1. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Challenges associated with ageing in women living with HIV

2. 2 Contents Introduction Physical challenges of ageing in women with HIV Emotional, psychological and psychiatric challenges of ageing in women with HIV Support Case studies Summary

3. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Introduction

4. 4 An ageing global population By 2050, ~25% of the global population will be ≥60 years Global population estimate US Census Bureau International Data Base

5. 5 The changing age distribution of people living with HIV People with access to ART can look forward to extended life spans, similar to the general population 1.Antiretroviral Therapy Cohort Collaboration (2008) Lancet 2. Swiss HIV Cohort Study (May 2009)

6. 6 The rate of HIV infection and new diagnoses among older people is increasing 1-3 ~In Europe, the proportion of women aged ≥50 years accounting for new HIV/AIDS cases in women rose from 7.4% in 2004 to 12.5% in 2010 4 ~UK data show that new diagnoses among older adults more than doubled between 2000 and 2009, accounting for 13% of all diagnoses in 2009 5 ~In the UK, women represent 25% of all diagnoses in people ≥50 years 6 ~However, true rates of infection in the population aged ≥50 years are often unknown due to poor testing rates 7 Proportion of new HIV/AIDS cases in older people 1. EuroHIV End-year Report (2006); 2. Simone MJ et al (2008) Geriatrics; 3. Dougan S et al (2004) Epidemiol Infect; 4. WHO/ECDC (2010) HIV/AIDS surveillance in Europe 2010 5. http://www.hpa.org.uk/hpr/archives/2010/hpr4710.pdf; 6. Smith R et al (2010) HIV Medicine; 7. Pratt G et al (2010) Age and Ageinghttp://www.hpa.org.uk/hpr/archives/2010/hpr4710.pdf

7. 7 Significance of age at diagnosis 1.Rotily M et al (2000) Int J STD AIDS 2.Kirk (2006) J Am Geriatr Soc 3. COHERE Study Group (2008) AIDS 4. Smith R et al (2010) Lancet 5. Perez JL et al (2003) Clin Infect Dis HIV testing is often delayed in older individuals 1 ~Older individuals may not perceive themselves as being at risk for HIV infection ~HCPs may fail to consider HIV as a potential cause of illness Delayed treatment and diagnosis may have more adverse consequences in older individuals compared with younger people 2-4 ~Older patients diagnosed with a CD4 cell count <200 cells/mm 3 at the time of their diagnosis are 14 times more likely to die than younger patients 4 However, older patients derive a similar level of benefit form ART as younger patients 5

8. HIV in older woman There is a lack of research on sexual activity in older individuals ~The successful integration of sexual health care can decrease morbidity and mortality, and enhance well-being and longevity in the patient 1 ~A considerable proportion of sexually active older adults with HIV practice unsafe sex 2 Shorter time from diagnosis to onset of AIDS (age- related faster progression to AIDS, late diagnosis) 3 HIV testing in older women is uncommon 4 1.AAHIVM (2011); 2. Golub SA et al (2010) Sex Transm Dis; 3. CDC (2006); 4. The Wellness Project; 5. Deeks SG (2011) Ann Rev Med 8

9. 9 Consequences of ageing as a woman with HIV Women living with HIV face all the challenges that the general population faces when growing older PLUS: 9 Conditions with increased incidence in women living with HIV: Hormonal changes Cardiovascular events Non-AIDS-defining infections Renal disease Non-AIDS-defining malignancy Muscular and skeletal changes Non-AIDS neurocognitive and psychiatric events, mood and CNS disorders The consequences of HIV The consequences of longer exposure to HIV treatment regimens

10. Research on ageing in those living with HIV is ongoing There is an emerging consensus that HIV and/or its treatment may affect: ~the process of ageing, and/or ~the development of illnesses typically associated with advancing age It is uncertain why people with HIV infection develop these conditions earlier in their life course, suggestions include: ~HIV speeds up the ageing process ~HIV is an additive to other risk factors which increases the risk of various illnesses Further research is required to understand the processes involved in HIV and ageing 10

11. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Physical challenges of ageing in women with HIV

12. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Menopause

13. The menopause The menopause is marked by the ending of menstruation and ovulation ~Falling levels of the female sex hormone, oestrogen Onset of the menopause is associated with an increased risk of: 1–3 ~cardiovascular disease (CVD) ~diabetes ~osteopenia / osteoporosis Early onset menopause (before 46 years): ~increases the risk of these diseases 4–6 ~may be linked to increased mortality 7,8 1. Santoro N et al (2009) Maturitas; 2. Carr MC (2003) J Clin Endocrinol Metab; 3. Isaia GC et al (1990) Exp Gerontol; 4. Kritz-Silverstein D et al (1993) Am J Public Health; 5. Lisabeth LD et al (2009) Stroke; 6. Janssen I et al (2008) Arch Intern Med; 7. Cooper et al (1998) Ann Epidemiol; 8. Jacobsen BK et al (2003) Am J Epidemiol; 9. Conde DM et al (2009) Menopause

14. 14 Onset of early menopause in women living with HIV 14 P=0.04 Schoenbaum et al (2005) Clin Infect Dis US study: 571 women (53% with HIV) Women with HIV were 73% more likely to experience early onset of menopause, compared with HIV-negative women (P=0.024) n=303n=268

15. 15 In the Italian DIDI study, the prevalence of early menopause (7.6%) was comparable with the general population (7.1%) however, a higher proportion of premature menopause was observed in women younger than 40 (5.2% vs. 1.8%) 1 Women with an earlier onset of menopause were more likely to: ~be at an advanced stage of HIV infection ~have been diagnosed with HIV for a significantly longer time ~have a history of drug misuse Average age at onset of menopause in women with CD4 <200 cells/mm 3 is lower than in the general population 2 Onset of early menopause in women living with HIV 1.Cicconi P et al. EACS Congress 2011 Abstract PS2/5; 2. de Pommerol M et al. Int J STD AIDS 2011;22(2):67-72.

16. 16 Impact of HIV on the symptoms of menopause 16 Menopause symptoms are common in women living with HIV 1 The symptoms associated with the menopause are more frequent among women with HIV than HIV- negative women 1–3 ~These include palpitations and insomnia in addition to vasomotor, psychological, genitourinary symptoms Post-menopausal women living with HIV have lower BMD, increased bone turnover, and higher rates of bone loss than HIV negative women 4 1. Ferreira CE et al (2007) J Gynaecol Endocrinol; 2. Santoro N et al. Maturitas 2009;64:160-164; 3. Boonyanurak et al. (2012) Menopause; 4. Yin MT et al. J Clin Endocrinol Metab 2012;97(2):554-62

17. Potential contributors to early onset of menopause in women with HIV Smoking Socioeconomic status Menopause can occur up to 1–2 years earlier in smokers, compared with non-smokers 2,3 Markers of low socioeconomic status (e.g. lower level of education, unemployment and poverty) have been associated with early menopause onset 3,4 Lower CD4+ count has been associated with early menopause onset 1 Immunosuppression 1. de Pommerol M et al (2011) Int J STD AIDS; 2. Cooper GS et al (1999) Epidemiology; 3. Luoto R et al (1994) Am J Epidemiol; 4. Gold EB et al (2001) Am J Epidemiol 17

18. Menopausal symptoms may mimic HIV-related symptoms It is important for women to monitor their menstrual cycle so that symptoms are not confused with effects from HIV or ART 18 Vaginal dryness Mood changes Irregular menstrual cycles Hot flushes at night Margolese S. http://www.thewellproject.org/en_US/Womens_Center/Menopause.jsp

19. Hormone replacement therapy in women living with HIV HRT may be useful for some women with HIV but should be used at the lowest effective doses for the shortest time possible Risks may outweigh the benefits if they: ~Smoke ~Are overweight ~Have had blood clots, breast cancer, diabetes, high cholesterol levels, liver problems, or a family history of heart disease Oestrogen and/or progesterone have been shown to interact with many HIV drugs and this must be considered when prescribing HRT New York State Department of Health AIDS Institute (2010); Margolese S. http://www.thewellproject.org/en_US/Womens_Center/Hormones_and_HIV.jsphttp://www.thewellproject.org/en_US/Womens_Center/Hormones_and_HIV.jsp 19

20. Managing the menopause in women with HIV Strategies to offset effects associated with menopause include 1 : ~Healthy lifestyle choices e.g. exercise and diet ~Smoking cessation ~Adherence to effective ART ~Symptom management ~Alternative therapies If these strategies don’t help then Hormone Replacement Therapy (HRT) can be considered 1 ~Many ART medications may be affected by HRT and so this should be discussed with a healthcare professional 2 1. Monroe A. BETA 2007:39-441; 2. New York State Department of Health AIDS Institute. Medical Care for Menopausal and Older Women With HIV Infection.

