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Challenges
associated with
ageing in women
living with HIV
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
2
Introduction
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
An ageing global population
•
By 2050, ~25% of the global population will be ≥60 years
Global population estimate
4
US Census Bureau International Data Base
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
5
1. Antiretroviral Therapy Cohort Collaboration (2008) Lancet
2. Swiss HIV Cohort Study (May 2009)
Proportion of new HIV/AIDS cases in
older people
•
The rate of HIV infection and new diagnoses among
older people is increasing1-3
~ 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 20104
~ UK data show that new diagnoses among older adults more
than doubled between 2000 and 2009, accounting for 13% of all
diagnoses in 20095
~ In the UK, women represent 25% of all diagnoses in people ≥50
years6
~ However, true rates of infection in the population aged ≥50
years are often unknown due to poor testing rates7
6
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 Ageing
Significance of age at diagnosis
•
HIV testing is often delayed in older individuals1
~ 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 people2-4
~ Older patients diagnosed with a CD4 cell count <200
cells/mm3 at the time of their diagnosis are 14 times more
likely to die than younger patients4
•
However, older patients derive a similar level of
benefit form ART as younger patients5
7
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 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 patient1
~ A considerable proportion of sexually active older adults
with HIV practice unsafe sex2
•
•
Shorter time from diagnosis to onset of AIDS (agerelated faster progression to AIDS, late diagnosis)3
HIV testing in older women is uncommon4
8
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
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:
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
9
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
Physical challenges
of ageing in women
with HIV
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
Menopause
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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 diseases4–6
~ may be linked to increased mortality7,8
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
Onset of early menopause in women
living with HIV
% of women experiencing
early onset of menopause
(<40 years)
P=0.04
30%
26%
25%
20%
15%
10%
10%
5%
0%
HIV-positive
n=303
•
•
HIV-negative
n=268
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)
14
Schoenbaum et al (2005) Clin Infect Dis
Onset of early menopause in women
living with HIV
• 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/mm3 is lower than in the general
population2
15
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.
Impact of HIV on the symptoms of
menopause
•
•
Menopause symptoms are common in women
living with HIV1
The symptoms associated with the menopause are
more frequent among women with HIV than HIVnegative women1–3
~ 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 women4
16
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
Potential contributors to early onset
of menopause in women with HIV
Immunosuppression
Lower CD4+ count
has been associated
with early
menopause onset1
Smoking
Socioeconomic status
Menopause can
occur up to 1–2
years earlier in
smokers, compared
with non-smokers2,3
Markers of low
socioeconomic
status (e.g. lower
level of education,
unemployment and
poverty) have been
associated with early
menopause onset3,4
17
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
Menopausal symptoms may mimic
HIV-related symptoms
•
Hot flushes at night
Mood changes
Vaginal dryness
Irregular menstrual
cycles
It is important for women to monitor their menstrual cycle
so that symptoms are not confused with effects from HIV
or ART
18
Margolese S. http://www.thewellproject.org/en_US/Womens_Center/Menopause.jsp
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
19
New York State Department of Health AIDS Institute (2010);
Margolese S. http://www.thewellproject.org/en_US/Womens_Center/Hormones_and_HIV.jsp
Managing the menopause in women
with HIV
•
Strategies to offset effects associated with menopause
include1:
~ 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 considered1
~ Many ART medications may be affected by HRT and so this
should be discussed with a healthcare professional2
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.
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
21
Osteoporosis
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
Risk factors for decreased bone mineral
density in women
Classic
Secondary
Chronic diseases
• Female sex
• White race
• Decreased
physical activity
• Family history
• Smoking
• Increasing age
• Alcohol
• Amenorrhoea
/premature
menopause
• Decreased bone
acquisition
(e.g. hyperthyroidism, hyperparathyroidism, liver
disease, rheumatological conditions, eating
disorders, etc.)
