I. Jean Davis, PhD, PA, AAHIVS Howard University College of Medicine

1. Delay in diagnosis and poor clinical outcomes for HIV infection in the older patient (greater than 50 years of age) is associated with: a)Unsuspected HIV infection b)Age-related differences in immune responses to HIV antigens c) Lack of understanding the increase mucosal risk of HIV acquisition in elderly d) a and B e) all of the above

2. This epidemiologic trend is expected due to longer survival of HIV-infected patients on antiretroviral therapy, and to increased case findings due to wider HIV testing. True False

3. Many age-associated diseases are less common in treated HIV disease than in age-matched HIV negative persons  Cardiovascular disease  Non-AIDS cancers  Osteopenia, bone fractures  Liver and renal failure True False

4. ART consideration for older adults include: a) Decreased kidney and liver function b) Drug-drug interactions c) Adherence d) a and b e) All of the above

At the end of this webinar the participating providers will have an enhanced ability to:  Describe the epidemiology of HIV in the population over 50  Explain the Delays in diagnosis due to unsuspected HIV infection  Describe the Age-related differences in immune responses to HIV antigens  Understand the Special Consideration Involving the Care of this Population

 Mr. Dominguez is a 65 year old Black Hispanic male. He is a retired electrical engineer. He was diagnosed with GC and Syphilis (presenting with an oral chancre) 3 months ago and denies sexual activity with men. Mr. Dominguez returns to the clinic for follow- up and a refill on his ED and topical testosterone medication. He has never been married and has no children. His twin brother died last year secondary to a MI. He is very close with his nieces and nephews and their children. He has become a father figure for his brother’s children. His girlfriend is 50 years old nurse. He admits to an emotional monogamous relationship, but states he has regular sexually active with younger women because he respects his girlfriend too much to ask her to participate in certain sexual activities.

 Secondary to the advancement in pharmacological therapies and a greater focus on patient centered care with a holistic point of view, including the importance of nutrition, physical activity and psychosocial issues, a greater prevalence of HIV-infected individuals over the age of 50 is projected  This epidemiologic trend is expected due to longer survival of HIV-infected patients on antiretroviral therapy, the sexual activity status of adults over 50 and to increased case findings due to wider HIV testing

 HIV infection in the older patient (age greater than 50 years) is associated with:  Delays in education or screening due to provider prejudgment  Delays in diagnosis due unsuspected HIV infection  Age-related differences in immune responses to HIV antigens leading to a less robust clinical outcomes  Issues specific to an aging population, such as neurological, cardiovascular disorders, diabetes, low testosterone, osteoporosis need to be addressed in the older HIV-infected patient

cdc.gov

 United States 2008:  Newly diagnosed persons with HIV  16.5% > 50 years old  30.5% persons living with HIV > 50 years old  By 2015, 50% people living with HIV will be > 50

 Lack of awareness of STD/HIV risk factors  Recently divorced or widowed  Menopause  No pregnancy risk, little condom use  Increased vaginal mucosal trauma/risk  Unprotected intercourse: less condom use in this generation associated with birth control pill as their primary mode to prevent pregnancy  Viagra: increased sex among older adults  Lack of HIV prevention services for older persons  Healthcare providers don’t consider older adults at risk  Providers not recognizing that 60 is the new 40 and the prevalence of cross generational sexual activities

 Loss of bone and muscle mass  Weight loss  Decline in kidney function  Memory loss  Immunosenescence  ↑ risk of Herpes zoster, UTI, bacterial infections, cancers  Lymphopenia, decline in CD4 cell count  “Inflamm-aging”  ↑ Proinflammatory cytokines, systemic low grade inflammation

 Since the introduction of ART, primary causes of illness/death:   AIDS-related illnesses  ↑ chronic non-communicable conditions typically associated with aging  Many age-associated diseases are more common in treated HIV disease than in age-matched HIV negative persons  Cardiovascular disease  Non-AIDS cancers  Osteopenia, bone fractures  Liver and renal failure

 Diagnosis of HIV often delayed in older adults is secondary to patient and provider bias, lack of screening and misdiagnosis  Manifestations of HIV/AIDS often present similar to other syndromes  Delirium  Dementia  Failure to Thrive: wasting, weight loss, frailty  Bacterial infections ▪ Pneumonia  Cytopenias

 Decreased kidney and liver function  Changes metabolism of drugs  Drug-drug interactions  Toxicities significant  Older persons often excluded from clinical trials  Inadequate pharmacokinetic data for older adult

 Patients often taking > 5 medications  Increased comorbidities with age Hasse B et al. CID 2011;53: 1130

 Epidemiology  Prevalence of HIV increasing among older adults  HIV patients living longer, aging  Older adults are sexually activity  Prevention  Reduction in provider bias  Patient education and screening for all STDs  Biology  HIV patients age more rapidly than HIV negative controls  HIV and aging may share link with chronic inflammation  Treatment Considerations  Consider starting older patients on ART earlier  Attention to co-morbidities, vascular disease important

 Mr. Dominguez is a 65 year old Black Hispanic male. He is a retired electrical engineer. He was diagnosed with GC and Syphilis (presenting with an oral chancre) 3 months ago and denies sexual activity with men. Mr. Dominguez returns to the clinic for follow- up and a refill on his ED and topical testosterone medication. He has never been married and has no children. His twin brother died last year secondary to a MI. He is very close with his nieces and nephews and their children. His girlfriend is 50 years old nurse. He admits to an emotional monogamous relationship, but states he has regular sexually active with younger women because he respects his girlfriend too much to ask her to participate in certain sexual activities.

Let’s Talk  GC and Syphilis (presenting with an oral chancre) 3 months ago  Denies sexual activity with men  RTC for follow-up/refill of ED and topical testosterone medications  Family  Girlfriend is 50 years old nurse  Emotional monogamous relationship  Sexually active with younger women  Certain sexual activities

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