1. HIV and Over 50 Kathleen M. Nokes, PhD,RN,FAAN Professor, Hunter College, CUNY, Hunter- Bellevue School of Nursing Chairperson, New York Association on HIV over Fifty (1995 – 2007) Clinical Consultant, Cicatelli Associates Inc July 2007

2. HIV/AIDS and middle-aged and older adults Objectives:  Identify demographic picture of persons 50+ living with HIV/AIDS.  Identify unique differences of middle- aged/older persons living with HIV/AIDS applied to a specific case.  Analyze programmatic considerations in providing services to this population.

3. Resources  National Association on HIV over Fifty www.hivoverfifty.org – extensive bibliography. www.hivoverfifty.org  New York Association on HIV over 50 www.nyahof.org  Public Health Library 455 First Ave. Room 1200 (nyc.gov/health)

4. Case Study MV is a 62 year old Hispanic woman from the Dominican Republic who has been married for 30 years; she presents to the clinic with herpes zoster; health history reveals chronic fatigue, weight loss; physical examination reveals lymphadenopathy. Her husband has also been losing weight and vague about his health problems.

5. Risk Behavior “TOO MANY UNKNOWNS” for both men and women living with AIDS aged 50 and older (Forlenza, 2002)

6. Epidemiology Data January 1, 2004 - December 31, 2004 New York City Data New York City HIV/AIDS Surveillance Statistics. New York: NYCDOHMH, 2005. http://www.nyc/gov/html/doh/html/dires/hivepi.shtml

7. 1 st Quarter Report: NYC  “Between 1993 and 2003, the number of PWA age 50 and over increased almost six-fold, from 2,904 to 16,900”. http://www.nyc.gov/html/doh/downloads/pdf/dires-dires- 2005-report-Qtr1.pdfhttp://www.nyc.gov/html/doh/downloads/pdf/dires-dires- 2005-report-Qtr1.pdf

8. Face of the epidemic in NYC: 2004 Men: (aged 50-59) 08.1%:dx with HIV 15.5%: dx with AIDS 23.9% of men living with HIV/AIDS 34.1% of the deaths Women: (aged 50-59) 11.7%:dx with HIV 17.1%: dx with AIDS 18.1% of women living with HIV/AIDS 26.4% of the deaths

9. Stage of HIV diagnosis: Comparing persons aged 30-39 to persons aged 50-59 – 1/1/04 through 12/31/04 HIV, not AIDS (71.6% of total cases)  30-39: 33.3%  50-59: 9.3% Concurrent with AIDS Dx (28.4% of total cases)  30-39: 29.1%  50-59: 16.0%

10. Three issues  Disclosure  Physical functioning  Co-morbidities

11. Disclosure  Increased social isolation  Increased internalized homophobia (?), socially marginalized due to: IDU and imprisonment  Decreased social support due to deaths; other losses, stigma  Possible decreased children in network due to decreased parenting; estranged from children

12. Case continued  MV hasn’t told her adult children of her fears. She is afraid of their reaction since their relationship with their father hasn’t been good.  She also hasn’t told her close friends or her church associates since she is embarrassed.

13. Decreased Physical Functioning (measured by SF- 36)  May get overwhelmed when asked to move from place-to-place  May feel physically tired from carrying heavy materials  May experience usual aging issues such as arthritis

14. Mortality from non-HIV/AIDS related causes “Mortality from non-HIV-related causes is five times higher for PWA age 50 and over than for 25-34 year-olds”. http://www.nyc/gov/html/doh/html/ah/hivtables2002.html

15. Co-morbidities Cardiovascular – major causes: chronic ischemic health disease, hypertension, and cerebrovascular disease HIV meds – lead to increased cholesterol, triglycerides Potential for strokes, heart disease – also higher risk in blacks/AA who are have higher rates of HIV disease in proportion to population rates. Older age is associated with increased risk of cardiovascular disease including MI and stroke especially for clients on HAART (The DAD Writing Committee (2004). Cardio-and cerebrovascular events in HIV-infected persons. AIDS 18: 1811-1817.)

16. Comorbidities (continued) Diabetes Injection drug use and alcohol abuse are associated with chronic pancreatitis Some HIV meds cause pancreatitis

17. Cancer – all persons with HIV/AIDS  Lung cancer is the leading cause in both men & women  Breast cancer in women; liver cancer in men

18. Comorbidities (continued) Hepatitis B/C Decreased liver function secondary to hepatitis Most drugs are detoxified by liver Liver disease most commonly reported co-morbidity and clients aged 50 and older could not differentiate mild from moderate liver damage.

19. Comorbidities (continued) Drug addiction/Alcohol abuse Methadone maintenance and liver function Methadone and HIV drug interactions

20. Comorbidities (continued) Erectile dysfunction Sexuality and HIV – prevention issues HIV drug interaction and drugs to treat erectile dysfunction such as viagra

21. Neuropsychological changes  Sanchez Rodriguez & Rodriguez Alvarez (2003) found remarkable similarity between the neuropsychological performance by the normal elderly and the much younger AIDS patients despite great age differences between the groups (70.5 vs. 29.9 years).  Implications for older persons living with AIDS….  No differences on MAT for older clients or on REALM.

22. Clinical Implications  Need clinical expertise in treatment modalities for multiple chronic illnesses  Need to consider risks inherent in polypharmacy – see chart by Ernst (2004) ACRIA Update Vol. 13 (3)– accessible on- line: www.acria.orgwww.acria.org  Need to carefully evaluate symptoms since older persons seem to underreport symptoms

23. Five sectors providing assistance to older adults Source: Topolski, J., Gotham, H., Klinkenberg, WD., O’Neill, D., & Brooks, A. (2002). Older adults, substance use, and HIV/AIDS: Preparing for a future crisis. Journal of Mental Health and Aging 8(4) Winter, 349-363.

24. These five sectors need to interface  AIDS Service Organizations  Health/Medical  Behavioral Health Treatment  Public Health  Aging Services

25. Components of an integrated system  communication  cross-training  cross-disciplinary consultation  coordinated treatment planning  co-location of services  integrated service teams  integrated funding sources.

26. Think about your program  Is it integrated?  Is it meeting the needs of mid-life and older adults with HIV/AIDS? If yes, how do you know. If no, what will you do to find out.

27. Case summary  MV has diabetes and HTN; she agreed to HIV testing and was staged finding her CD4 cell count of 180 and viral load of 70,000.  How do you treat her considering her other co-morbidities?