hiv and aging: shaping a relevant health system response

HIV and Aging:Shaping A Relevant Health

System Response

Wafaa El-Sadr, MD, MPHICAP at Columbia University

Outline of Presentation

• Characteristics of older PLWH• Age as a risk factor for co-

morbidities in PLWH • Health system challenges for older

PLWH• Shaping a health system for older

PLWH

Mil

lio

ns

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2002 2003 2004 2005 2006 2007 2008 2009 2010 20122011 2013

UNAIDS 2014

Scale-up of HIV Treatment

Optimal Models Study

Optimal Models is supported by tPEPFAR through the CDC under Cooperative Agreement 5U62PS223540 and 5U2GPS001537

Adults enrolled*

Children enrolled* Sites**

Ethiopia 113,096 9,057 32

Kenya 75,163 15,194 83

Rwanda 33,027 4,153 52

Mozambique 159,862 19,740 45

Tanzania 78,552 5,617 56

Total 459,700 53,761 268

*Total ever enrolled **Sites ever reporting

About 10% of PLWH enrolled in care are >50 years old and increasing proportion

initiated ART

Source: Eduardo et al, 2014, PLOS ONE (in press)Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

2005

2005-32006

2006-32007

2007-32008

2008-32009

2009-32010

2010-30%

4%

8%

12%

16%

Perc

enta

ge o

f adu

lts w

ho a

re

50 y

ears

of a

ge o

r old

er

Newly enrolling in HIV careNewly initiating ART

Active in HIV careActive on ART

p = 0.33

p < 0.001

Men represent larger proportion of those enrolled in HIV care and initiate

ART in older PLWH


15-24 years 25-39 years 40-49 years 50+ years0%

10%

20%

30%

40%

50%

Newly enrolling in HIV care Newly initiating ART

Perc

ent m

ale

0

200

400

600

Enrollment into HIV care ART initiation

Med

ian

(IQR)

CD

4 ce

ll co

unt,

cells

/mm

3Lower CD4+ count at enrollment

into HIV care for older PLWH


15-24 years 25-39 years 40-49 years 50+ years

Older PLWH have higher CD4+ cell loss during

follow-up in pre-ART care (CD4>600 at enrollment)

Enrollment 6 months 12 months 18 months 24 months600

650

700

750

800

850

15-40 years >40 years

• Patients >40 had lower median CD4+ at enrollment and during follow-up

• Patients >40 lost 10 more CD4+ cells per year compared to 15-40 year olds (p<0.01)

CD

4+

cou

nt

cell

s/m

m3

Teasdale CROI 2014, #913

Less robust CD4+ cell response after ART initiation in older

PLWH


All patients

Men Women

15-49 years

50+ years

Table 3. Loss to follow-up and death one year after enrollment into care and ART initiation, by age group

Cumulative incidence of loss to follow-up and recorded death one year after enrollment into HIV care

n = 392,131

% Loss to follow-up % Recorded Dead

Age Group (years) Overall Males Females Overall Males Females

>50 33.1 35.9 30.5 6.0 7.3 4.7

40-49 32.6 36.5 29.4 5.0 6.5 3.9

25-39 40.5 46.1 38.0 4.1 5.9 3.3

15-24 56.3 58.5 55.9 2.8 4.3 2.5

Cumulative incidence of loss to follow-up and recorded death one year after ART initiation

n = 184,689

% Loss to follow-up % Recorded Dead

Age Group (years) Overall Males Females Overall Males Females

≥ 50 16.1 17.8 14.5 6.0 7.1 4.8

40-49 15.3 17.5 13.6 5.1 6.4 4.1

25-39 19.3 24.1 17.2 4.5 6.6 3.6

15-24 28.0 32.9 26.9 4.4 5.6 4.1


Less risk of loss to follow-up but increased risk of death in older

PLWHHIV Care

ART

Age of PLWH and Risk of NCD

Age and Risk of Diabetes in PLWH

Petoumenos et al. JIAS 2012

Age and Risk for Hypertension in PLWH

Thiebaut et al. Antiviral Therapy 2005

Predictors of MI in PLWH

0.1 1 10 100

Relative rate of myocardial infarction (95% CI)Uni- and multivariable Poisson modelAdjusted for family history, BMI, HIV risk, cohort, calendar year and race

