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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.
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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.
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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
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When We Talk about the Elderly What Comes to Mind?
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Lindau, NEJM, 2007
Percent Having Sex
ELDERsexuals
Age Men Women
57-64 84% 62%
65-74 67% 40%
75-85 38% 16%
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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
new
infe
ctio
ns
White Black/African American Hispanic Latino
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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
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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*
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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
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Overcoming Barriers
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“Test and Treatment” Cascade
Cohen, 2011
72%
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Barriers to Linkage to Care
Counseling and Testing Care and Treatment
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Focused Prevention With Older Adults
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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).
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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.
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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
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Cultural, Clinical Competence: Quality Senior Care
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Cases: HIV Treatment Issues
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Kenji
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Kenji 63 yo MSM HIV+ 10 yrs, CD4 420, VL 10, SBP >160
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Normal Aging Process
Loss of bone and muscle mass
Weight loss Decrease in kidney function Memory loss
Immunosenescence
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Number of Non-HIV Meds by Age
B Haase CROI 2011
0
20
40
60
80
100
% o
f p
arti
cip
ants
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Incidence of comorbidities: by age
B Haase CROI 2011 Bac
teri
al p
neu
mo
nia
Cer
ebra
l in
farc
tio
n
Co
ron
ary
ang
iop
last
y
Myo
card
ial
infa
rcti
on
Pro
ced
ure
s o
n o
ther
art
erie
s
Pu
lmo
nar
y em
bo
lism
Frac
ture
, ad
equ
ate
trau
ma
Frac
ture
, in
adeq
uat
e tr
aum
a
Ost
eop
oro
sis
Dia
bet
es m
elli
tus
No
n A
IDS
def
inin
g m
alig
nan
cies
AID
S d
efin
ing
eve
nt
Dea
th
1 2
5 10 20
0.1 0.2
0.5 Age 50-64 years Age
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Potential Comorbidities among Older Patients with HIV
Cardiovascular disease Metabolic disorders
Diabetes Dyslipidemias
Neurocognitive abnormalities Liver and renal problems Bone
disorders
Osteopenia Osteoporosis
Malignancies
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The Changing Epidemic
ART-CC. CID, 2010
Among those initiating HAART(1996-2006)
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Polling Question: Would you recommend ART for this patient?
Yes No Not sure
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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
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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
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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
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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
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James
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James
64 yo MSM, HIV+ 22 years, no OIs Smokes 1 ppd x 40 yrs Multiple
ART, now on boosted darunavir,
etravirine, raltegravir CD4 321, VL
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To evaluate this patient’s concerns, he should have:
CBC/LFT’s/thyroid function tests PSA Free testosterone Total
testosterone All of the above
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Endocrine Testosterone Deficiency: 54% had
testosterone
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Polling Question: Which of the following should be your first
counseling priority?
Diet? Smoking? Exercise? Blood pressure control? Diabetes
Mellitus management? Not sure
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Law et al. HIV Med. 2006;7:218-230
0
1
2
3
4
5
6
7
8
Duration of cART exposure (years)
Rat
es p
er T
hous
and
Patie
nt-Y
ears
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Effect of Smoking on HIV
HIV infected smokers lose more life-years to smoking than to
HIV
35 year-old HIV-positive smoker has ~16 less life-years than
non-smoker
Risk of smoking doubles in HIV-positive smokers compared with
HIV-positive non-smokers
Helleberg M et.al. CID 2013
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James: Follow Up
Free/total testosterone decreased PSA, CBC, LFTs normal Started
on testosterone replacement Appropriate lab follow up done, no
improvement in symptoms Sildenafil added (dose-adjusted)
with
improvement
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Recommendations: Lipids
There is insufficient evidence to alter current recommendations
for management of dyslipidemia or CVD/cerebrovascular disease
screening by specific age criteria
Use Framingham Risk Score to guide decision
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Polling Question: Should this patient be screened for
osteoporosis?
Yes No Don’t Know
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BMD Lower and Fracture Prevalence Higher in HIV Infection BMD
lower in HIV+ men
at the femoral neck (p
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Since older patients have bone loss due to
osteoporosis, and since many HIV-infected patients on ART have
accelerated bone loss, screening for (and aggressive treatment of)
osteoporosis should be done
Since vitamin D deficiency is prevalent in older HIV-infected
persons, screening for vitamin D deficiency is warranted
Recommendations: Osteoporosis Screening
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Frailty
Frailty phenotype: 3 of 5 (weight loss, exhaustion, weakness,
slowness, and low physical activity). earlier occurrence in
HIV-infected patients
Functional status – may be better indicator
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Frailty increases with age and time with HIV
Desquilbet, et al. J Gerontol Med Sci 2007;62A:1279-86
HIV-infected for 8-12 years at age 55 13.4% exhibit the frailty
phenotype –
9-fold higher risk than age-matched controls
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Samantha
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Samantha
57 yo MTF TG, HIV x 15 years, CD4 500, VL
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What health maintenance issues should you discuss?
