managing hiv in the aging patient

Managing HIV in Managing HIV in the Aging the Aging

PatientPatient

Donna Gallagher,Donna Gallagher,

RNCS,MS,ANP,FAAN,MARNCS,MS,ANP,FAAN,MA

PI/Director NEAETCPI/Director NEAETC

HelenHelen

• 60 year old widow60 year old widow• Lives in a retirement communityLives in a retirement community• HTN, new Diabetes, skin rashes, HTN, new Diabetes, skin rashes,

some neuropathysome neuropathy• No history of operations, accidents, No history of operations, accidents,

blood transfusionsblood transfusions• Smokes 1/2 ppdSmokes 1/2 ppd• Drinks 1 bottle of “good wine” a weekDrinks 1 bottle of “good wine” a week

Helen con’tHelen con’t

• Married for 40 years, 5 sons grownMarried for 40 years, 5 sons grown• Husband died 3 months ago in ? Overdose Husband died 3 months ago in ? Overdose

sleeping pillssleeping pills• Feeling depressed and weak since thenFeeling depressed and weak since then• Seen regularly by LMDSeen regularly by LMD• Mild anemia, 21 lb weight lossMild anemia, 21 lb weight loss• Reports only 1 sexual partner in her Reports only 1 sexual partner in her

lifetimelifetime• Tested 2 months ago for HIV+ for change Tested 2 months ago for HIV+ for change

in insurancein insurance

Persons Older than 45 are at Persons Older than 45 are at Increasing Risk of HIV, AIDS and Increasing Risk of HIV, AIDS and

DeathDeath

0

5

10

15

20

25

HIV

AIDS

Deaths

Estimated HIV diagnoses, AIDS diagnoses and deaths of persons with AIDS, by age group in 2004

More than 11% of People Living More than 11% of People Living with AIDS are Older than 55 Yearswith AIDS are Older than 55 Years

0

10

20

30

40

50

13 13-19 20-34 35-44 45-54 55-64 65+

PA

USA

Estimated proportion of persons living with AIDSAnd the US by age group

The proportion of persons with The proportion of persons with HIV/AIDS over 55 years old HIV/AIDS over 55 years old

continues to increasecontinues to increase

10

15

20

1997 1998 1999 2000 2001

Estimated proportion of persons living with AIDSby age group

AIDS cases by age and sex AIDS cases by age and sex reported from 1981 reported from 1981

through 2000 through 2000

http://www.cdc.gov/hiv/graphics/surveill.htm.

OutlineOutline• EpidemiologyEpidemiology• Treatment IssuesTreatment Issues

– AdherenceAdherence– Virologic SuppressionVirologic Suppression– CD4 ResponseCD4 Response– Morbidity/ MortalityMorbidity/ Mortality– ToxicityToxicity– Drug-Drug InteractionsDrug-Drug Interactions

• Co-morbiditiesCo-morbidities• General Health MaintenanceGeneral Health Maintenance• Psychosocial IssuesPsychosocial Issues• Future Research NeedsFuture Research Needs

Older patients are getting Older patients are getting infected!infected!

• Seniors not considered at risk: don’t ask, don’t Seniors not considered at risk: don’t ask, don’t telltell

• Patient lack of awareness of HIV risk factors Patient lack of awareness of HIV risk factors – Many older people are newly single Many older people are newly single – Belief that HIV only affects younger people Belief that HIV only affects younger people

• Unprotected sexual activityUnprotected sexual activity– Use of Viagra and other ED drugs may Use of Viagra and other ED drugs may

contribute to increased rates of sexual activity contribute to increased rates of sexual activity – Menopause= No risk for pregnancy=No Menopause= No risk for pregnancy=No

condomcondom– No training in safer sexual activities No No training in safer sexual activities No

sexual negotiation skillssexual negotiation skills• Lack of HIV prevention education targeted at Lack of HIV prevention education targeted at

older peopleolder people

Demographics of Older vs. Demographics of Older vs. Younger HIV+ PatientsYounger HIV+ Patients

<50<50N=8,609N=8,609

>>5050N=1,664N=1,664

OverallOverallN=10,723N=10,723

Median Median AgeAge

39 (18 – 39 (18 – 49)49)

54 (50 – 54 (50 – 82)82)

42 (18 – 42 (18 – 82)82)

