1. HIV and Aging: Shaping A Relevant Health System Response Wafaa El-Sadr, MD, MPH ICAP at Columbia University

2. Outline of Presentation Characteristics of older PLWH Age as a risk factor for co-morbidities in PLWH Health system challenges for older PLWH Shaping a health system for older PLWH

3. UNAIDS, 2013 Millions 2.0 4.0 6.0 8.0 10.0 12.0 14.0 200220032004200520062007200820092010201220112013 UNAIDS 2014 Scale-up of HIV Treatment

4. Optimal Models Study Optimal Models is supported by tPEPFAR through the CDC under Cooperative Agreement 5U62PS223540 and 5U2GPS001537 Adults enrolled* Children enrolled*Sites** Ethiopia113,0969,05732 Kenya75,16315,19483 Rwanda33,0274,15352 Mozambique 159,86219,74045 Tanzania78,5525,61756 Total459,70053,761268 *Total ever enrolled **Sites ever reporting

5. About 10% of PLWH enrolled in care are >50 years old and increasing proportion initiated ART Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania Newly enrolling in HIV care Newly initiating ART Active in HIV care Active on ART p = 0.33 p < 0.001

6. Men represent larger proportion of those enrolled in HIV care and initiate ART in older PLWH Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

7. Lower CD4+ count at enrollment into HIV care for older PLWH Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania 15-24 years 25-39 years 40-49 years 50+ years

8. Older PLWH have higher CD4+ cell loss during follow-up in pre-ART care (CD4>600 at enrollment) Patients >40 had lower median CD4+ at enrollment and during follow-up Patients >40 lost 10 more CD4+ cells per year compared to 15-40 year olds (p<0.01) CD4+ count cells/mm 3 Teasdale CROI 2014, #913

9. Less robust CD4+ cell response after ART initiation in older PLWH Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania All patients MenWomen 15-49 years 50+ years

10. Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania Less risk of loss to follow-up but increased risk of death in older PLWH HIV Care ART

11. Age of PLWH and Risk of NCD

12. Age and Risk of Diabetes in PLWH Petoumenos et al. JIAS 2012

13. Age and Risk for Hypertension in PLWH Thiebaut et al. Antiviral Therapy 2005

14. Predictors of MI in PLWH Relative rate of myocardial infarction (95% CI) Uni- and multivariable Poisson model Adjusted for family history, BMI, HIV risk, cohort, calendar year and race CART per additional year Age per 5 year older Male sex Previous CVD Smoking Family history 1.0 0.1 10100 Age and Risk of MI in PLWH El-Sadr et al. CROI 2005

15. Health Systems Challenges for Older PLWH Early diagnosis of HIV Careful follow-up during pre-ART period and after initiation of ART Screening for and management of risk factors for NCDs and for NCD Continuity care models attentive to the characteristics of HIV disease and co-morbid conditions

16. Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics, standardized diagnostic protocols Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support Multidisciplinary family-focused care A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient Longitudinal monitoring Health information systems have standardized and easily retrievable data Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community Self management An informed, motivated patient is an effective manager of his/her own health Community linkages and partnerships Need functional partnerships between health facility- based providers and community-based groups that facilitate access to services across the care continuum Health System Strategies

17. Health Systems Challenges: Diagnosis and Enrollment in Care Patients and providers may be unaware of HIV risk in older individuals Messaging regarding HIV and importance of HIV testing largely targeted at younger individuals Current testing venues may be not suitable (e.g. ANC) or not “elder friendly” – HIV testing tailored to reach older persons e.g. PICT in inpatient settings and HTC in chronic disease clinics, family-focused testing

18. Health Systems Challenges: Monitoring, Retention and Adherence Retention in pre-ART and after ART initiation critical for monitoring disease progression (frequency?) Monitoring for side effects of ART and other medicines for management of co-morbidities Adherence counselling may be complicated by polypharmacy for non-HIV conditions (co- morbidities)

19. Health Systems Challenges: Monitoring, Retention and Adherence Peer educators may not be peers (tend to be young) Family-focused care may be targeted at younger families Innovative methods needed to screen and manage CVD, diabetes, hypertension, mental illness etc. among older PLWH

20. HIV Care Continuum ART Eligible Link McNairy et al AIDS 2012 HIV Care Continuum McNairy et al AIDS 2012 Screen and manage NCD risk factors and NCD Early Diagnosis Careful monitoring Of disease progression Monitor response To ART Monitor for side effects link

21. Health System Challenges: Models of Care for HIV and NCD

22. Opportunities for Implementation Research A missed opportunity for screening? – PLWH enrolled in care are rarely screened for CVD risk factors, despite their frequent contacts with the health system A missed opportunity for management? – Chronic care systems developed for HIV can theoretically be leveraged to manage chronic CVD risk factors (HTN, DM, high cholesterol) Rabkin, Goosby, El-Sadr Scientific American 2014 Rabkin, Nishtar JAIDS 2011 Rabkin, El-Sadr Global Pub Health 2011

23. Relevant ICAP Studies HEART study in South Africa – Feasibility of integrating CVD risk factor screening and risk stratification for PLWH on ART Link4Health CVD study in Swaziland Phase 1: Feasibility, acceptability, cost and time for CVD RF screening Phase 2: Participants with CVDRF randomized to management in HIV clinic versus OPD clinic Outcome: Combined linkage to CVDRF management and retention in both HIV and CVD care ARTIC Study in Kenya Prevalence of NCD risk factors and NCD Cohort of HIV-infected ART naïve, initiating ART Storage of samples for biomarker analyses Participant has > 40% 10-year risk

24. Conclusions Substantial, and likely increasing, proportion of PLWH enrolled in HIV care and initiating ART at older ages Enhanced efforts needed for earlier diagnosis of HIV in older persons and engaging them in programs that address their unique needs with regards to HIV and co-morbid conditions Research urgently needed to characterize older PLWH and to identify effective models of care for such individuals

25. Acknowledgements ICAP colleagues: Matt Lamb, Eduard Eduardo, Chloe Teasdale and Miriam Rabkin Patients and staff at health facilities Ministries of Health and partner organizations Funding from PEPFAR, NIH and Medtronic