21. 21 Managing the menopause in women with HIV As part of the HCP consultation, points to discuss include: ~Recognising menopausal symptoms ~Any medical tests required in relation to the menopause ~Things they can take or do to help them through the menopause ~Potential interactions between ART and HRT ~Menopause support groups ~Sources of further information

22. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Osteoporosis

23. Risk factors for decreased bone mineral density in women Female sex White race Family history Increasing age Amenorrhoea /premature menopause Decreased physical activity Smoking Alcohol Decreased bone acquisition ClassicHAART-related Nucleoside analogues /mitochondrial dysfunction Protease inhibitors Lipodystrophy HIV-related Cytokines (e.g. TNFa, IL6) Decreased muscle mass Decreased fat mass Fat deposition in marrow Chronic diseases ( e.g. hyperthyroidism, hyperparathyroidism, liver disease, rheumatological conditions, eating disorders, etc.) Hypogonadism Renal dysfunction Malnutrition/low BMI Medications (e.g. corticosteroids, anticonvulsants, anticoagulants) Secondary Adapted from Glesby MJ (2003) Clin Infect Dis 23

24. 24 Increased risk of osteoporosis in women living with HIV A decrease in bone mineral density (BMD) may be due to HIV itself or to ART 1–3 ~Vitamin D deficiency is relatively common among individuals with HIV In one study, hip and spine BMD was significantly reduced in women with HIV compared with HIV- negative controls 4 ~Older age was also associated with lower BMD 1. Rodriguez M et al. (2009) AIDS Res Hum Retroviruses; 2. Moore AL et al. (2001) AIDS; 3. Yin MT et al. (2010) J Clin Endocrinol Metab; 4. Arnsten JH et al. (2006) Clin Infect Dis

25. Women for Positive Action is supported by a grant from Abbott Clinical studies report an increased risk of osteoporosis in HIV Being HIV-positive conferred an increased risk for osteoporosis compared with HIV- negative individuals (n=654, mean age 38.1) 6.4 fold increased risk for reduced BMD Brown TT et al (2006) AIDS 25

26. 26 Consequences of osteoporosis Osteoporosis is a major risk factor for hip fractures Women living with HIV may be more likely to experience falls, increasing the likelihood of a fracture in patients with osteoporosis Triant VA et al (2008) J Clin Endocrinol Metab

27. 27 Managing osteoporosis in women living with HIV European AIDS Clinical Society (EACS) guidelines recommend screening for osteoporosis using a bone density scan in: 1 ~Postmenopausal women living with HIV ~Women living with HIV who have a history of low impact fracture or high fall risk ~Clinical hypogonadism ~Oral glucocorticoid users Strategies to help reduce the risk of developing osteoporosis in women can include 2–4 ~Weight-bearing exercise ~Adequate dietary calcium intake / vitamin D supplements ~Avoidance of smoking and excess alcohol ~Avoidance of ARTs related to increased BMD loss Standard medications approved for the treatment and prevention of osteoporosis may be appropriate for women with HIV 2 1. EACS Guidelines, Version 6, 2011; 2. Lee S. BETA 2006;18(2):33-35 3. National Osteoporosis Society 4. Lima AL et al. HIV AIDS (Auckl) 2011;3:117-24

28. 28 Questions women should ask during medical consultations Am I at risk of osteoporosis now? Will I be at risk as I get older? What symptoms should I look for? How can I reduce my risk of osteoporosis? Am I taking any medicines that could put me at higher risk for osteoporosis? Are there any tests or screening programs for osteoporosis that I should have?

