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HIV and Aging

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					   HIV Disease in Older Patients
              Donna M. Gallagher, ANP



DM Gallagher, ANP.
Presented at IAS–USA/RWCA Clinical Conference, June 2005.   The International AIDS Society–USA
                                                                               Slide #2


                         Current Challenges
        Case finding in the over 50 population
        Primary Care for over 50 in HIV setting
        HIV care in the Geriatric setting
        Prevention for Positives over 50
        Medication Fatigue
        Risk Reduction Fatigue
        Compassion Fatigue


DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #3

                 CDC: US population
              Top 5 causes of death: 2002
          55-64                                      > 65
          Malignancy 36.9%                           Cardiac disease 31.8%
          Cardiac disease                            Malignancy 21.6%
           25.4%                                      Cerebrovascular
          Lung disease 4.5%                           disease 7.9%
          Diabetes 4.0%                              Lung disease 6.0%
          Cerebrovascular                            Alzheimer's tied with
           disease 3.9%                                pneumonia/influenza
                                                       3.2%
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #4

           Massachusetts DPH 2004-2005
             People Living with HIV
          Male: 72%                                  Female: 28%
          MSM 46%, IVDU                              IVDU 34%,
           28%                                         heterosexual
          White 53%, Black                            contact 33%
           22%, Hispanic 23%                          White 32%, Black
          White:    MSM 66%                           39%, Hispanic 28%
           Black : IVDU 31%                           White: IVDU 52%
                     MSM 23%                            Black: hetero 41%
           Hispanic: IVDU 51%                           Hispanic: hetero 44%

DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #5

           Massachusetts DPH 2004-2005
             People Living with HIV

          21% over 50 years old
          20% 45-49 years old
          24% 40-45 years old




DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #6

          Massachusetts DPH 2004-2005
            People Living with HIV
        AIDS           diagnosis within 2 months
                        of HIV diagnosis  30%

              If over 50 42%
              Higher incidence of AIDS at time of
                diagnosis among infections from
                     heterosexual transmission
           Issues of Denial: Patient and Provider
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #7




             HIV Over Fifty (Who are they?)
       1. PLWHIV who were in their 30’s when
          they became infected
       2. Women who have begun to have sex again
          after a divorce, death or the introduction of
          sildenafil to their relationship
       3. IVDU who have continued to have risk
          while needle sharing
       4. Patients in mental health care, long term
          care facilities

DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #8


                Who are they (continued)?
        Patients who access the health care
         system and are not assessed for risk
        Men and women who are NOT
         accessing the health care system and are
         being missed
        People who see HIV prevention
         messages that don’t reach them because
         they are not represented in the message
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #9


             Aging and Immune Function
        Increased co-morbidities
        Increased risk of reactivation diseases with
         aging: TB, herpes zoster
        Cell mediated response to vaccines and
         infections are lost over time. Anergy testing
         not recommended
        Decreased survival after diagnosis of AIDS
         in individuals > 50 compared to < 40
        Increased likelihood of having AIDS at time
         of initial diagnosis
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #10


             Aging and Immune Function
        Thymic function decreases with age is
         important in the quantitative CD4
         response to HAART
        CD4 cells decrease and CD8 cells
         increase with aging so ratio needs a
         different view
        Genetic aging (polymorphisms in
         chemokine receptors) enhance HIV 1
         progression
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #11


                              Considerations
        Sexual and domestic violence as a backdrop
        Isolation
        Fear of rejection
        Meds, home remedies, herbal supplements
        Nutrition affected by poverty, lack of
         access, side effects
        Safety issues
        Responsible for caring for a loved one
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #12


                    Fenway Demographics
          HIV infected                               HIV infected
           patients over 50                            patients over 60
           years old                                   years old
               2000: 12 %                                     2000: 2%
                (107/917)                                     (15/917)
                2004: 19%                                    2004: 3%
               (202/1083)                                    (34/1083)


DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #13

                    Fenway Demographics
                       Co-morbidities
          Cardiovascular                             Cardiovascular
           disease under 50                            disease over 50
           years old                                   years old

          2000: 18%                                  2000: 49% (44/89)
           (161/872)
                                                      2004: 63%
          2004: 31%                                   (128/202)
           (272/881)
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #14

                    Fenway Demographics
                       Co-morbidities
          Bone disorders                             Bone disorders
            under 50 years old                          over 50 years old

          2000: 0.9% (4/795)                         2000: 0.9% (1/107)

          2004: 1.7%                                 2004: 5.4%
           (15/881)                                    (11/202)

DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #15

                    Fenway Demographics
                       Co-morbidities
          Neuro-cognitive                            Neuro-cognitive
           disorders under 50                          disorders over 50
           years old                                   years old

          2000: 0.5% (4/795)                         2000: 1.9% (2/107)

          2004: 1.0% (9/881)                         2004: 0.5% (1/202)


DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #16


                        Bone Abnormalities
        Nutrition for Healthy Living Cohort
        Baseline: Median age: 42 years old
                             Median CD4 count: 372
                                 Median Viral Load: 2.7 log
        DXA scan:                 0.22 % decrease in BMD
                                   at one year
                                0.68% decrease in BMD
                                   at three years
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #17


                        Bone Abnormalities
        BMD Decrease    associated with
         Longer duration of didanosine and
         tenofovir treatment
         Years known to be HIV positive
         Bilirubin > 2.0
        Less bone mass loss seen with
         stavudine and indinavir
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #18


               Neuro-Cognitive Disorders
          67 individuals with HIV over 50 year old
           compared with 52 individuals with HIV under
           35 years old
          No significant differences in demographics, CD4
           count or % with AIDS, younger group with
           higher plasma and CSF viral load
          Proportion with neuro-cognitive impairment
           slightly higher in older group
          Higher rates of impairment across most ability
           domains in older group
          Older individuals with detectable CSF virus had
           twice the prevalence of neuro-cognitive deficit
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #19


               Neuro-Cognitive Disorders
        Hawaii Cohort
        20% of people with HIV are over 50
        HIV dementia more common:
          25.2% in individuals over 50 vs. 13.7% in
         individuals 20-39 years old
        Adjusting for variables such as education,
         race, treatment and substance dependence
         odds of HIV Associated Dementia was 3.2
         times more likely in older vs. younger
         group
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #20


                                  Conclusions
          Individuals with HIV are living longer
          HIV Risk screening and prevention counseling
           remains important in older individuals
          Co-morbidities of aging overlap with many co-
           morbidities of HIV
          HIV treatments are associated with increased
           risk of some co-morbidities
          Preventive screening for lipid abnormalities,
           osteopenia, cognitive impairments are an
           important component of comprehensive HIV
           care
DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.
                                                                               Slide #21


                  Challenges for the future
        Prevention messages targeted to older
         people
        Sex and Drug histories across the lifespan
        More information on drug-drug interactions
         and the long term impact of HIV on aging
        A plan for integrating HIV care into elder
         services


DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

				
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