Managing HIV in the Aging Patient

1. Managing HIV in the Aging Patient Donna Gallagher, RNCS,MS,ANP,FAAN,MA PI/Director NEAETC

3. Helen • 60 year old widow • Lives in a retirement community • HTN, new Diabetes, skin rashes, some neuropathy • No history of operations, accidents, blood transfusions • Smokes 1/2 ppd • Drinks 1 bottle of “good wine” a week

4. Helen con’t • Married for 40 years, 5 sons grown • Husband died 3 months ago in ? Overdose sleeping pills • Feeling depressed and weak since then • Seen regularly by LMD • Mild anemia, 21 lb weight loss • Reports only 1 sexual partner in her lifetime • Tested 2 months ago for HIV+ for change in insurance

5. Persons Older than 45 are at Increasing Risk of HIV, AIDS and Death Estimated HIV diagnoses, AIDS diagnoses and deaths of persons with AIDS, by age group in 2004

6. More than 11% of People Living with AIDS are Older than 55 Years Estimated proportion of persons living with AIDS And the US by age group

7. The proportion of persons with HIV/AIDS over 55 years old continues to increase Estimated proportion of persons living with AIDS by age group

8. AIDS cases by age and sex reported from 1981 through 2000 http://www.cdc.gov/hiv/graphics/surveill.htm.

9. Outline • Epidemiology • Treatment Issues • Adherence • Virologic Suppression • CD4 Response • Morbidity/ Mortality • Toxicity • Drug-Drug Interactions • Co-morbidities • General Health Maintenance • Psychosocial Issues • Future Research Needs

10. Older patients are getting infected! • Seniors not considered at risk: don’t ask, don’t tell • Patient lack of awareness of HIV risk factors • Many older people are newly single • Belief that HIV only affects younger people • Unprotected sexual activity • Use of Viagra and other ED drugs may contribute to increased rates of sexual activity • Menopause= No risk for pregnancy=No condom • No training in safer sexual activities No sexual negotiation skills • Lack of HIV prevention education targeted at older people

11. Demographics of Older vs. Younger HIV+ Patients

12. Clinical Outcomes in Older Patients Treated with HAART • Adherence • Virologic Suppression • Immunologic Response • Morbidity and Mortality

13. Adherence: Some things do get better with Age Hinkin AIDS 2004

14. HIV-1 RNA <500 at 6 months: by Age Grabar AIDS 2004

15. Treatment Issues in Older HIV Patients • Older people may have age-related losses of kidney and/or liver function which may change metabolism of drugs • Drug-drug interactions • Toxicities significant • Older people often excluded from clinical trials and few subgroup analysis in older patients • Little pharmacokinetic data at extremes of age

16. Toxicities • Cardiovascular • Lipid Abnormalities • Lipid/Glucose metabolism • Renal Function • Hepatic Insufficiency • Peripheral Neuropathy • Pancreatitis

17. Contraindicated Drug-Drug Combinations • PI’s • Lipid Lowering Drugs: • Lovastatin and Simvastatin • Amiodarone: Ritonavir/lopinavir and ritonavir (Kaletra) • Quinidine: RTV/IDV • Cisapride • PPI’s (Atazanavir) • St. John’s Wort • NNRTI’s • Cisapride with DLV or EFV • NNRTIs and PI’s • Benzos: triazolam, midazolam

18. Use with Caution Drug-Drug Combinations • PI’s • Sildenafil and other ED drugs • Echinacea • St John’s Wort • Ecstasy • Methodone

19. HIV vs. Aging • Aging process may hide or mimic age-related diseases • Symptoms of SOB, fatigue, pain and weight loss treated as normal • Delay in diagnosis • Bacterial Pneumonia or PCP? • Arthritis or Avascular Necrosis? • Alzheimer’s or AIDS Dementia? • Poor Circulation or Neuropathy?