Male SexMale Sex 70.270.2 73.473.4 70.870.8

CaucasiaCaucasiann

BlackBlack

Hispanic Hispanic

29.529.541.741.726.626.6

27.827.844.244.226.126.1

29.229.242.142.126.626.6

IDUIDU 20.220.2 27.227.2 21.521.5

Clinical Outcomes in Older Clinical Outcomes in Older Patients Treated with Patients Treated with

HAARTHAART

• Adherence Adherence • Virologic SuppressionVirologic Suppression• Immunologic ResponseImmunologic Response• Morbidity and MortalityMorbidity and Mortality

Adherence: Adherence: Some things do get better Some things do get better

with Agewith Age

0102030405060708090

Overall 95% Adherence

<50 >50

Hinkin AIDS 2004

HIV-1 RNA <500 at 6 HIV-1 RNA <500 at 6 months: months: by Ageby Age

6768697071727374757677

Percent Undetectable

<50 >50 Grabar AIDS 2004

Treatment Issues in Treatment Issues in Older HIV PatientsOlder HIV Patients

• Older people may have age-Older people may have age-related losses of kidney related losses of kidney and/or liver function which and/or liver function which may change metabolism of may change metabolism of drugs drugs

• Drug-drug interactionsDrug-drug interactions• Toxicities significantToxicities significant• Older people often Older people often

excluded from clinical excluded from clinical trials and few subgroup trials and few subgroup analysis in older patientsanalysis in older patients

• Little pharmacokinetic Little pharmacokinetic data at extremes of agedata at extremes of age

ToxicitiesToxicities

• CardiovascularCardiovascular• Lipid AbnormalitiesLipid Abnormalities• Lipid/Glucose metabolismLipid/Glucose metabolism• Renal FunctionRenal Function• Hepatic InsufficiencyHepatic Insufficiency• Peripheral NeuropathyPeripheral Neuropathy• PancreatitisPancreatitis

Contraindicated Drug-Drug Contraindicated Drug-Drug CombinationsCombinations

• PI’sPI’s– Lipid Lowering Drugs: Lipid Lowering Drugs:

• Lovastatin and SimvastatinLovastatin and Simvastatin– Amiodarone: Ritonavir/lopinavir and Amiodarone: Ritonavir/lopinavir and

ritonavir (Kaletra)ritonavir (Kaletra)– Quinidine: RTV/IDVQuinidine: RTV/IDV– CisaprideCisapride– PPI’s (Atazanavir)PPI’s (Atazanavir)– St. John’s WortSt. John’s Wort

• NNRTI’s NNRTI’s – Cisapride with DLV or EFVCisapride with DLV or EFV

• NNRTIs and PI’sNNRTIs and PI’s• Benzos: triazolam, midazolamBenzos: triazolam, midazolam

Use with Caution Drug-Use with Caution Drug-Drug CombinationsDrug Combinations

• PI’sPI’s– Sildenafil and other Sildenafil and other

ED drugsED drugs– EchinaceaEchinacea– St John’s WortSt John’s Wort– EcstasyEcstasy– MethodoneMethodone

HIV vs. AgingHIV vs. Aging

• Aging process may hide or mimic age-Aging process may hide or mimic age-related diseasesrelated diseases

• Symptoms of SOB, fatigue, pain and Symptoms of SOB, fatigue, pain and weight loss treated as normalweight loss treated as normal

• Delay in diagnosisDelay in diagnosis– Bacterial Pneumonia or Bacterial Pneumonia or PCPPCP??

– Arthritis or Avascular Necrosis? Arthritis or Avascular Necrosis? – Alzheimer’s or AIDS Dementia?Alzheimer’s or AIDS Dementia?– Poor Circulation or Neuropathy?Poor Circulation or Neuropathy?

Multiple Comorbidities Kilbourne, et al. (2001)

Depressive Sx Only15%

Drug/AlcoholOnly: 6%

> Gen. Med.Conditions: 15%

12% 13%5%

7%

First Principles: Age May Exert its Effects Indirectly

HIV and Co MorbiditiesHIV and Co Morbidities

0

5

10

15

20

25

30

35

40

45

Comorbidities

HTNCOPDDMArthritisHCV+CADDepressionRenal Disease

Shah CID 2003

Co-Morbidities in HIVCo-Morbidities in HIV

• CancerCancer• DiabetesDiabetes• DepressionDepression• Substance AbuseSubstance Abuse• Memory ProblemsMemory Problems

