LGBT Aging: HIV Prevention and Primary Care for LGBT Older Adults

Transcription

1 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.

2 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.

3 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

4 When We Talk about the Elderly What Comes to Mind?

5 ELDERsexuals Percent Having Sex Age Men Women % 62% % 40% % 16% Lindau, NEJM, 2007

6 HIV Incidence by Race and Age at Infection, # of new infections White Black/African American Hispanic Latino

7 HIV Incidence and Prevalence in Adults 50 or older Incidence Prevalence Data from: CDC HIV Surveillance Report Supplement, 2010

8 *Data from 2008, onward projected based on trends (calculated by Dr. Amy Justice) data from CDC Surveillance Reports, % Projected Proportion of those Living with HIV in U.S. 50+Years, * 19% 21% 22% 25% 27% 27% 29% 33% Projected 35% 37% 39% 0 41% 44% 45% 47% 50%

9 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 longterm care

10 Overcoming Barriers

11 Test and Treatment Cascade 72% Cohen, 2011

12 Barriers to Linkage to Care Counseling and Testing Care and Treatment

13 Focused Prevention With Older Adults

14 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).

15 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.

16 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

17 Cultural, Clinical Competence: Quality Senior Care

18 Cases: HIV Treatment Issues

19 Kenji

20 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

21 Normal Aging Process Loss of bone and muscle mass Weight loss Decrease in kidney function Memory loss Immunosenescence

22 Number of Non-HIV Meds by Age % of participants Number of co-medications <50 years years 65+ years Age B Haase CROI 2011

23 Incidence of comorbidities: by age Incidence per 1000 pyrs (95% CI) B Haase CROI Bacterial pneumonia Cerebral infarction Coronary angioplasty Myocardial infarction Procedures on other arteries Pulmonary embolism Fracture, adequate trauma Fracture, inadequate trauma Osteoporosis Diabetes mellitus Age 65+ years Age years Age <50 years Non AIDS defining malignancies AIDS defining event Death

24 Potential Comorbidities among Older Patients with HIV Cardiovascular disease Metabolic disorders Diabetes Dyslipidemias Neurocognitive abnormalities Liver and renal problems Bone disorders Osteopenia Osteoporosis Malignancies

25 The Changing Epidemic Among those initiating HAART( ) ART-CC. CID, 2010

26 Polling Question: Would you recommend ART for this patient? Yes No Not sure

27 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

28 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 HIVinfected adults should be monitored closely

29 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

30 HIV Outcomes with ART: What We Know Already HIV-1 viral load suppression CD4 cell response Mortality Older > Younger, doesn t vary by class Younger > Older Older > Younger, usually due to non-hiv causes

31 James

32 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

33 To evaluate this patient s concerns, he should have: CBC/LFT s/thyroid function tests PSA Free testosterone Total testosterone All of the above

34 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

35 Polling Question: Which of the following should be your first counseling priority? Diet? Smoking? Exercise? Blood pressure control? Diabetes Mellitus management? Not sure

36 D:A:D Study: Is the Framingham Risk Estimation Valid in HIV-Infected Patients? Observed and predicted MI rates according to ART exposure (D:A:D Study n=23,468) Rates per Thousand Patient-Years Incidence of MIs is low: 345 over 94,469 patient-years follow-up (3.7/1,000 patient-years) None N=5973 Duration of cart exposure (years) < N=5292 N=6805 N=9050 N=10,574 N=8890 n = ART exposure Observed rates Best estimate of predicted rates Law et al. HIV Med. 2006;7:

37 Effect of Smoking on HIV HIV infected smokers lose more lifeyears to smoking than to HIV 35 year-old HIV-positive smoker has ~16 less life-years than non-smoker Risk of smoking doubles in HIVpositive smokers compared with HIVpositive non-smokers Helleberg M et.al. CID 2013

38 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

39 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

40 Polling Question: Should this patient be screened for osteoporosis? Yes No Don t Know

41 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 Arnsten AIDS 2007 Triant J Clin Endo Metab 2008

42 Recommendations: Osteoporosis Screening 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

43 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

44 Frailty increases with age and time with HIV HIV-infected for 8-12 years at age % exhibit the frailty phenotype 9-fold higher risk than agematched controls Desquilbet, et al. J Gerontol Med Sci 2007;62A:

45 Samantha

46 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

47 What health maintenance issues should you discuss? Mammogram? Prostate screening? Colon cancer screening? Heart disease? Osteoporosis? Advance directives? All of the above?

48 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.

49 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

50 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

51 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

52 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

53 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

54 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

55 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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57 Treatment Recommendations

58 Other Resources AOA: Know the Risks, Get the Facts: Older Adults and HIV Toolkit Hivoverfifty.org SAGEusa.org National Resource Center on LGBT Aging: rg LGBT Aging Project