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The Medical and Social Challenges of Aging with HIV

Alison Moore, MD, MPH, FACP Professor of Medicine and Psychiatry David Geffen School of Medicine at UCLA Division of Geriatric Medicine. Homero E. del Pino, PhD Assistant Professor Charles R. Drew University Psychiatry and Human Behavior. The Medical and Social Challenges of Aging with HIV.

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The Medical and Social Challenges of Aging with HIV

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  1. Alison Moore, MD, MPH, FACP Professor of Medicine and PsychiatryDavid Geffen School of Medicine at UCLADivision of Geriatric Medicine Homero E. del Pino, PhD Assistant Professor Charles R. Drew University Psychiatry and Human Behavior The Medical and Social Challenges of Aging with HIV African American HIV University Science and Treatment College Black AIDS Institute August 29, 2013

  2. Objectives By the end of this session, you will be able to • Explain the medical and psychosocial challenges of aging with HIV • List two challenges for African-Americans aging with HIV • List two consequences of at-risk drinking for older people with HIV

  3. Another Kind of AIDS CrisisNew York Magazine, November 1,2009Article by David France, Photos by Marco Grob Norma Martinez. Age: 61 HIV: 12 yrs Has lipodystrophy, fatigue. Russell Steinke Age: 56 HIV: 23 yrs Has memory loss, nerve damage in feet, lipodystrophy, fatigue. Enrico McLane. Age: 52 HIV: 17 yrs Has short-term memory loss, two hip replacements.

  4. HIV in Older Populations-Facts • By 2015, half of people living with HIV will be 50 years old and older • Partly due to increased life expectancy with HAART and also newly diagnosed infections • CDC estimates that 15% of new HIV cases occur in people 50 years old and older • Rates of HIV/AIDS among 50+ • Whites 4.2/100K • Hispanics 21.4/100K (5 x Whites) • Blacks 51.7/100K (12 x Whites)

  5. Aging with HIV • 50 years of age is considered “older” because: • HIV infection may “accelerate” the aging process • Evidence of earlier onset of age-related disease states. • HIV associated with non-AIDS comorbidities such as diabetes mellitus and coronary heart disease, depression, non-AIDS cancers, etc. • Complex cases of cognitive impairment associated with chronic, HIV-driven inflammation of the aging brain.

  6. Aging with HIV BrideleeGittens, 48 Living with HIV: 22 years “AIDS is different than before. It’s not Kaposi’s sarcoma and PCP. Now it’s more diabetes and heart disease, high blood pressure and cancers. That’s what’s going on now. The disease has evolved.” http://www.nytimes.com/interactive/2013/06/02/nyregion/faces-of-hiv.html?_r=0

  7. What are aging comorbidities? Neurodegeneration, memory loss Osteoporosis Macular degeneration, hearing loss Heart disease Vascular disease Sarcopenia, frailty Diabetes, metabolic syndrome Decreased lung, kidney, etc function Slide adapted from Judith Campisi, PhD

  8. How HIV Impacts Successful Aging Vance, et. al. Successful Aging and the Epidemiology of HIV. Clinical Interventions in Aging. 2011:6 181-192

  9. Prevention and Screening Challenges • Many older adults sexually active but not practicing safe sex; thinner mucosal membranes increase transmission risk. • Older adults and particularly minority populations may face ageism, discrimination, stigma, that lead to later testing, diagnosis and reluctance to seek services. • Health care professionals may underestimate risk and not ask about sexual activity, test, or miss diagnosing AIDS because it mimics age-associated symptoms like fatigue, mental confusion.

  10. HIV in Older Populations- Risks • Age-specific challenges • Lack of understanding of HIV transmission • Low perception of risk • Less likely to use condoms, even w/ multiple partners • Older substance users • Less frequent high-risk behaviors, e.g., needle sharing, than younger adults • Equal sexual risk-taking as younger adults, e.g., sex for $ or drugs

  11. Initiating and Maintaining Care • Better medication adherence among older adults unless cognitively impaired. • With increased number of comorbidities, higher risk for polypharmacy and drug-drug interactions. • Higher risk for social isolation. • Discussion of advanced care planning/end-of-life preferences

  12. Implications for African-Americans • Little data specifically on issues specific to aging in African-Americans but given higher rates of HIV infection in younger age groups, this emerging population will pose challenges and successes.

