I. Jean Davis, PhD, PA, AAHIVS

Howard University College of Medicine

1. Delay in diagnosis and poor clinical outcomes for HIV infection in the older patient (greater than 50 years of age) is associated with:a)Unsuspected HIV infectionb)Age-related differences in immune responses

to HIV antigensc) Lack of understanding the increase mucosal

risk of HIV acquisition in elderly d) a and Be) all of the above

2. This epidemiologic trend is expected due to longer survival of HIV-infected patients on antiretroviral therapy, and to increased case findings due to wider HIV testing.

True

False

3. Many age-associated diseases are less common in treated HIV disease than in age-matched HIV negative persons

Cardiovascular disease Non-AIDS cancers Osteopenia, bone fractures Liver and renal failure

True

False

4. ART consideration for older adults include:

a) Decreased kidney and liver functionb) Drug-drug interactionsc) Adherenced) a and be) All of the above

At the end of this webinar the participating providers will have an

enhanced ability to:

Describe the epidemiology of HIV in the population over 50

Explain the Delays in diagnosis due to unsuspected HIV infection

Describe the Age-related differences in immune responses to HIV antigens

Understand the Special Consideration Involving the Care of this Population

Mr. Dominguez is a 65 year old Black Hispanic male. He is a retired electrical engineer. He was diagnosed with GC and Syphilis (presenting with an oral chancre) 3 months ago and denies sexual activity with men. Mr. Dominguez returns to the clinic for follow-up and a refill on his ED and topical testosterone medication. He has never been married and has no children. His twin brother died last year secondary to a MI. He is very close with his nieces and nephews and their children. He has become a father figure for his brother’s children. His girlfriend is 50 years old nurse. He admits to an emotional monogamous relationship, but states he has regular sexually active with younger women because he respects his girlfriend too much to ask her to participate in certain sexual activities.

Secondary to the advancement in pharmacological therapies and a greater focus on patient centered care with a holistic point of view, including the importance of nutrition, physical activity and psychosocial issues, a greater prevalence of HIV-infected individuals over the age of 50 is projected

This epidemiologic trend is expected due to longer survival of HIV-infected patients on antiretroviral therapy, the sexual activity status of adults over 50 and to increased case findings due to wider HIV testing

HIV infection in the older patient (age greater than 50 years) is associated with:

Delays in education or screening due to provider prejudgment

Delays in diagnosis due unsuspected HIV infection

Age-related differences in immune responses to HIV antigens leading to a less robust clinical outcomes

Issues specific to an aging population, such as neurological, cardiovascular disorders, diabetes, low testosterone, osteoporosis need to be addressed in the older HIV-infected patient

cdc.gov

United States 2008:

Newly diagnosed persons with HIV 16.5% > 50 years old

30.5% persons living with HIV > 50 years old

By 2015, 50% people living with HIV will be > 50

Lack of awareness of STD/HIV risk factors Recently divorced or widowed Menopause

No pregnancy risk, little condom use Increased vaginal mucosal trauma/risk

Unprotected intercourse: less condom use in this generation associated with birth control pill

astheir primary mode to prevent pregnancy

Viagra: increased sex among older adults Lack of HIV prevention services for older persons Healthcare providers don’t consider older adults

at risk Providers not recognizing that 60 is the new 40

and the prevalence of cross generational sexual activities

Loss of bone and muscle mass Weight loss Decline in kidney function Memory loss Immunosenescence

↑ risk of Herpes zoster, UTI, bacterial infections, cancers

Lymphopenia, decline in CD4 cell count “Inflamm-aging”

↑ Proinflammatory cytokines, systemic low grade inflammation

Since the introduction of ART, primary causes of illness/death: AIDS-related illnesses ↑ chronic non-communicable conditions

typically associated with aging

Many age-associated diseases are more common in treated HIV disease than in age-matched HIV negative persons Cardiovascular disease Non-AIDS cancers Osteopenia, bone fractures Liver and renal failure

Diagnosis of HIV often delayed in older adults is secondary to patient and provider bias, lack of screening and misdiagnosis

Manifestations of HIV/AIDS often present similar to other syndromes Delirium Dementia Failure to Thrive: wasting, weight loss, frailty Bacterial infections

▪ Pneumonia Cytopenias

Decreased kidney and liver function Changes metabolism of drugs

Drug-drug interactions

Toxicities significant

Older persons often excluded from clinical trials

Inadequate pharmacokinetic data for older adult

Patients often taking > 5 medications

Increased comorbidities with age

Hasse B et al. CID 2011;53: 1130

Epidemiology Prevalence of HIV increasing among older adults HIV patients living longer, aging Older adults are sexually activity

Prevention Reduction in provider bias Patient education and screening for all STDs

Biology HIV patients age more rapidly than HIV negative controls HIV and aging may share link with chronic inflammation

Treatment Considerations Consider starting older patients on ART earlier Attention to co-morbidities, vascular disease important

Mr. Dominguez is a 65 year old Black Hispanic male. He is a retired electrical engineer. He was diagnosed with GC and Syphilis (presenting with an oral chancre) 3 months ago and denies sexual activity with men. Mr. Dominguez returns to the clinic for follow-up and a refill on his ED and topical testosterone medication. He has never been married and has no children. His twin brother died last year secondary to a MI. He is very close with his nieces and nephews and their children. His girlfriend is 50 years old nurse. He admits to an emotional monogamous relationship, but states he has regular sexually active with younger women because he respects his girlfriend too much to ask her to participate in certain sexual activities.

Let’s Talk GC and Syphilis (presenting with an oral chancre) 3 months

ago

Denies sexual activity with men

RTC for follow-up/refill of ED and topical testosterone medications

Family

Girlfriend is 50 years old nurse

Emotional monogamous relationship

Sexually active with younger women

Certain sexual activities

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