C E L I A J. M A X W E L L, M. D

Transcription

1 H I V / A I D S I N O L D E R I N D I V I D U A L S T H E G R A Y I N G O F T H E D I S E A S E E X T E N U A T I N G V S M I T I G A T I N G F A C T O R S C E L I A J. M A X W E L L, M. D., F A C P A S S O C I A T E D E A N F O R R E S E A R C H H O W A R D U N I V E R S I T Y C O L L E G E O F M E D I C I N E

2 HIV & AIDS IN LATIN AMERICA & THE CARIBBEAN In this area of the world overall rate of new infections stable Marked differences in the epidemic between countries, however, poverty, migration, homophobia, stigma & discrimination act as barriers to progress throughout the region 2.1 million PLWA 0.5 % adult HIV prevalence 115,000 new HIV infections 45,000 Aids related deaths Avert global info & educ. On HIV & Aids 2017

3 HIV/AIDS IN THE CARIBBEAN 2017 Progress towards the targets 64% PLWA know their status 81% of those who know status on treatment 67% of people on treatment virally suppressed Problems still continue with late diagnosis, especially among men and treatment access to young or vulnerable populations still an issue. UNAIDS Global Aids Update 2017

4 HAITI SCORECARD 61% of PLWA know their status. 89% of PLWA who know their status are on treatment 69% of PLWA who are treatment are virally suppressed However, less than 50% of PLWA on art have received a viral load test UNAIDS 2017

5 CDC CAMPAIGN PREVENTION IS CARE Risk remains a challenge; % diagnosed with HIV in medical care, 58% virally suppressed. Additionally, only 57% retained in care Early ART initiation and sustained adherence are critically important Retaining HIV-infected patients in care is essential and can be achieved Brief discussions about safer sexual behaviors can change behavior CDC Campaign Prevention is Care 2017

6 HIV SCREENING AMONG OLDER ADULTS 13% of the US population 65 years old. Projections 20% by half of HIV infected persons are 50 years or older Study reviewed 12,366 adults 50 with questionnaire Results: HIV screening within this population 25.4% Race had no statistically significant effect Low risk perception of HIV exposure 84.1% Routine medical checkup most common reason for HIV screening, 36% Only 52% of tests were suggested by a HCP Conclusion: Increase HCP input critical PLoS One. 2012;7(8):e43618.

7 NEW DIAGNOSES OF HIV AMONG ADULTS AGED 50 YEARS AND OLDER At the end of Age Group 44% of all new HIV diagnoses were for adults ages years old Race/Ethnicity African Americans (AA) accounted for 43% of all diagnosed among older adults The rate for AA (28.4) was 2x the rate for Hispanics (11.4) and 8x the rate for whites (3.4) Transmission Males: 67% of diagnosed infections were attributed to male-to-male sexual contact, 10% to injection drug use Females: 85% of diagnosed infections were attributed to heterosexual contact, 15% to injection drug use CDC HIV Surveillance Report

8 ADULTS AGED 50 YEARS AND OLDER LIVING WITH HIV INFECTION At the end of Age Group Adults aged accounted for 41% of older adults living with HIV, followed by those aged at 29% Race/Ethnicity AA s accounted for the largest population with 40% of older adults living with HIV 38% were white, 17% were Hispanic/Latino Transmission Males: 62% were attributed to male-to-male sexual contact, 17% to injection drug use, 12% to heterosexual contact Females: 69% were attributed to heterosexual contact, 30% to injection drug use CDC HIV Surveillance Report

9 ENHANCE AWARENESS TO DECREASE RISK OF HIV/AIDS HIV is often assumed to only affect young people, many older people do not recognize that they may be at risk Sexual transmission most common way for HIV infection in older adults Many health care providers (HCP) assume older patients have no sexual desires and are sexually inactive Reality!! Sexual behavior is likely to change over time. Meeting the criteria for successful aging nonconformance with the stereotype of sexless elderly. Rapid dx and treatment important in older adults due to frailty and comorbidity levels Important for HCP to identify persons at risk and adapt approaches to them Aging Clin Exp Res Dec;26(6):665-9

10 SEXUAL RISK BEHAVIORS IN ADULTS 50 YEARS OR OLDER Limited information of this behavior in older Americans. Study: Low prevalence of condom use among older adults (even if not in a long-term relationship with one partner) Condom use at last intercourse highest among those aged (24.3%; 95 confidence interval, ) but declined 17.1% among those ages Substance abuse risk for sexual risk taken Older adults likely dx with HIV-related medical disorders later compared to younger persons Clinician education important to mitigate Subst Abuse Rehabil Apr 21;6:51-60.