  13. Social Support • Older people with HIV may score higher on social isolation scales than younger people HIV+, but size and level of support similar • Obstacles to obtaining social support • Non-disclosure • HIV stigma • Desire to be self-reliant • Variation due to race/ethnicity, sex/gender, length of infection, and route of exposure

  14. Alcohol Use and HIV • Alcohol use associated with nonadherence • Alcohol use decreases survival • Lifetime prevalence of alcohol use disorder two to three times higher than the general population

  15. Low Risk Drinking Guidelines for Healthy Adults 1 drink= 12 oz. of beer, 5 oz. of wine, 1.5 oz. spirits Low risk drinking Men aged < 65 years: No more than 14 drinks per week and no more than 4 drinks on any single day. Women and Men aged >65 years: No more than 7 drinks per week and no more than 3 drinks on any single day.

  16. Alcohol Use and Aging • Increased brain sensitivity to alcohol and increased blood alcohol levels for a given dose compared to younger persons • Alcohol, even at “low risk” levels, may adversely affect a variety of medical and psychiatric conditions and impact ngatively with a variety of medications

  17. Q&A

  18. Case Study: Mr. K. Mr. K is a 67 year-old man • HIV since 1997 on cART • HCV positive, hypertension, mild cognitive impairment • Takes 6 medicines Mr. K reports that • He lives alone, is retired, drives to the store • He is in contact with a brother • He drinks 3-4 drinks a few times a week at home, no other substance use

  19. Case Study: Mrs. L Mrs. L is a 62 year-old woman with • HIV for 5 years on cART • Diabetes, Hypertension, Osteoporosis, Depression • Takes 10 medicines Ms. L reports that • She is widowed for 1 year, lives with her daughter and grandson, and she watches TV during the day, goes to senior center sometimes. • She walks with a cane and is afraid to walk outside by herself.

  20. Role Play • Choose one person to be Mr. K. • Choose one person to be a health and social services advisor • Develop an action plan to address needs that you identify and be prepared to share with the group • Switch roles for the second case.

  21. Report Back

  22. Contact Information • Alison Moore, MD, MPH, FACP aamoore@mednet.ucla.edu • Homero E. del Pino, PhD homerodelpino@cdrewu.edu

  23. Resources • Administration on Aging website • http://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/ • Thebody.com

  24. Bibliography • CDC. HIV/AIDS among Persons Aged 50 and Older. 2008 • Greene et. al. Management of Human Immunodeficiency Virus in Advanced Age. JAMA. 2013; 309(13):1397-1405 • EffrosRB, Fletcher CV, Gebo K, et al. Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis. 2008;47(4):542-553. • YouleM and Murphy G. Coming of Age: a guide to ageing well with HIV. HIV Research and Training Institute. http://www.natap.org/2011/PDF/ComingAgeBook.pdf Accessed July 12, 2013. • SankarA, Nevedal A, Neufeld S, et al. What do we know about older adults and HIV? A review of social and behavioral literature. AIDS Care. 2011;23(10):1187-1207. • Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health. 2013;103(3):e7-e15. • Rowe, et. al. Successful Aging. The Gerontologist. Vol. 37, #4, 433-440 • Moore AA, Blow FC, Hoffing M, et al. Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial. Addiction. 2011;106(1):111-120. • WeathermonR, Crabb DW. Alcohol and medication interactions. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism. 1999;23(1):40-54. • Moore AA, Giuli L, Gould R, et al. Alcohol use, comorbidity, and mortality. J Am Geriatr Soc. 2006;54(5):757-762.

  25. Bibliography • Vance, et. al. Successful Aging and the Epidemiology of HIV. Clinical Interventions in Aging. 2011:6 181-192 • Moore AA, Beck JC, Babor TF, et al. Beyond alcoholism: identifying older, at-risk drinkers in primary care. J Stud Alcohol. 2002;63(3):316-324. • Fink A, Morton SC, Beck JC, et al. The alcohol-related problems survey: identifying hazardous and harmful drinking in older primary care patients. J Am Geriatr Soc. 2002;50(10):1717-1722. • Barnes AJ, Moore AA, Xu H, et al. Prevalence and correlates of at-risk drinking among older adults: the project SHARE study. J Gen Intern Med. 2010;25(8):840-846. Effros RB, Fletcher CV, Gebo K, et al. Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis. 2008;47(4):542-553. • YouleM and Murphy G. Coming of Age: a guide to ageing well with HIV. HIV Research and Training Institute. http://www.natap.org/2011/PDF/ComingAgeBook.pdf Accessed July 12, 2013. • SaagMS. HIV now firmly established in the Middle Ages. Clin Infect Dis. 2011;53(11):1140-1142. • Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health. 2013;103(3):e7-e15.

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