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  • LGBT Aging: HIV Prevention and Primary Care for LGBT Older Adults

    Jonathan S. Appelbaum, MD, FACP, AAHIVS Associate Professor and Education Director, Internal Medicine

    Florida State University College of Medicine Harvey Makadon, MD

    Director, National LGBT Health Education Center This publication was produced by the National LGBT Health Education Center, The Fenway Institute, Fenway Health with funding under cooperative agreement# U30CS22742 from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HHS or HRSA.

  • Continuing Medical Education Disclosures Program Faculty: Jonathan S. Appelbaum, MD Current Position: Associate Professor and Education Director, Internal

    Medicine Florida State University College of Medicine, Tallahassee, FL Disclosure: Speaker’s Bureau: Florida AETC and Clinical Care

    Options/HealthHIV Program Faculty: Harvey J Makadon, MD Current Position: Director, the National LGBT Health Education Center,

    Assistant Professor of Medicine, Harvard Medical School Disclosure: No significant financial relationships to disclose It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

  • Learning Objectives

    At the end of this webinar, participants will be able to:  Describe current HIV/AIDS epidemiology and

    risk factors among older adults  Identify treatment and prevention issues in older

    HIV patients  Access and understand screening and treatment

    guidelines for HIV and co-morbidities found in older HIV patients

  • When We Talk about the Elderly What Comes to Mind?

  • Lindau, NEJM, 2007

    Percent Having Sex

    ELDERsexuals

    Age Men Women

    57-64 84% 62%

    65-74 67% 40%

    75-85 38% 16%

  • HIV Incidence by Race and Age at Infection, 2010

    0

    1000

    2000

    3000

    4000

    5000

    6000

    13-24 25-34 35-44 45-54 55+

    # of

    n ew

    in fe

    ct io

    ns

    White Black/African American Hispanic Latino

  • HIV Incidence and Prevalence in Adults 50 or older

    7371

    7135

    6822

    6612

    6200

    6400

    6600

    6800

    7000

    7200

    7400

    7600

    2007 2008 2009 2010

    Incidence

    211651 235992

    262595

    0

    50000

    100000

    150000

    200000

    250000

    300000

    2007 2008 2009

    Prevalence

    Data from: CDC HIV Surveillance Report Supplement, 2010

  • 17% 19%

    21% 22% 25%

    27% 27% 29%

    33% 35%

    37% 39%

    41% 44%

    45% 47%

    50%

    2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

    *Data from 2008, onward projected based on 2001-2007 trends (calculated by Dr. Amy Justice). 2001-2007 data from CDC Surveillance Reports, 2007.

    0

    Projected

    Projected Proportion of those Living with HIV in U.S. 50+Years, 2001-2017*

  • Challenges to Prevention and Care

     Prevention fatigue  Knowing treatment is possible  Avoidance of discussion by clinicians  Isolation makes prevention and care

    more complex  Discrimination in housing and long-

    term care

  • Overcoming Barriers

  • “Test and Treatment” Cascade

    Cohen, 2011

    72%

  • Barriers to Linkage to Care

    Counseling and Testing Care and Treatment

  • Focused Prevention With Older Adults

  • Barriers to Routine HIV Testing

     50% of EDs are aware of CDC’s guidelines, and only 56% offer HIV testing (Haukoos, 2011).

     Only 61% of general internists offer HIV testing regardless of risk (Korthuis, 2011).

  • Accessing Antiretroviral Therapy

     Newly diagnosed patients should be linked to HIV care as soon as possible.

     HIV counseling and testing

    should be integrated with HIV care.

     Socio-economic and cultural factors impeding HIV care must be addressed.

  • Building a Program for Effective HIV Prevention  Outreach/Counseling

    and Testing  Access

     Integrated Prevention  Knowledge, Attitudes

    and Skills  Retention

     Peer Navigation/Case Management

     Regular Follow Up  Counseling  Behavior Change

  • Cultural, Clinical Competence: Quality Senior Care

  • Cases: HIV Treatment Issues

  • Kenji

  • Kenji  63 yo MSM  HIV+ 10 yrs, CD4 420, VL 10, SBP >160

  • Normal Aging Process

     Loss of bone and muscle mass

     Weight loss  Decrease in kidney function  Memory loss  Immunosenescence

  • Number of Non-HIV Meds by Age

    B Haase CROI 2011

    0

    20

    40

    60

    80

    100

    % o

    f p

    ar ti

    ci p

    an ts

  • Incidence of comorbidities: by age

    B Haase CROI 2011 B ac

    te ri

    al p

    n eu

    m o

    n ia

    C er

    eb ra

    l in

    fa rc

    ti o

    n

    C o

    ro n

    ar y

    an g

    io p

    la st

    y

    M yo

    ca rd

    ia l

    in fa

    rc ti

    o n

    P ro

    ce d

    u re

    s o

    n o

    th er

    a rt

    er ie

    s

    P u

    lm o

    n ar

    y em

    b o

    li sm

    Fr ac

    tu re

    , ad

    eq u

    at e

    tr au

    m a

    Fr ac

    tu re

    , in

    ad eq

    u at

    e tr

    au m

    a

    O st

    eo p

    o ro

    si s

    D ia

    b et

    es m

    el li

    tu s

    N o

    n A

    ID S

    d ef

    in in

    g m

    al ig

    n an

    ci es

    A ID

    S d

    ef in

    in g

    e ve

    n t

    D ea

    th

    1 2

    5 10 20

    0.1 0.2

    0.5 Age 50-64 years Age

  • Potential Comorbidities among Older Patients with HIV

     Cardiovascular disease  Metabolic disorders

     Diabetes  Dyslipidemias

     Neurocognitive abnormalities  Liver and renal problems  Bone disorders

     Osteopenia  Osteoporosis

     Malignancies

  • The Changing Epidemic

    ART-CC. CID, 2010

    Among those initiating HAART(1996-2006)

  • Polling Question: Would you recommend ART for this patient?

     Yes  No  Not sure

  • Key Updates in 2012 DHHS Guidelines

     Timing of ART initiation in treatment-naive patients  Treatment as prevention  Guidance on new regimens  Considerations for older patients  Considerations for HIV-infected women of

    childbearing age  Coadministration of antiretrovirals and HCV

    protease inhibitors  Timing of ART initiation in pt with TB

  • Key Considerations for Older HIV+ Patients

     ART recommended in patients >50 years of age, regardless of CD4 cell count (BIII)

     Why? The risk of non-AIDS related complications may increase and the immunologic response to ART may be reduced in older HIV+ patients

     But, ART-associated adverse events may occur more frequently in older adults

     Therefore, the bone, kidney, metabolic, cardiovascular, and liver health of older HIV- infected adults should be monitored closely

  • Key Considerations for Older HIV+ Patients  The increased risk of drug-drug interactions

    between ART and other medications commonly used in older HIV-infected patients should be assessed regularly, especially when starting or switching medications

     HIV experts and primary care providers should work together to optimize the medical care of older HIV-infected patients with complex comorbidities

     Counseling to prevent secondary transmission of HIV remains an important aspect of the care of the older HIV-infected patient

  • HIV Outcomes with ART: What We Know Already

    HIV-1 viral load suppression

    Older > Younger, doesn’t vary by class

    CD4 cell response Younger > Older Mortality Older > Younger,

    usually due to non-HIV causes

  • James

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