Increased Risk of Cancer In Increased Risk of Cancer In Elderly HIV PatientsElderly HIV Patients

ObserveObservedd

ExpecteExpectedd

RR (95% CI)RR (95% CI)

AllAll 548548 423.5423.5 1.3 (1.2-1.3 (1.2-1.4)1.4)

ProstateProstate 118118 153.1153.1 0.8 (0.6-0.8 (0.6-0.9)0.9)

LungLung 105105 54.554.5 1.9 (1.6-1.9 (1.6-2.3)2.3)

LeukemiLeukemiaa

1919 7.8 7.8 2.4 (1.5-2.4 (1.5-3.8)3.8)

Hodgkin’Hodgkin’ss

1515 1.11.1 13.1 (7.4-13.1 (7.4-21.6)21.6)

MyelomaMyeloma 1515 5.65.6 2.7 (1.5-2.7 (1.5-4.4)4.4)

LiverLiver 88 2.02.0 3.9 (1.7-3.9 (1.7-7.8)7.8)

AnusAnus 66 0.70.7 8.2 (3.0-8.2 (3.0-17.8)17.8)

Biggar JAIDS 2004

Risk of diabetes in Risk of diabetes in HIV/HCV+ Veterans by age HIV/HCV+ Veterans by age

category category

Butt, Hepatology 2004

Prevalence of Depression Prevalence of Depression in HIV+ vs. HIV- Veterans in HIV+ vs. HIV- Veterans

by Ageby Age

Justice AIDS 2004

Prevalence of Drug Use Prevalence of Drug Use among Veterans: by HIV among Veterans: by HIV

status and age status and age

Justice AIDS 2004

Prevalence of ETOH Abuse Prevalence of ETOH Abuse among Veterans: by HIV among Veterans: by HIV

status and agestatus and age

Justice AIDS 2004

Self-Reported Memory Self-Reported Memory Problems in HIV+ vs. HIV- Problems in HIV+ vs. HIV-

Veterans Free of Veterans Free of Depression by AgeDepression by Age

Justice AIDS 2004

Older Infected Individuals are More Older Infected Individuals are More Likely to Have Cognitive Impairment:Likely to Have Cognitive Impairment:

The Allegheny County Neuropsychiatric The Allegheny County Neuropsychiatric Survey (ACNS)Survey (ACNS)

0

10

20

30

40

<50 50+

Dementia

CIND

Older Infected Individuals are Older Infected Individuals are Also More Likely to Develop Mild Also More Likely to Develop Mild

Impairment over 12 MonthsImpairment over 12 Months

0

5

10

15

20

25

>40 40+

CIND

Older Infected Individuals are Older Infected Individuals are More Likely to Develop Peripheral More Likely to Develop Peripheral

Neuropathy Neuropathy

Lopez

HIV+ patients HIV+ patients >>55 years 55 years old with Adequate Health old with Adequate Health Maintenance ScreeningMaintenance Screening

0102030405060708090

100

Health Maintenance

PCP ProphylaxisAny CholesterolAnnual PPD Influenza vaxPneumo Vax ( 5 years)Mammo within 2 yearsAnnual Pap

Shah CID 2002

Medications for common Medications for common age related illnessesage related illnesses

10

15

20

25

Inhaled B-agonist Ca Channel BlockerNSAID’s Anti Peptic Ulcer DrugAce inhibitor DiureticOral Hypoglycemic Antidepressant Shah CID 2002

General Routine Health General Routine Health MaintenanceMaintenance

• All MedicationsAll Medications• Tobacco/ETOH/drug useTobacco/ETOH/drug use• NutritionNutrition• Injury Prevention: Burns/Falls/DrivingInjury Prevention: Burns/Falls/Driving• IncontinenceIncontinence• Sexuality including a review of HIV risk Sexuality including a review of HIV risk

behaviorsbehaviors• MobilityMobility• Mentation/DepressionMentation/Depression• Hearing/VisionHearing/Vision• Activities of daily livingActivities of daily living• Social supportSocial support• Advance directivesAdvance directives

General Routine Health General Routine Health ScreeningScreening

• Screening:Screening:– Lipids: Yearly, especially if on HAARTLipids: Yearly, especially if on HAART– Diabetes: Yearly, quarterly if on HAARTDiabetes: Yearly, quarterly if on HAART– Thyroid Disease: screen every 5 yearsThyroid Disease: screen every 5 years– Osteoporosis: women >65 densitometryOsteoporosis: women >65 densitometry– Colonoscopy every 5 yearsColonoscopy every 5 years– Prostate exam annuallyProstate exam annually