Mammogram? Prostate screening? Colon cancer screening? Heart
disease? Osteoporosis? Advance directives? All of the above?
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Recommendations: Cancer Screening As part of general health
maintenance practices,
cancer screening in clinically stable HIV-infected patients 50
years and older should be in accordance to current guidelines for
the general population.
For cervical cancer, anal cancer, and liver cancer where
HIV-specific recommendations exist, these guidelines should be
adhered to instead.
For all patients, providers should take into consideration
functional status and life expectancy in applying these
recommendations.
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When to Stop Screening
When life expectancy less than natural history of disease: for
example, colorectal cancer
Patient desires/expectations Current guidelines—for example, PSA
and
colon cancer screening after age 75
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Impact of Hormones on HIV and Aging
MTF: Current estrogen use: 3x increase risk in CVD
mortality Total mortality 51% higher, but due to other
causes (suicide, HIV, CVD, drug abuse) FTM: No difference in
mortality
Asscheman H. European Journal of Endocrinology 2011
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General Routine Health Maintenance
Review ALL medications every visit Tobacco/ETOH/drug use
Nutrition Injury Prevention: Burns/Falls/Driving Bowel
Habits/Incontinence Psychosocial issues- $, end-of-life,
social support Please see the first two webinars in this series
for more information
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Other Important Issues: Holistic Care for the Older Patient
Sexuality Mobility Cognitive Impairment Depression Dealing with
“triple” stigma: HIV, age, being gay Sensory Deprivation:
Hearing/Vision Activities of daily living Housing stability
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Conclusions
HIV infection is increasing in the older population
Older patients present later=>need to improve testing and
linkage to care
Compared to younger patients, older HIV patients have: Better
virologic response, less immunologic
boost, shortened survival Psychosocial issues and advanced
directives
are important
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Recommendations Start older patients with ART earlier for
improved CD4 counts and reducing comorbidities Watch closely for
side effects/toxicities
Screen for comorbid disease (but stop screening when
appropriate!) DeXA for osteoporosis Cancer screening STI’s
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Recommendations Avoiding comorbid disease (good primary
care!) Vaccinations (Flu, S. pneumoniae? HZV) Smoking cessation,
exercise, diet
Treat comorbid disease Treat lipids, hypertension, diabetes
Substance abuse and mental health HCV
Address psychosocial issues and advanced directives
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Treatment Recommendations
www.aahivm.org/hivandagingforum
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Other Resources AOA: Know the Risks,
Get the Facts: Older Adults and HIV Toolkit
Hivoverfifty.org SAGEusa.org National Resource
Center on LGBT Aging: www.lgbtagingcenter.org
LGBT Aging Project
http://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/toolkit.aspxhttp://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/toolkit.aspxhttp://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/toolkit.aspxhttp://www.sageusa.org/http://www.lgbtagingcenter.org/http://www.lgbtagingcenter.org/
Slide Number 1Continuing Medical Education DisclosuresLearning
ObjectivesWhen We Talk about the Elderly What Comes to Mind?Lindau,
NEJM, 2007HIV Incidence by Race and Age at Infection, 2010HIV
Incidence and Prevalence in Adults 50 or olderSlide Number
8Challenges to Prevention and CareOvercoming Barriers“Test and
Treatment” CascadeBarriers to Linkage to CareFocused Prevention
With Older AdultsBarriers to Routine HIV TestingAccessing
Antiretroviral TherapyBuilding a Program for Effective HIV
PreventionCultural, Clinical Competence: �Quality Senior CareCases:
HIV Treatment IssuesKenjiKenjiNormal Aging ProcessNumber of Non-HIV
Meds by AgeIncidence of comorbidities: by agePotential
Comorbidities among Older Patients with HIVThe Changing
EpidemicPolling Question: Would you recommend ART for this
patient?Key Updates in 2012 DHHS GuidelinesKey Considerations for
Older HIV+ PatientsKey Considerations for Older HIV+ PatientsHIV
Outcomes with ART:�What We Know AlreadyJamesJamesTo evaluate this
patient’s concerns, he should have:EndocrinePolling Question: Which
of the following should be your first counseling priority?D:A:D
Study: Is the Framingham Risk Estimation Valid in HIV-Infected
Patients?Effect of Smoking on HIVJames: Follow UpRecommendations:
LipidsPolling Question: Should this patient be screened for
osteoporosis?BMD Lower and Fracture Prevalence Higher in HIV
Infection�FrailtyFrailty increases with age and time with
HIVSamanthaSamanthaWhat health maintenance issues should you
discuss?Recommendations: Cancer ScreeningWhen to Stop
ScreeningImpact of Hormones on HIV and AgingGeneral Routine Health
MaintenanceOther Important Issues: Holistic Care for the Older
PatientConclusionsRecommendationsRecommendationsSlide Number
56Treatment RecommendationsOther Resources