20. First Principles: Age May Exert its Effects Indirectly

21. HIV and Co Morbidities Shah CID 2003

22. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

23. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

24. Increased Risk of Cancer In Elderly HIV Patients Biggar JAIDS 2004

25. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

26. Risk of diabetes in HIV/HCV+ Veterans by age category Butt, Hepatology 2004

27. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

28. Prevalence of Depression in HIV+ vs. HIV- Veterans by Age Justice AIDS 2004

29. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

30. Prevalence of Drug Use among Veterans: by HIV status and age Justice AIDS 2004

31. Prevalence of ETOH Abuse among Veterans: by HIV status and age Justice AIDS 2004

32. Co-Morbidities in HIV • Cancer • Diabetes • Depression • Substance Abuse • Memory Problems

33. Self-Reported Memory Problems in HIV+ vs. HIV- Veterans Free of Depression by Age Justice AIDS 2004

34. Older Infected Individuals are More Likely to Have Cognitive Impairment:The Allegheny County Neuropsychiatric Survey (ACNS)

35. Older Infected Individuals are Also More Likely to Develop Mild Impairment over 12 Months

36. Older Infected Individuals are More Likely to Develop Peripheral Neuropathy Lopez

37. HIV+ patients >55 years old with Adequate Health Maintenance Screening Shah CID 2002

38. Medications for common age related illnesses Shah CID 2002

39. General Routine Health Maintenance • All Medications • Tobacco/ETOH/drug use • Nutrition • Injury Prevention: Burns/Falls/Driving • Incontinence • Sexuality including a review of HIV risk behaviors • Mobility • Mentation/Depression • Hearing/Vision • Activities of daily living • Social support • Advance directives

40. General Routine Health Screening • Screening: • Lipids: Yearly, especially if on HAART • Diabetes: Yearly, quarterly if on HAART • Thyroid Disease: screen every 5 years • Osteoporosis: women >65 densitometry • Colonoscopy every 5 years • Prostate exam annually

41. Psychosocial Issues • Disclosure • Isolation • Lack of support • Financial issues/Poverty • End of life suffering/Poor pain management • Suicide

42. Conclusions • Increasing prevalence of HIV in patients >50, Consider HIV in the differential • Ask ALL patients about sexual history/drug use, alcohol use, herbs, spices and recreational drugs • Older adults may still have worse HIV disease progression and shortened survival, even with HAART • The beneficial effects of HAART therapy may be less in older HIV patients

43. Conclusions • Toxicity from HAART is substantial and may be exacerbated in older patients • Drug-drug interactions are common • Unclear what the “ideal” HIV regimen is for older patients • High rates of comorbidities in older HIV patients • General routine health maintenance and screening is important • Future research is essential for developing accurate treatment recommendations in older patients

45. Resources for the Older HIV Patient Organizations • National Association on HIV Over Fifty (NAHOF)www.hivoverfifty.org (617) 233-7107 • New York Association on HIV Over Fiftywww.nyahof.org (212) 481-7594 • HIV Wisdom for Older Womenwww.hivwisdom.org (913) 722-3100 • National Institute On Aging www.nia.nih.gov/health/agepages/aids.htm • American Association of Retired Persons (AARP) www.aarp.org

46. Resources for the Older HIV Patient Books • AIDS in an Aging Society: What We Need to Know; Riley, Ory & Zablotsky 1989 • HIV & AIDS and Older People; Kaufmann 1995 • HIV/AIDS and the Older Adult; Nokes 1996 • Aging with HIV: Psychological, Social, and Health Issues; Nichols, et al. 2002 • HIV/AIDS and Older Adults: Challenges for Individuals, Families, and Communities; Emlet 2004 • Midlife and Older Adults and HIV: Implications for Social Services Research, Practice, and Policy; Poindexter & Keigher 2004

47. Resources for the Older HIV Patient Videos • HIV/AIDS and Older Americans; video produced by the National Minority AIDS Council Sept. 2001 • HIV and Older Adults: Age is No Barrier; video New York State Department of Health/AIDS Institute May 2003