29. 29 Women with HIV should ask questions during medical consultations What medications are available for osteoporosis? ~What are their benefits and side effects? ~Will these drugs interact with any other medications that I am taking, like my HIV medications? Are there any other things I can do, besides taking medication, to reduce my risk of osteoporosis and bone fracture? Lifestyle, activities, diet? How much calcium and vitamin D should I get from my diet? ~Should I take supplements? What should I do to make sure I'm getting enough vitamin D and dairy products? Where can I get further information?

30. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Cardiovascular disease

31. 31 Cardiovascular disease among women living with HIV Women living with HIV may be at increased risk of CVD Several other major factors increase risk of CVD ~Smoking ~Blood pressure and cholesterol ~Physical activity ~Obesity and overweight ~Diabetes ~Renal disease ~Smoking ~Blood pressure and cholesterol ~Physical activity ~Obesity and overweight ~Diabetes ~Renal disease Factors that CAN be changed or controlled by treatment or lifestyle modification ~Increasing age ~Male gender though a women's risk increases after menopause ~Heredity including race ~Increasing age ~Male gender though a women's risk increases after menopause ~Heredity including race Factors that can NOT be changed

32. Women for Positive Action is supported by a grant from Abbott Increased risk of myocardial infarction in women with HIV Large data registry 3,851 HIV-infected patients 1,044,589 non HIV-infected patients HIV+ HIV- Triant VA et al (2007) J Clin Endocrinol Metab 32

33. 33 Cardiovascular disease risk and exposure to ART Incidence of myocardial infarction (MI) has been shown to increase with longer exposure to combination ART The DAD Study Group (2003) N Engl J Med DAD Study: incidence of MI in HIV+ compared to patients not exposed to ART Exposure (yr) None<11-22-3 3-4 >4 8 7 6 5 4 3 2 1 0 Incidence per 1000 Person-Yr P<0.001 for trend

34. 34 No. of Patients With EventsParameterRR (95% CI) Severe complications114 1.5 CVD, liver, or renal deaths Nonfatal CVD events 31 63 1.4 1.5 Nonfatal hepatic events Nonfatal renal events 14 7 1.4 2.5 1.010.00.1 Risk of Complications SMART: Higher CVD incidence with interruption vs. continuous HAART CD4-guided drug conservation strategy was associated with significantly greater disease progression or death, compared with continuous viral suppression RR 2.5 (95% CI: 1.8-3.6; P<0.001) El-Sadr W, et al. CROI 2006. Abstract 106 LB.

35. 35 Managing CVD risk in women living with HIV Strategies to help reduce the risk of CVD in women can include: ~Smoking cessation ~Control of hypertension ~Diet and cholesterol management ~Diabetes control ~Physical activity / exercise ~Management of depression Standard medications approved for the treatment and prevention of CVD may be appropriate for women living with HIV

36. 36 Managing CVD risk in women living with HIV As part of the HCP consultation, points to discuss include: ~Personal risk factors for developing CVD and treatments/interventions to help address these factors ~Adherence and avoidance of unstructured treatment interruptions ~Signs and symptoms of CVD ~Lifestyle activities and supplements/medication that may help offset the risk for, or consequences of CVD ~Motivation to feel responsible for oneself ~Sources of further information

37. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Cancer

38. 38 Cancer in HIV Many cancers are now treatable, especially when diagnosed early Late diagnosis and older age at diagnosis can lead to poorer outcomes and greater disease and treatment burden Cancers can be classified as AIDS-defining and non-AIDS defining AIDS-defining cancers among women include: ~Kaposi's sarcoma ~Lymphomas ~Cervical cancer

39. 39 Increased risk for cancer among women living with HIV Ratio of observed to expected cancer cases a AIDS-defining cancers Kaposi's sarcoma178.49 Non-Hodgkins Lymphoma48.97 Invasive cervical cancer9.20 a Standardised incidence ratio (SIR) Non-AIDS-defining cancers Cancer of the lung7.95 Oesophagus7.69 Multiple myeloma7.37 Oral cavity and pharynx6.55 Hodgkin’s disease5.65 Leukaemias4.52 Rectal/anal cancers3.23 Fordyce EJ et al (2000) AIDS Public Policy

40. 40 Human Papillomavirus and cervical cancer Human Papillomavirus (HPV) is a group of over 100 different viruses HPV is spread through skin to skin sexual contact Some viral strains of HPV can cause cervical cancer in women People living with HIV are more likely to be infected with HPV than HIV-negative people

