HIV and Aging. Le Ann Dolan and Michael Bailey. Canadian AIDS Society. Wednesday June 13 th, 2012

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1 HIV and Aging Canadian AIDS Society Wednesday June 13 th, 2012 Le Ann Dolan and Michael Bailey

2 Acknowledgements This workshop was made possible in part through a financial contribution from the Public Health Agency of Canada. The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada Thank you to CAS for including CWGHR and CATIE in this event

3 Welcome and Introductions Workshop presenters Housekeeping items

4 Overview of Agenda Who are older PHAs? Is it HIV or am I just getting old? Review of some common conditions The polypharmacy challenge Some ideal strategies for aging gracefully with HIV The National Coordinating Committee on HIV & Aging Resources

5 What gives me the most enthusiasm is still being alive and in very good health after more than 16 years. I am here to say that it s possible to live with HIV and find a path that allows us to live in a positive way. --Jacques, 63

6 Terminology Comorbidities Are the presence of one or more health conditions (or diseases) in addition to HIV. Older Adult Generally defined in the HIV community as 50 years of age or older

7 Who are older people living with HIV? There are three groups of older people living with HIV: Long term survivors of HIV Recently diagnosed Those who have HIV, but who haven t been diagnosed

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9 HIV in Older Canadians HIV test reports among those 50+: 11% in 1999 rising to 15% in 2008 In 2008, new HIV Infections among Canadians 50+: 40% MSM 38% heterosexual contact 11% older adults who use injection drugs Gay men and other Men who have Sex with Men (MSM) remain the majority of older PHAs Public Health Agency of Canada. HIV/AIDS Epi Updates, July

10 Some factors contributing to older HIV infections HAART drugs that help PHAs survive Viagra, Cialis and sexual performance drugs Easy online access to sexual partners (Grindr!) HIV/safe sex fatigue HIV is solved (by one pill/day) Age related body changes: tissue fragility Ignorance about HIV risks (& lack of sex ed) Doctor/practitioner ignorance about HIV risks Misconceptions about older people not having sex!

11 So, why don t older people just use condoms like everyone else? Older people are less likely to practice safer sex because: Birth control is no longer an issue Lack of HIV education and messaging They don t consider themselves at risk

12 Don t ask, don t tell Health Care Providers Symptoms of HIV resemble those of many agerelated conditions May not review sexual histories of older patients Lack of education for older patients about safer sex Older adults May lack knowledge on how HIV is transmitted May be reluctant to initiate discussions about sex with health care providers

13 Is it HIV, or am I just getting old?

14 HIV outcomes: What we know already Adherence HIV-1 RNA suppression Older > Younger Older > Younger CD4 response Mortality Younger > older Older > younger Usually due to non-hiv causes Source: Dr. Gordon Arbess (2010) CWGHR s Partners in Aging Forum, March 3, 4, 2010 in Montreal

15 The Potential Impact of HIV and Aging Source: Dr. Gordon Arbess (2010), CWGHR s Partners in Aging Forum, March 3,4, 2010 in Montreal.

16 What is normal aging? Biological, physiological changes to the body and mind, increased risk of: heart disease, cancer, dementia Bone loss, frailty (weight/strength loss, exhaustion), liver/kidney impairment, changing hormones, diabetes Social changes: ageism (stigma towards aging), isolation, depression, financial constraints, needing help & support

17 Psychosocial Impact of Aging Some of the psychosocial challenges that some people experience: Increased isolation Depression Stigma

18 The Inflamm aging connection the underlying culprit in HIV and aging? What is Inflammation? The immune response to infection or problems in the body (i.e., blood vessel damage by high blood pressure, high blood sugar) Untreated/poorly treated HIV = Chronic inflammation Low grade, ongoing inflammation Immune system is always ON, overactive and damaging your cells, shortening your telomeres Guidelines are starting to recommend that all PHAs over 50 be on treatment

19 The dangers of chronic inflammation caused by inadequately treated HIV Stiffening and thickening of blood vessels (increasing heart disease and stroke risks) Accelerating tissue/organ damage in the body, bones and brain Causing accelerated aging Inflammation can begin doing damage in the early stages of HIV Source: D.M. Kaminski (2010). HIV and inflammation: A new threat.