CART per additional year

Age per 5 year older

Male sex

Previous CVD

Smoking

Family history

1.00.1 10 100

Age and Risk of MI in PLWH

El-Sadr et al. CROI 2005

Health Systems Challenges for Older PLWH

• Early diagnosis of HIV• Careful follow-up during pre-ART

period and after initiation of ART• Screening for and management of

risk factors for NCDs and for NCD• Continuity care models attentive to

the characteristics of HIV disease and co-morbid conditions

Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics , standardized diagnostic protocols

Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support

Multidisciplinary family-focused care

A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient

Longitudinal monitoring Health information systems have standardized and easily retrievable data

Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community

Self management An informed, motivated patient is an effective manager of his/her own health

Community linkages and partnerships

Need functional partnerships between health facility-based providers and community-based groups that facilitate access to services across the care continuum

Health System Strategies

Health Systems Challenges:Diagnosis and Enrollment in Care

• Patients and providers may be unaware of HIV risk in older individuals

• Messaging regarding HIV and importance of HIV testing largely targeted at younger individuals

• Current testing venues may be not suitable (e.g. ANC) or not “elder friendly” – HIV testing tailored to reach older persons

e.g. PICT in inpatient settings and HTC in chronic disease clinics, family-focused testing

Health Systems Challenges:Monitoring, Retention and

Adherence• Retention in pre-ART and after ART

initiation critical for monitoring disease progression (frequency?)

• Monitoring for side effects of ART and other medicines for management of co-morbidities

• Adherence counselling may be complicated by polypharmacy for non-HIV conditions (co-morbidities)

Health Systems Challenges:Monitoring, Retention and

Adherence• Peer educators may not be peers

(tend to be young)• Family-focused care may be

targeted at younger families• Innovative methods needed to

screen and manage CVD, diabetes, hypertension, mental illness etc. among older PLWH

HIV Care Continuum

ART Eligible

Link

McNairy et al AIDS 2012

HIV Care Continuum

McNairy et al AIDS 2012

Screen and manage NCD risk factors and NCD

Early Diagnosis Careful monitoringOf disease progression

Monitor response To ART

Monitor for side effects

link

Health System Challenges:Models of Care for HIV and NCD

Opportunities for Implementation Research

• A missed opportunity for screening?– PLWH enrolled in care are rarely screened

for CVD risk factors, despite their frequent contacts with the health system

• A missed opportunity for management? – Chronic care systems developed for HIV

can theoretically be leveraged to manage chronic CVD risk factors (HTN, DM, high cholesterol) Rabkin, Goosby, El-Sadr Scientific American 2014

Rabkin, Nishtar JAIDS 2011 Rabkin, El-Sadr Global Pub Health 2011

Relevant ICAP Studies• HEART study in South Africa

– Feasibility of integrating CVD risk factor screening and risk stratification for PLWH on ART

• Link4Health CVD study in Swaziland• Phase 1: Feasibility, acceptability, cost

and time for CVD RF screening• Phase 2: Participants with CVDRF randomized

to management in HIV clinic versus OPD clinic

• Outcome: Combined linkage to CVDRF management

and retention in both HIV and CVD care • ARTIC Study in Kenya

• Prevalence of NCD risk factors and NCD • Cohort of HIV-infected ART naïve, initiating ART• Storage of samples for biomarker analyses

Participant has > 40% 10-year risk

Conclusions

• Substantial, and likely increasing, proportion of PLWH enrolled in HIV care and initiating ART at older ages

• Enhanced efforts needed for earlier diagnosis of HIV in older persons and engaging them in programs that address their unique needs with regards to HIV and co-morbid conditions

• Research urgently needed to characterize older PLWH and to identify effective models of care for such individuals

Acknowledgements

• ICAP colleagues: Matt Lamb, Eduard Eduardo, Chloe Teasdale and Miriam Rabkin

• Patients and staff at health facilities• Ministries of Health and partner

organizations• Funding from PEPFAR, NIH and

Medtronic

hiv and aging: shaping a relevant health system response

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