Hypogonadism
Renal dysfunction
Malnutrition/low BMI
Medications
(e.g. corticosteroids, anticonvulsants, anticoagulants)
HIV-related
HAART-related
Cytokines (e.g. TNFa, IL6)
Decreased muscle mass
Nucleoside analogues /mitochondrial
dysfunction
Decreased fat mass
Protease inhibitors
Fat deposition in marrow
Lipodystrophy
23
Adapted from Glesby MJ (2003) Clin Infect Dis
Increased risk of osteoporosis in
women living with HIV
•
A decrease in bone mineral density (BMD) may be
due to HIV itself or to ART1–3
~ 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 HIVnegative controls4
~ Older age was also associated with lower BMD
24
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
Clinical studies report an increased
risk of osteoporosis in HIV
• Being HIV-positive
conferred an increased
risk for osteoporosis
compared with HIVnegative individuals
(n=654, mean
age 38.1)
• 6.4 fold increased risk
for reduced BMD
25
Women for Positive Action is supported by a grant from Abbott
Brown TT et al (2006) AIDS
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
26
Triant VA et al (2008) J Clin Endocrinol Metab
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 include2–4
~ 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 HIV2
1. EACS Guidelines, Version 6, 2011; 2. Lee S. BETA 2006;18(2):33-35
27
3. National Osteoporosis Society 4. Lima AL et al. HIV AIDS (Auckl) 2011;3:117-24
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?
28
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?
29
Cardiovascular disease
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
Factors that
can NOT be changed
~ Increasing age
~ Male gender
though a women's risk increases
after menopause
~ Heredity
including race
Factors that CAN be changed or controlled
by treatment or lifestyle modification
~ Smoking
~ Blood pressure and cholesterol
~ Physical activity
~ Obesity and overweight
~ Diabetes
~ Renal disease
31
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-
32
Women for Positive Action is supported by a grant from Abbott
Triant VA et al (2007) J Clin Endocrinol Metab
Cardiovascular disease risk and
exposure to ART
Incidence of myocardial infarction (MI) has been
shown to increase with longer exposure to
combination ART
Incidence per 1000 Person-Yr
•
8
DAD Study: incidence of MI in HIV+ compared to
patients not exposed to ART
7
6
5
4
3
2
1
P<0.001 for trend
0
None
<1
1-2
2-3
3-4
>4
Exposure (yr)
33
The DAD Study Group (2003) N Engl J Med
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)
Parameter
No. of Patients With Events
Severe complications
RR (95% CI)
1.5
114
Risk of
Complications
1.4
CVD, liver, or renal deaths
31
Nonfatal CVD events
63
Nonfatal hepatic events
14
Nonfatal renal events
7
1.5
1.4
2.5
0.1
1.0
10.0
34
El-Sadr W, et al. CROI 2006. Abstract 106 LB.