20 Common CONDITIONS in HIV and aging Cognitive issues Bone loss Kidney and/or liver damage Cardiovascular disease Cancer

21 The Polypharmacy (multiple drug) Challenge Increasing age = increase in meds Multiple drugs =higher risk of adverse reactions In 2005, pharmacists in Canada dispensed an average of 35 prescriptions per person aged 60 to 79 Drug clearance and drug absorption can be less consistent in older individuals, sometimes resulting in irregular drug levels Drug clearance/absorption changes with body size and liver and kidney health Source: Stats Canada, 2009

22 Strategies to manage the polypharmacy dilemma Check liver enzymes (liver health) in regular bloodwork (AST, ALT, GGPT, AP, LDH) Check ALL potential interactions with your doctor and on your own at: druginteractions.org

23 What we can do to stay healthy

24 Smoking Smoking prevalence was 59% (Tesoriero, 2010) 3 times the general population rate. > 50% of current smokers were moderately or highly dependent on nicotine. Less than half of HIV/AIDS service providers reported always assessing tobacco use status, history, dependence, or interest in quitting at intake. Elevated risk of lung cancer

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26 Smoking Cigarette smoking is the most important modifiable factor among HIV infected patients Cessation of smoking is more likely to reduce cardiovascular risk than either the choice of antiretroviral therapy or the use of any lipid lowering therapy Greenspoon, S. Carr, A. Cardiovascular risk and body fat abnormalities in HIV infected Adults. N Engl J Med, 2005:352: 48 62

27 Additional issues for older HIV+ women

28 HIV + women - Anemia Lack of iron in the blood is one of the most common HIVrelated problems for women, clearly linked to disease progression and risk of death. Some factors that can lead to anemia include: Poverty, intravenous drug use, lack of access to food Lack of intake of iron, or lack of B12 and folic acid; Loss of blood HIV infection, and some opportunistic infections Low CD4 or high viral load Kidney or bone marrow damage Some HIV-related drugs such as Retrovir (zidovudine, AZT)

29 HIV+ women - Higher risk of HPV HIV+ women have more risk of catching Human Papilloma Virus. Four kinds of HPV are of concern: HPV 6 and 11 cause genital warts. HIV can lead to more frequent outbreaks of warts that are larger and harder to treat. HPV 16 and 18 cause changes to the cells of the cervix, and can lead to cervical cancer. HIV-positive women should get regular PAP tests, and protect themselves as much as possible against infection.

30 HIV + women - Early menopause Drug use and cigarette smoking was linked to an earlier onset of menopause (Schoenbaum et. al. in Monroe 2007) 47 years HIV-, 46 years HIV+, compared to the average age of 51 years; Women with CD4 counts below 200 started menopause at 42.5 years on average. Patterson et al (2009). found HIV+ women not on HAART had significantly higher viral loads after menopause, but there was no difference for women on HAART.

31 Some ideal strategies for aging gracefully with HIV You only have so many options of how you can deal with the disease. But the control you have is in learning everything you can about the disease and the options available to you to stay healthy. Then you can take control of making the right choices for you Louise

32 Group exercise

33 National Coordinating Committee on HIV and Aging A collaborative approach to plan initiatives and to exchange information amongst HIV and aging sectors The Committee efforts are intended to enhance the work that is done by individual participants. More information contact Le Ann ldolan@hivandrehab.ca

34 What is Rehabilitation? Rehabilitation = a dynamic process, including all prevention and/or treatment activities and/or services that address body impairments, activity limitations and participation restrictions for an individual Broad definition, containing maintenance, restoration, and enhancement of well being among those living with HIV Involved at any stage of the disease process along a wellness and illness continuum Client centred Goal focused Rehabilitation in HIV/AIDS: Development of an Expanded Conceptual Framework. Worthington, Myers, O'Brien, Nixon & Cockerill. AIDS Patient Care and STDs, 2005, 19:4,

35 Roles for Rehabilitation Neurological neuropathy, stroke Musculoskeletal Weakness, Cardiorespiratory Reduced activity tolerance, fatigue Cardiac Rehabilitation HIV and Aging

36 When I tested positive in the 80s, there wasn t much hope. There was no medication available. It was a death sentence. You had maybe a few years. I wish I had known then that researchers were working on medications that would mean that you could one day lead a somewhat normal and productive life. That you could hold onto your dreams Christian, 53

37 Resources CWGHR HIV and Aging: Le Ann Dolan: ext 224 CATIE Resources: HIV & aging Managing Your Health Positive Side Face Sheets

38 Evaluation

39 Thank you Le Ann Dolan Michael Bailey