11 HIV AND STI TESTING IN OLDER ADULTS: MISSED OPPORTUNITIES FOR THE PRIMARY CARE PHYSICIAN Limited research on topic Testing for HIV and STIs of older adults infrequent STI testing with genital symptoms more likely than asymptomatic screening Sexual health assessment essential to comprehensive health care Tillman JL et. Al J Clin Nurs Aug;24(15-16):

12 THE CHALLENGE: MANAGING HIV AND OTHER DISORDERS ASSOCIATED WITH AGING Older adults living with HIV have a greater risk of other comorbidities Research on Older Adults with HIV (ROAH) done in 2010 in NYC 1,000 people ages 50 and older were interviewed: 640 men, 264 women, and 10 transgender 50% respondents black, 36% Hispanic, 14% white >90% of the participants had at least one comorbidity The most common were depression (52%), arthritis (31%), hepatitis (31%), neuropathy (30%), and hypertension (27%) Current use of illicit drugs in this population was as follows: marijuana 23%, crack 16%, cocaine 15%, and heroin 7% (though lifetime use of illicit drugs was 84%) Smoking was higher in blacks & Latinos 63% & 58% compared to whites PCP should address HIV risks in all patient populations Research on Older Adults with HIV. ACRIA 2010.

13 COMORBIDITIES A BIG ISSUE More than 50% PLWH in the US, > 50years Even with great advantage of HAART, life expectancy less than general population, about 5years Have increased prevalence of age related morbidity i.e. Cardiovascular disease (CVD), Hypertension, Diabetes, fractures, Cancer and neuro cognitive impairment (NCI) Comorbidities seem to develop earlier than in HIV negative persons Inflammation independent predictor of mortality and morbidity in PLWH and general population. However, source of inflammation in HIV not completely understood. Gueler et al AIDS 2017;31: Teeraananchai et al HIV Med (4): Brenchley et al Nat Med 2006;12:

14 TA B L E 2 C L I N I C A L E V I D E N C E O F A G E - A C C E N T U AT E D A N D A G E - A C C E L E R AT E D A S S O C I AT I O N S I N P E O P L E L I V I N G W I T H H U M A N I M M U N O D E F I C I E N C Y V I R U S Cardiovascular disease Cancer (Myeloma, lung, and anal) Kidney disease Liver disease Cognitive impairment Frailty Bone Disease Age Accentuated Age Accelerated Infec dis clin of N. America Dec 2017

15 CARDIOVASCULAR DISEASE IN PLWH PLWH in the U.S. have 2x risk for MI, sudden death and heart failure as general population Longer use of HAART and low T4 cell counts associated inc. risk of MI Despite PLWH higher incid. of MI, mean age at initial MI diagnosis not different form uninfected cohort Althoff et al Clin Infect Dis 2015 ; 60:

16 CANCER IN PLWH PLWH have higher risk of cancer some AIDS-defining (Kaposi cervical non-hodgkin lymphoma) Some non-aids-defining (rectal, liver, melanoma, lung cancer) However, risk of prostate and breast cancer (high in gen. population) may be lower in PLWH Brickman C et al Curr HIV/AIDS Rep 2015; 12: MCGinnis KA et al J Clin 24:

17 NEURO COGNITIVE IMPAIRMENT (NCI) NCI common in PLWH despite viral load suppression and ART (plasma and CSF) Usually asymptomatic Asymptomatic NCI ass. with higher risk of impairments in activities of daily living Clifford DB et al Lancet Infect Dis 2013; 13: Grant I et al Neurology 2014; 82:

18 BONE DISEASE IN PLWH PLWH have reduced bone mineral density and inc. risk of fractures Surprisingly, HAART increases bone loss especially during the first year if initiation Greater ass. tenoforvir (fumarate) or PI containing regimen Grund B et al AIDS 2009; 23: Cazanave C et al AIDS 2008; 22:

19 PLEASE REMEMBER PREVENTION IS CARE Risk remains a challenge; % diagnosed with HIV in medical care, 58% virally suppressed. Additionally, only 57% retained in care Early ART initiation and sustained adherence are critically important Retaining HIV-infected patients in care is essential and can be achieved Brief discussions about safer sexual behaviors can change behavior CDC Campaign Prevention is Care 2017

20 Thank you! Questions?

21 CONTACT Celia J. Maxwell, MD, FACP Associate Dean for Research Howard University College of Medicine