Healthy Aging for People Living with HIV: Achieving the 4th 90 AIDS 2018 25 July 2018 Tiffany G. Harris, PhD, MS Director of Strategic Information Associate Professor of Epidemiology at CUMC

Introduction Availability of potent antiretroviral therapy (ART) has transformed the HIV epidemic In higher-income countries, life expectancy for people living with HIV (PLWH) has increased substantially with similar gains seen in some parts of sub-Saharan Africa Need to understand Effect of aging on PLWH Effect of HIV infection on the aging process Optimal approaches to HIV prevention among older individuals Aim for healthy aging among PLWH: “the 4th 90”

Older Adults with HIV Number of older PLWH (age 50 years) predicted to increase by 47% to 6.9 million by 2020 Sub-Saharan Africa will bear a large burden 15% of PLWH are currently aged ≥50 Predict that by 2040 will increase to 27% or 9.1 million PLWH UNAIDS. Get on the Fast-Track, The life-cycle approach to HIV 2016 Hontelez et al. AIDS 2012

HIV Prevalence among Older Adults Until recently most population-based HIV prevalence surveys in sub-Saharan Africa have not included older adults 2015-2018 Population HIV Impact Assessments (PHIAs) results from the surveys conducted in Malawi, Zambia, and Zimbabwe have found a high HIV prevalence among older adults HIV prevalence among persons 0-64 years by sex and age, Zimbabwe Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA) 2015-16: First Report Age 50-64

HIV Incidence among Older Adults Little published data from the last five years on HIV incidence among older adults in sub-Saharan Africa Nationally representative survey from Rwanda conducted in 2013-14 (Nsanzimana et al. Lancet HIV 2017)

HIV Testing and Prevention among Older Adults Older adults continue to be at risk for HIV acquisition but often lack awareness about risk, leading to unrecognized infection Behavioral interventions to reduce risk among older adults are lacking and there are challenges to providing HIV education for older adults (Milaszewski et al., J Evid Based Soc Work 2012) Ageism among health professionals Reluctance to discuss sexuality Misconceptions about HIV risk

HIV Prevention and Care Continuum: Challenges for Older Individuals in LMIC SOCIAL/BEHAVIORAL STRUCTURAL BIOLOGICAL/PHYSIOLOGICAL Perception of low risk Providers unaware of HIV risk among older individuals Suboptimal immunological response to antiretroviral drugs Low rates of HIV testing Limited availability of tailored HIV prevention and treatment services Some antiretroviral drugs may increase risk of some non-communicable conditions Low rates of condom use Lack of access to services for non-HIV conditions Increased risk of co-morbid conditions (e.g. hypertension, cancer) Adherence challenges Limited mobility hinders access to services Increased risk of polypharmacy with risk of non-adherence, adverse events and drug-drug interactions Continued engagement in risky behaviors Increased risk of poverty Lack of social support LMIC=low and middle-income countries Harris et al., AIDS 2018;32:1563-1569

Summary With ART scale-up, there has been an increase in older adults living HIV Small, growing body of work focused on HIV and aging Limited amount from LMIC, which have the highest burden of HIV Need more focus on healthy aging among PLWH especially in LMIC