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Aging and HIVIdentifying Care Needs
Cynthia L. Gibert, MD, MScProfessor of Medicine, George Washington University
School of Medicine and Health SciencesWashington DC Veterans Affairs Medical Center
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Percentage of Adults Living with HIV Aged 50+ By Year and Region
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Epidemiology of HIV in US
• By 2050, of the expected 1.5 M living with HIV in the US, about 50% will be age 50 and older
• In 2012, people aged 55 and older accounted for one-quarter (24%, 288,700) of the 1.2 M living with HIV
• Older people more likely to be diagnosed later and to die sooner
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CDC. Diagnosis of HIV infection in the US and dependent areas, 2013. HIV Surveillance Report 2015; vol. 25.
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Challenges Faced
• Multi-morbidities• Access to care• Transportation• Activities of daily living• Economic issues• Social isolation/stigma• Depression• Chronic pain/addiction• Housing/homelessness• Incarceration• End of life issues
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HIV is Associated with IncreasedRisk for Non-AIDS Conditions
Increased risk done not necessarily mean that these events occur “prematurely”
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Primary Care Issues
• Screening for HIV
• Engagement in care
• Antiretroviral therapy
– Initiation of ART
– Simplification of ART
– Measuring CD4, HIVRNA, GART
• Preventive care
– Vaccines, TB screening, hepatitis A/B/C
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Primary Care
• Screening for HIV in at risk patients
• Engagement in care
• Antiretroviral therapy
– Initiation of ART
– Simplification of ART
– Measuring CD4, HIVRNA, GART
• Preventive care
– Vaccines, TB screening, hepatitis A/B/C
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Primary Care• Labs – CBC, CMP, vitamin D, lipids, PSA• Cancer screening – colon, anal, lung, liver, oral/pharyngeal• Cervical cancer, breast cancer• Ophthalmology and dental• Cardiovascular – EKG, aspirin, stress testing, AICD• Smoking cessation, alcohol use and abuse• Substance abuse – cannabis, opioids, cocaine• Chronic pain management• Mental health – depression, suicide• Bone health – DEXA, vitamin D, iPTH• Exercise and fitness• Psychosocial/economic/housing
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Multi-morbidities
• Cardiovascular disease
• End-stage renal disease
• Non-AIDS defining cancers –
• Diabetes/obesity
• Fractures
• End stage liver disease
• HIV-associated neurocognitive disorder (HAND)
• Frailty
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Coinfection with HIV and HCV• 3.2 M in US with chronic HCV infection
– 75% born during 1945-1965
• 10-30% of HIV-infected co-infected with HCV– 90% injection drug-users infected
• More rapid progression of liver fibrosis than HCV alone
• More rapid progression to decompensated liver disease than without HCV mono-infected
• HCV now a leading non-AIDS cause of death
• Patients with cirrhosis higher incidence of hepatocellular carcinoma
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Risk of End-stage Liver Disease in ART-treated HIV/HCV Co-infected Patients
Lo Re V et al., Open Forum Infectious Diseases 2015
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HIV Associated Neurocognitive Disorders (HAND): Frascati Criteria
HIV-associated Dementia
marked cognitive impairment with marked
functional impairment
3.2%
Mild Neurocognitive Disorder cognitive impairment with mild
functional impairment
12.6%
Asymptomatic Neuropsychological Impairment
abnormality in 2 or more cognitive areas
15%
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Frailty in People Aging with HIV
• The cumulative effects of age-related deterioration in multiple physiologic systems and homeostatic mechanisms greater vulnerability to stressors
• Nonspecific health complaints, fluctuating disability, falls, delirium.
• At higher risk for adverse outcomes
Brothers D et al. Frailty in people aging with HIV infection. JID 2014;210:1170-9
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Deficits Defining Frailty in HIV
• Weight loss: unintentional weight loss of 10 lbs. or > 5% of previous weight in last year
• Exhaustion: 3-4 times/wk
• Low activity: limited a lot – strenuous activity
• Slowness: timed 4 minute walk
• Weakness: grip strength by dynamometer
• Considered frail if 3 or more deficits present
Brothers D et al. Frailty in people aging with HIV infection. JID 2014;210:1170-9
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Multi-morbidity and Polypharmacy
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Polypharmacy
• Typically defined as >5 chronic drugs – Associated with diminished marginal benefit from
additional medication due to: – Drug-drug interactions and cumulative toxicity
• Cognitive compromise, falls, and organ system injury
– Confusion leading to non-adherence
• Risk of adverse events increases approximately 10% with each additional medication
• Interacts with alcohol, tobacco, other substances
Salazar JA. Expert Opin Drug Saf (2007) 6(6):695-704Gandhi TK. N Engl J Med 2003;348:1556-64
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DHHS Guidelines Individualized Care
• Antiretroviral regimen – choice must include review of other conditions
• Older people at greater risk of adverse effects and drug-drug interactions
• Encourage regimen simplification with discontinuation of unnecessary medications as feasible
DHHS Guidelines: 2013 HIV, Aging and Antiretroviral Therapy
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Preventive Care
• Immunizations – flu, Tdap, pneumococcal
• Smoking cessation
• Alcohol screening and treatment
• Cancer screening
• Chronic hepatitis B and C screening/treatment
• Sexual health – screening for STIs
• Diet and exercise - obesity
• Neurocognitive function
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US Preventive Services Task Forcefor Seniors
• Abdominal aortic aneurysm
• Type 2 diabetes mellitus
• Alcohol misuse
• Aspirin use: prevention of CVD and colon cancer
• Cervical cancer
• Cognitive impairment
• Colorectal cancer screening
• Coronary heart disease screening
• Dental and periodontal disease
• Depression
• Drug use: illicit screening
• Falls prevention
• Glaucoma screening
• Hearing loss
• High blood pressure
• Impaired visual acuity
• Intimate partner violence and abuse
• Lipid disorders
• Motor vehicle occupant restraints
• Obesity/healthy diet
• Osteoporosis
• Suicide risk
• Tobacco smoking cessation
Published recommendations of USPSTF http://www.usprevtiveservicestaskforce.org
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