1. Overview of Ageing: a How Can We Optimize Care in the Context of Multimorbidity?
Amy C. Justice, MD, PhD
Professor, Yale University
Schools of Medicine and Public Health
Section Chief, General Internal Medicine
VA Connecticut Healthcare System

2. Everyone with access to ART and those who contract HIV at older ages.
Who is Ageing with HIV?
Everyone with access to ART and those who contract HIV at older ages.

3. In US: More People Living with HIV Infection Every Year (+38K/yr*)
Each year: 56K new infections-18K deaths=38K*

4. Projected
For years , data is based on 33 states and U.S. dependent areas with confidential name-based HIV infection reporting, Centers for Disease Control: HIV/AIDS Surveillance Report, 2005.
For years , data is based on 34 states and 5 U.S. dependent areas with confidential name-based HIV infection
reporting, Centers for Disease Control: HIV/AIDS Surveillance Report, 2007
*Data from 2009, onward projected based on trends (calculated by author), data from CDC Surveillance Reports New York and San Francisco data from Departments of Public Health

5. In New York City
HIV Epidemiology & Field Services Semiannual Report, NYCDOH. April 2010

6. Africa is No Exception
An estimated 14% of adults with HIV infection in Sub Saharan Africa are >50 years
AIDS is leading cause of death among >50 yrs. in Nyanza Providence, Western Kenya
Negin J. Bull World Health Organ 2010 Nov 1;88(11):

7. Projected HIV Prevalence by Age in Hlabisa Sub-district of KwaZulu-Natal, South Africa
Hontelez J. Ageing with HIV in South Africa. AIDS :

8. Sex is Not Only for the Young
Proportion reporting sex in last 12 months
Based on ACRIA brochure, HIV and Older Adults (first three bullets)
The first three bullets seem to be conflicting, but I rechecked the book from which the stats came (HIV/AIDS in Older Adults) and they were listed as such
Lindau ST, et al. NEJM. 2007;357:

9. Sexual Risks Among Older Adults
Newly single (widowed/divorced) status
Ratio of men to women increasingly skewed
Less likely to use condoms
Postmenopausal women--pregnancy no longer possible
Men may have erectile dysfunction complicating condom use
Lower estrogen leads to vaginal dryness and likely increases risk of viral transmission

10. Among HIV+ on ART, What Drives Morbidity and Mortality?
Multi morbidity define as co occurrence of health conditions that cannot be cured and likely interact, but require ongoing monitoring and treatment.

11. Delayed Presentation By Age (NA ACCORD)
Altoff K. et al. JAIDS 2011

12. AIDS Events Increasingly Rare
ART-CC, Archives Int Med 2005:

13. AIDS Events Variably Associated with CD4 and Survival
By Median (IQR) CD4
By Relative Hazard of Death
ART-CC, CID 2009;48:

14. >50% of Deaths Attributed to Non-AIDS Events
Cumulative Mortality by COD Among Those on cART ( ) ART-CC, CID 2010:

15. Death Rate Disparities by HIV, Race/Ethnicity and Age
Per capita rate of HIV among persons 50+:
AA 12x as likely as whites
Latinos 5x as likely as whites
In 2001, African American women made up:
11% of women over 50
More than 65% of all HIV infections among all older women in the U.S.
HIV Epidemiology & Field Services Semiannual Report, NYCDOH. April 2010

16. Strategies for Management of ART (SMART)
*More AIDS and “Non-AIDS” Events Among Rx. Sparing Arm (HR 1.7 in SMART) NEJM 2006;355:

17. HIV Associated Non AIDS(HANA) Conditions
After adjustment for established risk factors, association with HIV remains
Compare to demographically and behaviorally similar uninfected controls
Weaker (<2 fold) associations may be due to inadequate adjustment for risk factors
May be due to HIV, ART, or both
Not necessarily closely tied to CD4 count

18. Premature or Accentuated Aging???
Some studies suggest HANA conditions occur years earlier than expected among HIV+
Most are not adjusted for differences in the underlying age distribution
Others are not adjusted for differences in established risk factors (smoking, alcohol, drug use, or hepatitis C co-infection)

19. Premature or Accentuated Cancer?
A. Premature cancer : cancer occurs earlier among those with HIV than uninfected comparators.
B. Accentuated risk: cancer could occur at the same ages but more often than among comparators.
Shiels MS. Ann Intern Med 2010:153:

20. Multimorbidity in HIV In North America and Europe In Africa
HCV co infection, alcohol, tobacco, and opioid abuse
In Africa
Tuberculosis, malaria, obstructive lung disease (smoke inhalation) and alcohol abuse
Among all those ageing: HANA conditions
Vascular disease, liver disease, renal disease, osteoporosis, and specific cancers

21. Justice AC. HIV and Aging: time for a new paradigm
Justice AC. HIV and Aging: time for a new paradigm. Curr HIV/AIDS Rep 2010: &:69-76

