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

new

infe

ctio

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 <50 copies PMH: HTN, depression, DM, hyperlipidemia Meds: emtricitabine/tenofovir/efavirenz, HCTZ,

citalopram, glargine insulin, lisinopril, EcASA, pravastatin

SH: lives alone, no tobacco, IDU, has boyfriend and uses condoms intermittently

Difficulty with adherence to non-ART medicines HbA1C >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

arti

cip

ants

<50 years 50-64 years 65+ years

Age

4+

3

2

1

0

Number of co-medications

Incidence of comorbidities: by age

B Haase CROI 2011 Bac

teri

al p

neu

mo

nia

Cer

ebra

l in

farc

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Co

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AID

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eve

nt

Dea

th

1 2

5 10 20

0.1 0.2

0.5 Age 50-64 years Age <50 years

Age 65+ years

50

Inci

den

ce

per

10

00

pyr

s (9

5%

CI)

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

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<48 copies Facial lipoatrophy, truncal lipohypertrophy Other meds: metformin, lisinopril, ASA Reports decreased libido and ED

To evaluate this patient’s concerns, he should have:

CBC/LFT’s/thyroid function tests PSA Free testosterone Total testosterone All of the above

Endocrine Testosterone Deficiency: 54% had

testosterone <300 ng/dL Low androgen levels were associated with

increasing age, HIV+ IDU, HCV+ and use of psychotropic medications

Menopause: Occurs at younger age in HIV infection 46 (IQR 39-49)

Associated with increased symptoms of estrogen withdrawal

Klein CID 2005; Schoenbaum E CID 2005

Polling Question: Which of the following should be your first counseling priority?

Diet? Smoking? Exercise? Blood pressure control? Diabetes Mellitus management? Not sure

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

<1 1-2 2-3 3-4 4+

Observed rates

Best estimate of predicted

rates

None

Observed and predicted MI rates according to ART exposure (D:A:D Study n=23,468)

N=5292 N=6805 N=9050 N=10,574 N=8890 N=5973

Incidence of MIs is low: 345 over 94,469 patient-years follow-up (3.7/1,000 patient-years)

D:A:D Study: Is the Framingham Risk Estimation Valid in HIV-Infected Patients?

n = ART exposure

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

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

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

Polling Question: Should this patient be screened for osteoporosis?

Yes No Don’t Know

BMD Lower and Fracture Prevalence Higher in HIV Infection BMD lower in HIV+ men

at the femoral neck (p<.05) and lumbar spine (p=0.06)

Differences significant after adjusting for age, weight, race, testosterone level, and prednisone and IDU

A 38% increase in fracture rate among HIV+ men

Triant J Clin Endo Metab 2008 Arnsten AIDS 2007

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

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

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

Samantha

Samantha

57 yo MTF TG, HIV x 15 years, CD4 500, VL <50 copies

PMH: HTN, stable CAD, depression, Meds: tenofovir/emtricitabine/efavirenz,

carvedilol, HCTZ, citalopram, pravastatin, conjugated estrogen, spironolactone

SH: lives with partner, no tobacco, ETOH, IDU

What health maintenance issues should you discuss?

Mammogram? Prostate screening? Colon cancer screening? Heart disease? Osteoporosis? Advance directives? All of the above?

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.

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

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

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

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

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

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

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

Treatment Recommendations

www.aahivm.org/hivandagingforum

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