41. Relationship between HIV suppression and HPV At time of first HPV screen, high-risk-HPV prevalence was 43% in 2011 1 Presence of high-risk HPV infection was significantly less frequent in women: ~>30 years ~with higher CD4 count ~who had prior CD4 nadir >500/µL ~who had received cART for >24 months ~with sustained VL 24 months Sustained HIV suppression for more than 40 months and CD4 count above 500 cells/µL for more than 18 months are independently associated with a lower risk of cervical high-risk-HPV infection 41 1. Konopnicki D et al (2011) EACS Congress 2011

42. 42 Cervical Cancer One of the most common types of cancer among women worldwide Women living with HIV are at a significantly higher risk for cervical cancer than are HIV-negative women Women living with HIV may be particularly vulnerable to high risk HPV type infections that can lead to cancer 1,2 HAART is associated with regression of cervical intraepithelial neoplasia (CIN) ~the HAART has not shown a clear benefit of HAART in decreasing the incidence of invasive cervical cancer 3 1. Frisch M et al (2000) J Natl Cancer Inst; 2. Palefsky J (2009) Curr Opin HIV AIDS; 3. Adler DH et al (2010) Curr HIV Res

43. 43 Breast cancer The most common cancer among women worldwide; its incidence appears not to be increased among women living with HIV Women living with HIV are less likely to undergo routine screening mammography ~May lead to later diagnosis and more advanced disease at presentation HCP should ensure women with HIV are referred to screening mammography services 43

44. 44 Highly effective ART regimens significantly reduce the risk of AIDS-defining cancers Healthcare vigilance and screening is important to ensure early diagnosis and intervention Drug ‒ drug interactions between cancer drugs and ART are common but can be predicted and managed The HIV physician should work closely with the oncologist to ensure optimal care As part of the HCP consultation, points to discuss include: ~Screening programs for cancer, particularly cervical cancer ~HPV vaccination if available ~Sources of further information Managing cancer in women with HIV

45. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Renal disease

46. 46 Renal disease and age Age is one of the major risk factors for renal disease Special monitoring of glomerular filtration rates should be considered in women aged ≥45 years, especially if using an ART that may increase risk for CKD and/or concomitant risk factors are present: ~Dyslipidaemia ~High blood pressure ~Diabetes Mellitus ~Obesity ~Use of other nephrotoxic drugs

47. 47 Renal disease in women living with HIV Women living with HIV may be at an increased risk for acute renal failure or CKD 1, affecting 1 in 6 people living with HIV 2 ~risk of HIV-associated nephropathy and/or ART induced renal dysfunction 1 ~The mortality risk for women with CKD is twice that of those who do not have CKD 5 P<0.0001 Gardner LI et al (2003) J Acquir Immune Defic Syndr

48. Frequency of renal impairment in women living with HIV The ANRS C03 Aquitaine cohort study reported a significantly higher frequency of renal impairment in women living with HIV compared to men (Odds ratio = 2.5 (2.1–3.9) ~Renal impairment was also associated with being older, having a low BMI, and having a high blood pressure Deti et al (2010) HIV Med P<0.0001 n = 1922n = 665 Frequency of renal impairment (%) 48

49. 49 Kidney care in women living with HIV Regular monitoring of renal function Treat concomitant risk factors for kidney disease ~diabetes ~hypertension ~dyslipidaemia In patients with renal damage: ~adjust ARTs and other drugs as necessary ~avoid nephrotoxic treatments unless no alternative ~take special care with drug ‒ drug interactions

50. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Frailty

51. 51 Definition of frailty In attempting to define frailty as an independent syndrome (or phenotype), three of the following criteria need to be present: Unintentional weight loss Self-reported exhaustion Low physical activity Slowness – measured by time taken to walk 3m Weakness – grip strength Fugate Woods N et al (2005) J Am Geri Soc