22. What are the Implications of Multimorbidity?

23. In the US General Population
Screening and Treatment Guidelines do not consider it (RCTs exclude multimorbidity)
50% of >65 years have >3 comorbid conditions
A disconnect between healthcare focusing on individual patient vs. individual disease
Multimorbidity represents the next frontier in the evolution of Evidence Based Medicine
Campbell-Scherer D. Multimorbidity: a challenge for EBM. Evid Based Med 2010: 15:

24. Guidelines do not Consider
Harms from polypharmacy
Interactions with substance use or depression
Hepatitis B or C
Social issues which compete with ability to adhere to complex treatment regimens

25. Guideline Overload
Considered guidelines for 10 chronic diseases to a panel of 2500 with age, sex, and chronic disease prevalence matched to US
Did not allow for new patients
Estimated MD time required assuming
All stable (3.5 hours/day)
Some active disease (10.6 hours/day)
Did not allow for new problems
Ostbye T, Ann Fam Med 2005;3:209-14

26. Multimorbidity is a Game Changer
Increases treatment benefit if condition interacts with other conditions (e.g. HCV)
Decreases time to benefit from screening (e.g. cancer screening)
Increases risk of toxicity
Creates competing demands: there isn’t time to address HIV and primary care guidelines and adequately care for active problems

27. We Need a New Paradigm and a New Approach to Measuring Disease to Guide Us

28. We Need to Prioritize Synergies
Hypertension causes cardiovascular disease, stroke, and renal disease
Smoking increases risk of cardio- vascular disease, stroke, lung disease, and cancer
Alcohol causes microbial translocation, elevates bp, speeds HCV progression, causes liver cirrhosis and cancer, impedes adherence, and may substantially contribute to vascular disease

29. And to Tailor Screening and Treatment to Individual Risk
Use prediction tools to estimate net benefit
Rather than relative benefit
Account for treatment disutilities
Requires two inputs:
Accurate estimation of risk
Risk reduction associated with interventions
Hayward RA. et al. Optimizing Statin Treatment for Primary Prevention of CAD. Ann Int Med 2010:152:69-77
Eddy DM. et al. Individualized Guidelines: The Potential for Increasing Quality and Reducing Costs Ann Intern Med 2011;154:

30. Veterans Aging Cohort Study Risk Index (VACS Index)
An index composed of routinely collected laboratory values that accurately predicts all cause mortality among those with HIV infection
Justice, AC. et. al, HIV Med Feb;11(2): Epub 2009 Sep 14.

31. The Veterans Aging Cohort Study (VACS)
Well characterized NIAAA cohort
>40,000 HIV+ matched to >80,000 HIV-
Matched on age, race/ethnicity, region
All HIV+ entering care since 1998
Controls had to be seen in VA in same year
~10 yrs. of longitudinal data
Clinically arbitrated endpoints for MI, stroke, cancer, pneumonia, and cirrhosis
Nested in-depth cohort of >7,000 (half HIV+)

32. Validated in Cross Cohort Collaborations
ART-CC: Largely European, 19 cohorts
NA-ACCORD: North American, 21 cohorts
VA mortality rates are somewhat higher and population is older and more likely to be male
Associations with outcomes very consistent

33. Veterans Aging Cohort Study Risk Index (VACS Index)
Composed of age and laboratory tests currently recommended for clinical management
HIV Biomarkers: HIV-1 RNA and CD4 Count
“non HIV Biomarkers”: Hemoglobin, hepatitis C, composite markers for liver and renal injury

34. Composite Biomarkers AGE * AST FIB 4 = PLT * sqrt(ALT ) eGFR =
186.3 * CREAT
-1.154
* AGE
-0.203
* FEM_VAL * BLACK_VAL
FEM_VAL =
0.742 if female, 1 if male
BLACK_VAL =
1.21 if black, 1 otherwise 34

35. VACS Index Thresholds and Weights
Index Score
Restricted
VACS
Age (years)
<50
50 to 64 23 12
> 65 44 27
CD4
> 500
cells/mm3
350 to 499 10 6
200 to 349
100 to 199 19
50 to 99 40 28
< 50 46 29
HIV-1 RNA
< 500
copies/ml
500 to 1x105 11 7
> 1x105 25 14
Hemoglobin
> 14
g/dL
12 to 13.9
10 to 11.9 22
< 10 38
FIB-4
< 1.45
1.45 to 3.25
> 3.25
eGFR mL/min
> 60
45 to 59.9
30 to 44.9 8
< 30 26
Hepatitis C Infection 5
Age
HIV Specific
Biomarkers
Biomarkers of General
Organ System Injury
Tate J. et al. IDSA Vancouver, BC October 21-24th. Poster 1136

36. VACS Index Highly Predictive of Long Term (5 Year) All Cause Mortality
Aggregated Scores
Individual Scores
Justice, AC. et. al, HIV Med Feb;11(2): Epub 2009 Sep 14.
Justice AC. HIV and Aging: Time for a New Paradigm. Curr HIV/AIDS Rep May;7(2):69-76

