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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