52. 52 HIV and premature frailty in women 52 A 55-year old individual living with HIV for ≤4 years has the same frailty as a seronegative individual of 65 years 1 80% of women living with HIV for ≥15 years felt they were prematurely ageing, compared with 18% of men (p <0.001) 2 Women recorded a significantly higher average intensity of mobility difficulty, joint pain, postural balance difficulty, dry skin, hair thinning, sadness, anxiety, and loss of sexual interest than men 2 Prevalence of frailty 1 0% 2% 4% 6% 3540455055 Age, years Years living with HIV: 0 0–4 4–8 8–12 1.Desquilbet L et al (2007) J Gerontol A Biol Sci Med 2.Fumaz CR et al (2010) 1st International Workshop on HIV and Aging

53. 53 Frailty in women living with HIV Severe CD4+ cell depletion is an independent predictor of slowness, weakness, and frailty 1 Women with CD4+ counts <100 cells/mm 3 have 2.7 times higher prevalence of frailty 1 Independent predictors of frailty include: 2 ~unemployment ~greater number of co-morbid conditions and past opportunistic illnesses ~higher depression severity score ~receipt of antidepressants ~lower serum albumin Hospitalisation rates are greater for frail persons with a five-fold longer duration of inpatient stay 2 53 1. Terzian AS et al; (2009) J Womens Health; 2. Onen NF et al. (2009) J Infect

54. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Emotional, psychological and psychiatric challenges of ageing in women with HIV

55. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Neurocognitive disorders

56. 56 HIV-associated neurocognitive disorders Neurocognitive changes associated with HIV consist of cognitive and motor dysfunctions 1 Neurocognitive deficits and effects on motor functioning increase with age in the HIV population 2,3 Main psychiatric and neurocognitive changes include major depressive disorder and HIV-associated neurocognitive disorder (HAND) 4 HAND is characterised by neurocognitive changes of different degrees and is associated with, or is one manifestation of, a depressive mood 4 Women with HIV and neurocognitive difficulties may have problems performing everyday tasks, learning new things, movement and balance 1. Ances BM et al. (2007) Semin Neurol; 2. Kim DH et al. (2001) Can J Neurol Sci; 3. Valcour V et al. (2008) J Neurovirol; 4. Valcour V et al. (2012) CROI

57. 57 Neurological function in women with HIV Some degree of neurological impairment occurs in >50% of HIV-infected individuals Neurological dysfunction, including memory impairment and psychomotor function, has been shown to be increased in women with HIV Risk increases with age, especially with respect to neurocognitive deficits Clifford DB (2008) Top HIV Med CDC: Centers for Disease Control and Prevention; A = asymptomatic; B = Symptomatic; C = AIDS indicator conditions

58. 58 Factors influencing neurological function in women with HIV Risk of neurocognitive impairment is no higher for HIV positive women taking ART than for seronegative women 1 ~Risk of neurocognitive impairment is significantly increased for seropositive women not taking ART HCV co-infection is an independent risk factor for neurocognitive damage in women 2 Memory impairment is associated with alterations in the hippocampus 3 AIDS diagnosis and HIV seropositivity predict psychomotor slowing 4 1. Richardson JL et al (2002) J Int Neuropsychol Soc; 2. Richardson JL et al (2005) AIDS; 3. Maki PM (2009) Neurology; 4. Durvusala RS et al (2001) J Clin Exp Neuropsychol

59. 59 Neurological function and adherence with ART Neurocognitive impairment among older patients provokes poor adherence with medication Suboptimal ART adherence can make patients vulnerable to neurocognitive dysfunction Negative adherence cycle Ettenhofer ML et al (2009) Am J Geriatr Psychiatry Adherence to effective ART that penetrates into the CNS may be important to maintain neurocognitive health

60. 60 Managing neurocognitive changes in women with HIV A healthy lifestyle may help to preserve cognitive function: ~Diet: fruits, vegetables, beans, soy, fish, whole grains, no added fat, no added salt, little or no coffee and alcohol ~Vitamin D3 supplementation ~Exercise ~Stress management: meditation, yoga ~Smoking cessation ~Sufficient sleep 60 Atkinson M. (2010) Positive Side; Levy L (2007) The Positive Side

61. 61 Managing neurocognitive changes in women with HIV As part of the HCP consultation, points to discuss include: ~Screening programs/assessments for neurological disorders ~Lifestyle activities and supplements/medication that may help ~Management of symptoms of depression ~Sources of further information 61

62. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Depression and anxiety

63. 63 Depression and anxiety in women with HIV Depression and anxiety are common among women with HIV 1 Rates of depression in people living with HIV and AIDS are 5 ‒ 10 times greater than in the general population 1 Older people with HIV may have latent depression and low frequency use of mental health services compared to younger people, possibly due to greater support 2 1. Pence BW (2009) J Antimicrob Chemother; 2. Mavandadi S et al (2009) J Acquir Immune Defic Syndr

64. 64 Depression can lead to poor ART adherence and increased mortality Time on ART therapy by depressive symptoms 1 HIV-related mortality by depressive symptoms 2 1. Bangsberg DR et al (2001) ICAAC, Chicago, USA 2. Ickovics JR et al (2001) JAMA

65. 65 Managing depression and anxiety in women with HIV Women with HIV should be screened for depression and anxiety to ensure appropriate intervention is offered Strategies for managing depression and anxiety that have been shown to have a positive effect in people with HIV include: ~Interpersonal therapy ~Exercise ~Massage ~Drug therapy ~Cognitive behavioural therapy

66. 66 CRANIum study: Prevalence of anxiety and depression in Western Europe and Canada 35.5% and 17.9% of females screened positive for anxiety and depressive symptoms, respectively Depressive symptoms were significantly more common when compared with men living with HIV however this difference was reported only in ART naïve population (20.8 vs 10.6%) Prevalence of depressive symptoms in women in the study is twice as high as the general population in Europe 1. Bayon et al (2012) 2 nd International Workshop on HIV and Women, Abst 0_1

67. 67 Managing depression and anxiety in women with HIV As part of the HCP consultation, points to discuss include: ~Signs and symptoms of depression/anxiety ~Screening programs/assessments for depression/anxiety ~Support groups for depression/anxiety ~Lifestyle activities and supplements/medication that may help offset the risk for, or consequences of depression/anxiety ~Sources of further information 67

68. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Insomnia

69. 69 The causes and consequences of poor sleep quality Insomnia and sleep disturbances are medical conditions that can require treatment If untreated, sleep disturbances can make other conditions, such as depression, worse Insomnia is more prevalent in women than men and increases with age Mood, depression, anxiety Sleep quality, insomnia

70. 70 Managing sleep disturbances in women with HIV Strategies to help alleviate sleep disturbances in women living with HIV can include: ~Identification of potential causative factors including ART regimen ~Drug therapy ~Improved sleep hygiene, including less napping and more daytime activity ~Management of depression and anxiety ~Relaxation techniques ~Smoking cessation ~Possible change of schedule of food intake ~Exercise

71. 71 Managing sleep disturbances in women with HIV As part of the HCP consultation, points to discuss include: ~Signs and symptoms of insomnia ~Lifestyle activities and supplements/medication ~Sources of further information

72. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Family and parenting issues

73. Parenting and caregiver challenges in older women living with HIV Older women often have a dual role of caring for their own health whilst caring for children, grandchildren or elderly parents Older women are more likely to have issues around disclosure to their children Delaying starting a family due to HIV may be compounded by premature menopause, having implications for parenthood 73

74. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Support

75. 75 Support for women living with HIV as they age Older women living with HIV may require more healthcare and emotional support than those without HIV Alleviate concerns/fears around their health Additional community or healthcare support Information and support on caring and bereavement Older women living with HIV may be reassured by more regular healthcare screenings Financial circumstances and support from a partner may be decreased with older women with HIV Double role of caring for ailing parents or coping with parental loss

76. 76 Supporting women with HIV as they age Feelings of stigma and isolation still common among ageing women with HIV Information available to women with HIV about ageing is limited with regard to what is due to the disease and what is due to the normal ageing process Healthcare professionals need to take the lead in understanding the challenges facing women with HIV as they age in order to better support and provide answers for this population Community groups, and sharing experiences with others ageing with HIV, can offer essential support and encourage women to take on meaningful duties and tasks Healthcare professionals need to take the lead in understanding the challenges facing women with HIV as they age in order to better support and provide answers for this population Community groups, and sharing experiences with others ageing with HIV, can offer essential support and encourage women to take on meaningful duties and tasks Enriquez M et al (2008) J Assoc Nurses AIDS Care

