment important in older adults due to frailty and ↑ comorbidity levels

Important for HCP to identify persons at risk and adapt approaches to them

Aging

Clin

Exp

Res. 2014 Dec;26(6):665-9Slide7

Sexual Risk Behaviors in Adults 50 years or OlderLimited information of this behavior in older Americans. Study:Low prevalence of condom use among older adults (even if not in a long-term relationship with one partner)

Condom use at last intercourse highest among those aged 50-59 (24.3%; 95 confidence interval, 15.6-35.8) but declined 17.1% among those ages 60-69

Substance abuse ↑ risk for sexual risk taken

Older adults likely dx with HIV-related medical disorders later compared to younger persons

Clinician education important to mitigate

Subst

Abuse

Rehabil

. 2015 Apr 21;6:51-60.Slide8

HIV and STI testing in older adults:Missed opportunities

for the primary care physician

Limited research on topic

Testing for HIV and STIs of older adults infrequent

STI testing with genital symptoms more likely than asymptomatic screening

Sexual health assessment essential to comprehensive health care

Tillman JL et. Al J

Clin

Nurs

. 2015 Aug;24(15-16):2074-95. Slide9

The challenge: Managing hiv and other disorders associated with agingOlder adults living with HIV have a greater risk of other comorbidities Research on Older Adults with HIV (ROAH) done in 2010 in NYC 1,000 people ages 50 and older were interviewed: 640 men, 264 women, and 10 transgender

50% respondents black, 36% Hispanic, 14% white

>90% of the participants had at least one comorbidity

The most common were depression (52%), arthritis (31%), hepatitis (31%), neuropathy (30%), and hypertension (27%)

Current use of illicit drugs in this population was as follows: marijuana 23%, crack 16%, cocaine 15%, and heroin 7% (though lifetime use of illicit drugs was 84%) Smoking was higher in blacks & Latinos 63% & 58% compared to whites

PCP should address HIV risks in all patient populations

Research on Older Adults with HIV. ACRIA 2010.Slide10

Comorbidities a big issueMore than 50% PLWH in the US, > 50yearsEven with great advantage of HAART, life expectancy less than general population, about 5yearsHave increased prevalence of age related morbidity i.e. Cardiovascular disease (CVD), Hypertension, Diabetes, fractures, Cancer and neuro cognitive impairment (NCI)

Comorbidities seem to develop earlier than in HIV negative persons

Inflammation independent predictor of mortality and morbidity in PLWH and general population. However, source of inflammation in HIV not completely understood.

Gueler

et al AIDS 2017;31:427-36

Teeraananchai

et al HIV Med 2017 18(4):256-66

Brenchley

et al Nat Med 2006;12:1365-71Slide11

Table 2Clinical evidence of age-accentuated and age- accelerated associations in people living with human immunodeficiency virus

Age Accentuated

Age Accelerated

Cardiovascular

disease

Cancer (Myeloma,

lung, and anal)

Kidney disease

Liver

disease

Cognitive impairment

Frailty

Bone Disease

√

√

√

√

√

√

√

√

√

√

Infec

dis

clin

of N. America Dec 2017Slide12

Cardiovascular Disease in PLWHPLWH in the U.S. have 2x risk for MI, sudden death and heart failure as general population Longer use of HAART and low T4 cell counts associated inc. risk of MI

Despite PLWH higher

incid

. of MI, mean age at initial MI diagnosis not different form uninfected cohort

Althoff

et al

Clin

Infect Dis 2015 ; 60: 627-38Slide13

Cancer IN PlWHPLWH have higher risk of cancer some AIDS-defining (Kaposi cervical non-Hodgkin lymphoma)Some non-AIDS-defining (rectal, liver, melanoma, lung cancer) However, risk of prostate and breast cancer (high in gen. population) may be lower in PLWH

Brickman C et al

Curr

HIV/AIDS Rep 2015; 12: 388-96

MCGinnis

KA et al J

Clin

Oncol

@006; 24: 5005-9Slide14

Neuro Cognitive Impairment (NCI)NCI common in PLWH despite viral load suppression and ART (plasma and CSF)Usually asymptomaticAsymptomatic NCI ass. with higher risk of impairments in activities of daily living

Clifford DB et al Lancet Infect Dis 2013; 13: 976-86

Grant I et al Neurology 2014; 82: 2055-62Slide15

Bone Disease in PLWHPLWH have reduced bone mineral density and inc. risk of fractures Surprisingly, HAART increases bone loss especially during the first year if initiation

Greater ass.

t

enoforvir

(fumarate) or PI containing regimen

Grund

B et al AIDS 2009; 23: 1519-29

Cazanave

C et al AIDS 2008; 22: 395-402Slide16

Please remember “prevention IS CARE”Risk remains a challenge; 2014 73% diagnosed with HIV in medical care, 58% virally suppressed. Additionally, only 57% retained in care

Early ART initiation and sustained adherence are critically important

Retaining HIV-infected patients in care is essential and can be achieved

Brief discussions about safer sexual behaviors can change behavior

CDC Campaign “Prevention is Care” 2017Slide17

Thank you! Questions?