Psychosocial IssuesPsychosocial Issues

• DisclosureDisclosure• IsolationIsolation• Lack of supportLack of support• Financial Financial

issues/Povertyissues/Poverty• End of life End of life

suffering/Poor pain suffering/Poor pain managementmanagement

• SuicideSuicide

ConclusionsConclusions

• Increasing prevalence of HIV in patients Increasing prevalence of HIV in patients >50, Consider HIV in the differential >50, Consider HIV in the differential

• Ask ALL patients about sexual Ask ALL patients about sexual history/drug use, alcohol use, herbs, history/drug use, alcohol use, herbs, spices and recreational drugsspices and recreational drugs

• Older adults may still have worse HIV Older adults may still have worse HIV disease progression and shortened disease progression and shortened survival, even with HAARTsurvival, even with HAART

• The beneficial effects of HAART therapy The beneficial effects of HAART therapy may be less in older HIV patientsmay be less in older HIV patients

ConclusionsConclusions

• Toxicity from HAART is substantial Toxicity from HAART is substantial and may be exacerbated in older and may be exacerbated in older patientspatients

• Drug-drug interactions are commonDrug-drug interactions are common• Unclear what the “ideal” HIV regimen Unclear what the “ideal” HIV regimen

is for older patientsis for older patients• High rates of comorbidities in older High rates of comorbidities in older

HIV patients HIV patients • General routine health maintenance General routine health maintenance

and screening is importantand screening is important• Future research is essential for Future research is essential for

developing accurate treatment developing accurate treatment recommendations in older patientsrecommendations in older patients

Resources for the Older Resources for the Older HIV PatientHIV Patient

OrganizationsOrganizations• National Association on HIV Over Fifty National Association on HIV Over Fifty

(NAHOF)(NAHOF)www.hivoverfifty.orgwww.hivoverfifty.org (617) 233-7107 (617) 233-7107

• New York Association on HIV Over FiftyNew York Association on HIV Over Fiftywww.nyahof.orgwww.nyahof.org (212) 481-7594 (212) 481-7594

• HIV Wisdom for Older WomenHIV Wisdom for Older Womenwww.hivwisdom.orgwww.hivwisdom.org (913) 722-3100 (913) 722-3100

• National Institute On AgingNational Institute On Agingwww.nia.nih.gov/health/agepages/aids.htmwww.nia.nih.gov/health/agepages/aids.htm

• American Association of Retired American Association of Retired Persons (AARP)Persons (AARP)

www.aarp.orgwww.aarp.org


BooksBooks• AIDS in an Aging Society: What We Need to AIDS in an Aging Society: What We Need to

KnowKnow; Riley, Ory & Zablotsky 1989 ; Riley, Ory & Zablotsky 1989 • HIV & AIDS and Older PeopleHIV & AIDS and Older People; Kaufmann 1995 ; Kaufmann 1995 • HIV/AIDS and the Older AdultHIV/AIDS and the Older Adult; Nokes 1996 ; Nokes 1996 • Aging with HIV: Psychological, Social, and Aging with HIV: Psychological, Social, and

Health IssuesHealth Issues; Nichols, et al. 2002 ; Nichols, et al. 2002 • HIV/AIDS and Older Adults: Challenges for HIV/AIDS and Older Adults: Challenges for

Individuals, Families, and CommunitiesIndividuals, Families, and Communities; Emlet ; Emlet 2004 2004

• Midlife and Older Adults and HIV: Midlife and Older Adults and HIV: Implications for Social Services Research, Implications for Social Services Research, Practice, and PolicyPractice, and Policy; Poindexter & Keigher ; Poindexter & Keigher 20042004


VideosVideos• HIV/AIDS and Older Americans; HIV/AIDS and Older Americans;

videovideoproduced by the National Minority produced by the National Minority AIDS Council Sept. 2001AIDS Council Sept. 2001

• HIV and Older Adults: Age is No HIV and Older Adults: Age is No Barrier; videoBarrier; videoNew York State Department of New York State Department of Health/AIDS InstituteHealth/AIDS InstituteMay 2003May 2003

managing hiv in the aging patient

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