77. Peer support and peer education Allows sharing of feelings, experiences and information Provides mutual support Helps women to realise they are not alone Acceptance of HIV Disclosure to family or loved ones Many opportunities for women with HIV to provide support and encouragement to others Active participant in a support group Giving presentations Communicating personal experiences Becoming a peer worker Offers support women with HIV to understand instances when people may be uninformed about HIV e.g. a healthcare professional without HIV specialist knowledge 77

78. Existing peer support initiatives for women living with HIV 78

79. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Case studies

80. 80 Case study 1 – characteristics 54-year-old woman ~Owns a restaurant business ~Works long hours ~Diagnosed with HIV in 2005 and was devastated She has suffered episodes of depression since diagnosis and is recently feeling more anxious, with mood swings and problems sleeping She wants to know when she will be able to feel like herself again ~Needs to concentrate to handle the duties of her job ~Wants to be in better control of her moods and emotional wellbeing

81. 81 Case study 1 – actions Assess for depression/anxiety and insomnia Review ART for ARVs that may affect mood ~Consider changes to ART to exclude potential drug causes for depression/anxiety? Discuss pharmacologic and behavioural interventions to treat both depression/anxiety and insomnia ~Cognitive behavioural therapy ~Improved exercise routine ~Relaxation therapies e.g. massage ~Anti-depressant and/or mood stabiliser? ~Sedative?

82. 82 Case study 1 – actions Suggest peer support ~Help to manage emotional stress ~Develop effective coping skills Individual/group counseling ~Encouragement often required for patients to seek social or psychological support Ongoing screening for co-morbidities of ageing and management of any physical symptoms ~Osteopenia/osteoporosis ~CVD ~Renal disease ~Cancer ~Menopause

83. 83 Case study 2 – characteristics 42-year-old woman ~Diagnosed with HIV over 15 years ago ~Started treatment 7 years ago Family history of CVD ~Medical history of moderately elevated cholesterol and blood pressure Heavy smoker since early teenage ~Significant alcohol intake and cannabis use ~Has sleep problems and suffers from anxiety

84. 84 Case study 2 – actions Discuss behavioral changes to decrease risk of CVD and early onset of menopause ~Smoking and drug cessation ~Alcohol moderation ~Improved diet and exercise routines Ongoing monitoring for CVD risk factors including raised cholesterol or blood pressure Assess for depression/anxiety and insomnia Review ART for ARVs that may affect mood ~Consider changes to ART to exclude potential propagators of depression/anxiety? Discuss pharmacologic and behavioural interventions to treat both depression/anxiety and insomnia Suggest peer support and individual/group counseling ~Encouragement often required for patients to seek social or psychological support

85. 85 Case study 3 – characteristics 65-year-old woman ~Lives alone ~Is barely managing to get by on state benefits ~Diagnosed with HIV in 1991 ~On long-term ART She feels socially isolated and lonely, and suffers bouts of severe depression She is becoming increasingly frail and suffers from short-term memory loss It is probable that she will have to move into a care home in the next few months ~She worries about how she will be accepted because of her HIV status

86. 86 Case study 3 – actions Assess for depression/anxiety and insomnia Review ART for ARVs that may affect mood ~Consider changes to ART to exclude potential propagators of depression/anxiety? Discuss pharmacologic and behavioural interventions to treat depression/anxiety ~Relaxation techniques e.g. massage ~Improved exercise routine ~Anti-depressant and/or mood stabiliser? Monitor for development of comorbidities that increase with age e.g. osteoporosis

87. 87 Case study 3 – actions Suggest peer support ~Opportunity to interact with women who may have had similar experiences and increase social interaction ~Develop effective coping skills Individual/group counseling ~Encouragement often required for patients to seek social or psychological support Discuss option of care homes with experience of managing HIV Screening for co-morbidities and management of any physical symptoms ~Osteopenia/osteoporosis ~Cardiovascular disorders ~Renal disease ~Cancer ~Menopause

88. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Summary

89. 89 Ageing in women living with HIV Women living with HIV face many potential physical and emotional health issues as they age With the appropriate interventions, lifestyle choices and integrated support from healthcare professionals and community groups, the impact of these challenges can be effectively managed Women living with HIV may require additional medical and emotional support as they age

90. Women for Positive Action is an educational program funded and initiated by Abbott Laboratories Thank you for your attention Any questions?