1. HIV Disease in Older Patients Donna M. Gallagher, ANP The International AIDS Society–USA DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005.

2. Slide #2 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Current Challenges Case finding in the over 50 population Case finding in the over 50 population Primary Care for over 50 in HIV setting Primary Care for over 50 in HIV setting HIV care in the Geriatric setting HIV care in the Geriatric setting Prevention for Positives over 50 Prevention for Positives over 50 Medication Fatigue Medication Fatigue Risk Reduction Fatigue Risk Reduction Fatigue Compassion Fatigue Compassion Fatigue

3. Slide #3 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. CDC: US population Top 5 causes of death: 2002 55-64 55-64 Malignancy 36.9% Malignancy 36.9% Cardiac disease 25.4% Cardiac disease 25.4% Lung disease 4.5% Lung disease 4.5% Diabetes 4.0% Diabetes 4.0% Cerebrovascular disease 3.9% Cerebrovascular disease 3.9% > 65 Cardiac disease 31.8% Malignancy 21.6% Cerebrovascular disease 7.9% Lung disease 6.0% Alzheimer's tied with pneumonia/influenza 3.2%

4. Slide #4 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Massachusetts DPH 2004-2005 People Living with HIV Male: 72% Male: 72% MSM 46%, IVDU 28% MSM 46%, IVDU 28% White 53%, Black 22%, Hispanic 23% White 53%, Black 22%, Hispanic 23% White: MSM 66% White: MSM 66% Black : IVDU 31% Black : IVDU 31% MSM 23% MSM 23% Hispanic: IVDU 51% Hispanic: IVDU 51% Female: 28% IVDU 34%, heterosexual contact 33% White 32%, Black 39%, Hispanic 28% White: IVDU 52% Black: hetero 41% Hispanic: hetero 44%

5. Slide #5 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Massachusetts DPH 2004-2005 People Living with HIV  21% over 50 years old  20% 45-49 years old  24% 40-45 years old

6. Slide #6 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Massachusetts DPH 2004-2005 People Living with HIV AIDS diagnosis within 2 months AIDS diagnosis within 2 months of HIV diagnosis  30% of HIV diagnosis  30% If over 50  42% If over 50  42% Higher incidence of AIDS at time of Higher incidence of AIDS at time of diagnosis among infections from heterosexual transmission diagnosis among infections from heterosexual transmission Issues of Denial: Patient and Provider Issues of Denial: Patient and Provider

7. Slide #7 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. 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

8. Slide #8 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Who are they (continued)? Patients who access the health care system and are not assessed for risk 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 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 People who see HIV prevention messages that don’t reach them because they are not represented in the message

9. Slide #9 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Aging and Immune Function Increased co-morbidities Increased co-morbidities Increased risk of reactivation diseases with aging: TB, herpes zoster 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 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 50 compared to < 40 Increased likelihood of having AIDS at time of initial diagnosis Increased likelihood of having AIDS at time of initial diagnosis

10. Slide #10 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Aging and Immune Function Thymic function decreases with age is important in the quantitative CD4 response to HAART 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 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 Genetic aging (polymorphisms in chemokine receptors) enhance HIV 1 progression

11. Slide #11 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Considerations Sexual and domestic violence as a backdrop Sexual and domestic violence as a backdrop Isolation Isolation Fear of rejection Fear of rejection Meds, home remedies, herbal supplements Meds, home remedies, herbal supplements Nutrition affected by poverty, lack of access, side effects Nutrition affected by poverty, lack of access, side effects Safety issues Safety issues Responsible for caring for a loved one Responsible for caring for a loved one

12. Slide #12 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Fenway Demographics HIV infected patients over 50 years old HIV infected patients over 50 years old 2000: 12 % 2000: 12 % (107/917) (107/917) 2004: 19% 2004: 19% (202/1083) (202/1083) HIV infected patients over 60 years old 2000: 2% (15/917) 2004: 3% (34/1083)

13. Slide #13 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Fenway Demographics Co-morbidities Cardiovascular disease under 50 years old Cardiovascular disease under 50 years old 2000: 18% (161/872) 2000: 18% (161/872) 2004: 31% (272/881) 2004: 31% (272/881) Cardiovascular disease over 50 years old 2000: 49% (44/89) 2004: 63% (128/202)

14. Slide #14 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Fenway Demographics Co-morbidities Bone disorders Bone disorders under 50 years old under 50 years old 2000: 0.9% (4/795) 2000: 0.9% (4/795) 2004: 1.7% (15/881) 2004: 1.7% (15/881) Bone disorders over 50 years old 2000: 0.9% (1/107) 2004: 5.4% (11/202)

15. Slide #15 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Fenway Demographics Co-morbidities Neuro-cognitive disorders under 50 years old Neuro-cognitive disorders under 50 years old 2000: 0.5% (4/795) 2000: 0.5% (4/795) 2004: 1.0% (9/881) 2004: 1.0% (9/881) Neuro-cognitive disorders over 50 years old 2000: 1.9% (2/107) 2004: 0.5% (1/202)

16. Slide #16 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Bone Abnormalities Nutrition for Healthy Living Cohort Nutrition for Healthy Living Cohort Baseline: Median age: 42 years old Baseline: Median age: 42 years old Median CD4 count: 372 Median Viral Load: 2.7 log Median CD4 count: 372 Median Viral Load: 2.7 log DXA scan: 0.22 % decrease in BMD DXA scan: 0.22 % decrease in BMD at one year 0.68% decrease in BMD at three years 0.68% decrease in BMD at three years

17. Slide #17 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Bone Abnormalities BMD Decrease associated with 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 Less bone mass loss seen with stavudine and indinavir

18. Slide #18 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Neuro-Cognitive Disorders 67 individuals with HIV over 50 year old compared with 52 individuals with HIV under 35 years old 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 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 Proportion with neuro-cognitive impairment slightly higher in older group Higher rates of impairment across most ability domains 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 Older individuals with detectable CSF virus had twice the prevalence of neuro-cognitive deficit

19. Slide #19 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Neuro-Cognitive Disorders Hawaii Cohort Hawaii Cohort 20% of people with HIV are over 50 20% of people with HIV are over 50 HIV dementia more common: HIV dementia more common: 25.2% in individuals over 50 vs. 13.7% in individuals 20-39 years old 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 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

20. Slide #20 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Conclusions Individuals with HIV are living longer Individuals with HIV are living longer HIV Risk screening and prevention counseling remains important in older individuals HIV Risk screening and prevention counseling remains important in older individuals Co-morbidities of aging overlap with many co- morbidities of HIV Co-morbidities of aging overlap with many co- morbidities of HIV HIV treatments are associated with increased risk of some co-morbidities 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 Preventive screening for lipid abnormalities, osteopenia, cognitive impairments are an important component of comprehensive HIV care

21. Slide #21 DM Gallagher, ANP. Presented at IAS–USA/RWCA Clinical Conference, June 2005. Challenges for the future Prevention messages targeted to older people Prevention messages targeted to older people Sex and Drug histories across the lifespan Sex and Drug histories across the lifespan More information on drug-drug interactions and the long term impact of HIV on aging More information on drug-drug interactions and the long term impact of HIV on aging A plan for integrating HIV care into elder services A plan for integrating HIV care into elder services