37. Discrimination of VACS vs. Restricted Index
Subgroup
VACS Index
C-stat
Restricted Index
p-value**
Overall
0.80
0.75
<0.0001
Male
Female
0.81
0.77
<0.001
White
Black
Hispanic
0.79
0.90
0.74
0.76
0.78
Age
<50
>= 50
0.69
HIV-1 RNA
<500
>=500
0.68
Justice AC. et al. A Prognostic Index for those Aging with HIV. CROI Poster # 793

38. Calibration of VACS vs. Restricted Index (5 Year Mortality)
Justice AC. et al. A Prognostic Index for those Aging with HIV. CROI Poster # 793

39. VACS Index Response to 1st Year of cART (+/- 80% adherence)
Notice greater discrimination with VACS index
Solid lines indicate >80% adherence
Tate J. et al. IDSA Vancouver, BC October 21-24th. Poster 1136

40. VACS Index Correlated with Biomarkers of Inflammation
Justice AC et al,“Biomarkers of Inflammation, Coagulation, and Monocyte Activation are Strongly Associated with the VACS Index among Veterans on cART” CROI 2011 Poster # 796

41. VACS Vs. Restricted Index Summary
More accurately predicts mortality among patients in North America and Europe
More responsive to antiretroviral treatment
More strongly correlated with markers of hyper-coagulability, microbial translocation, and inflammation

42. Why Should Clinicians Care?
Uses lab tests currently part of routine care
Identifies modifiable risk at lower test thresholds
Incorporates age, and effects of HANA and toxicity
Computation easy, can be included in lab reports and available through websites/apps
Offers approach that incorporates multifaceted HIV effects, multimorbidity, and toxicity

43. Case
HIV+ 45 yr old man. After 1 yr. of ART, CD4 count is 500 cells/mm3, HIV-1 RNA undetectable. HCV+ and has a FIB-4 >3.25.
Restricted Index
Score=0
Expected 5 yr mortality 2%
VACS Index
Score=30 (5 pts HCV ;25 pts FIB-4)
Expected 5 yr mortality 12%

44. Case Continued
Just as Framingham charts CVD risk over time the VACS Index can chart overall health over time
For this patient, we would target sources of liver injury: HCV, alcohol, toxic medications, and obesity
If we achieve a SVR and his FIB-4 normalizes score drops to 0; new 5 yr mortality 2%
If we decrease his FIB-4 from “high” to “moderate” his score would drop to 11; new 5 yr mortality 3-fold lower (from 12% to 4%)

45. Future Work
Informatics: tools to calculate index, counsel on risk, identify modifiable risk, and suggest patient and provider action
Observational Analyses: estimate likely effect size for potential interventions: eg, alcohol cessation, HCV treatment, adherence, etc.
RCT: compare VACS Index guided management to usual care among multimorbid HIV+ patients
Possible outcomes: hospitalization, MICU admission, nursing home placement, or death

46. National VACS Project Team 2010

47. Veterans Aging Cohort Study
PI and Co-PI: AC Justice, DA Fiellin
Scientific Officer (NIAAA): K Bryant
Participating VA Medical Centers: Atlanta (D. Rimland), Baltimore (KA Oursler, R Titanji), Bronx (S Brown, S Garrison), Houston (M Rodriguez-Barradas, N Masozera), Los Angeles (M Goetz, D Leaf), Manhattan-Brooklyn (M Simberkoff, D Blumenthal, H Leaf, J Leung), Pittsburgh (A Butt, E Hoffman), and Washington DC (C Gibert, R Peck)
Core Faculty: K Akgun, S Braithwaite, C Brandt, K Bryant, R Cook, K Crothers, J Chang, S Crystal, N Day, R Dubrow, M Duggal, J Erdos, M Freiberg, M Gaziano, M Gerschenson, A Gordon, J Goulet, N Kim, M Kozal, K Kraemer, V LoRe, S Maisto, K Mattocks, P Miller, P O’Connor, C Parikh, C Rinaldo, J Samet
Staff: H Bathulapalli, T Bohan, D Cohen, A Consorte, P Cunningham, A Dinh, C Frank, K Gordon, J Huston, F Kidwai, F Levin, K McGinnis, L Park, C Rogina, J Rogers, L Sacchetti, M Skanderson, J Tate, E Williams
Major Collaborators: VA Public Health Strategic Healthcare Group, VA Pharmacy Benefits Management, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Yale Center for Interdisciplinary Research on AIDS (CIRA), Center for Health Equity Research and Promotion (CHERP), ART-CC, NA-ACCORD, HIV-Causal
Major Funding by: National Institutes of Health: NIAAA (U10-AA13566), NIA (R01-AG029154), NHLBI (R01-HL095136; R01-HL090342; RCI-HL100347) , NIAID (U01-A ), NIMH (P30-MH062294), and the Veterans Health Administration Office of Research and Development (VA REA ) and Office of Academic Affiliations (Medical Informatics Fellowship).