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
35
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
36
Cancer
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
38
Increased risk for cancer among
women living with HIV
Ratio of observed to
expected cancer casesa
AIDS-defining cancers
Kaposi's sarcoma
178.49
Non-Hodgkins Lymphoma
48.97
Invasive cervical cancer
9.20
Non-AIDS-defining cancers
Cancer of the lung
7.95
Oesophagus
7.69
Multiple myeloma
7.37
Oral cavity and pharynx
6.55
Hodgkin’s disease
5.65
Leukaemias
4.52
Rectal/anal cancers
3.23
aStandardised
incidence ratio (SIR)
39
Fordyce EJ et al (2000) AIDS Public Policy
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
40
Relationship between HIV
suppression and HPV
•
•
At time of first HPV screen, high-risk-HPV
prevalence was 43% in 20111
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< 50 cp/ml for >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
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 cancer1,2
•
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 cancer3
1. Frisch M et al (2000) J Natl Cancer Inst;
42
2. Palefsky J (2009) Curr Opin HIV AIDS; 3. Adler DH et al (2010) Curr HIV Res
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
Managing cancer in women with HIV
•
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
44
Renal disease
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
46
Renal disease in women living with
HIV
•
Women living with HIV may be at an increased risk for acute
renal failure or CKD1, affecting 1 in 6 people living with HIV2
~ risk of HIV-associated nephropathy and/or ART induced renal
dysfunction1
~ The mortality risk for women with CKD is twice that of those who
do not have CKD 5
P<0.0001
47
Gardner LI et al (2003) J Acquir Immune Defic Syndr
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
P<0.0001
100
Frequency of renal
impairment (%)
•
80
60
55
33
40
20
0
Women
Men
n = 665
n = 1922
48
Deti et al (2010) HIV Med
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
49
Frailty
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
51
Fugate Woods N et al (2005) J Am Geri Soc
HIV and premature frailty in women
Prevalence of frailty1
6%
Years living
with HIV:
4%
0
0–4
2%
4–8
8–12
0%
35
•
•
•
40
45
Age, years
50
55
A 55-year old individual living with HIV for ≤4 years has the same frailty as a
seronegative individual of 65 years1
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 men2
52
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
Frailty in women living with HIV
•
•
•
Severe CD4+ cell depletion is an independent
predictor of slowness, weakness, and frailty1
Women with CD4+ counts <100 cells/mm3 have 2.7
times higher prevalence of frailty1
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 stay2
53
1. Terzian AS et al; (2009) J Womens Health; 2. Onen NF et al. (2009) J Infect
Emotional,
psychological and
psychiatric challenges
of ageing in women
with HIV
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
Neurocognitive disorders
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
HIV-associated neurocognitive disorders
Women with HIV and
neurocognitive
difficulties may have
problems performing
everyday tasks,
learning new things,
movement and balance
•
Neurocognitive changes
associated with HIV consist
of cognitive and
motor dysfunctions1
• Neurocognitive deficits and
effects on motor functioning
increase with age in the HIV population2,3
• 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 mood4
56
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
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
CDC: Centers for Disease Control and Prevention; A =
asymptomatic; B = Symptomatic; C = AIDS indicator conditions
57
Clifford DB (2008) Top HIV Med
Factors influencing neurological
function in women with HIV
•
Risk of neurocognitive impairment is no higher for HIV
positive women taking ART than for seronegative
women1
~ 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 women2
• Memory impairment is associated with alterations in the
hippocampus3
• AIDS diagnosis and HIV seropositivity predict
psychomotor slowing4
58
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
Neurological function and adherence
with ART Negative adherence cycle
Neurocognitive
impairment among older
patients provokes poor
adherence with
medication
Suboptimal ART
adherence can make
patients vulnerable to
neurocognitive
dysfunction
Adherence to effective ART that
penetrates into the CNS may be
important to maintain neurocognitive
health
59
Ettenhofer ML et al (2009) Am J Geriatr Psychiatry
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
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
Depression and anxiety
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
Depression and anxiety in women
with HIV
•
Depression and anxiety are common among
women with HIV1
• Rates of depression in people
living with HIV and AIDS are
5‒10 times greater than in
the general
population1
• Older
people with HIV may
have latent depression
and low frequency use of
mental health services compared to
younger people, possibly due to
greater support2
63
1. Pence BW (2009) J Antimicrob Chemother;
2. Mavandadi S et al (2009) J Acquir Immune Defic Syndr
Psychiatric Disorders in HIV-Infected Patients
Depression
can lead to poor ART
adherence
andIncreases
increased mortality
Depression
Mortality in
ontinuation
of on
ARTART
Patients
on ART therapy by
HIV-related mortality by depressive
rsons Time
Study assessed
association of
depressive
symptoms
symptoms
s
1
% of
and
721.
depressive symptoms with HIV-related
mortality and decline in CD4+ cell
BDI(N
< 15
= 765)
1.0 counts in HERS cohort
 15 as limited,
 Depression (CES-D)BDI
defined
0.8 intermittent, or chronic

Multivariate analysis: increased
RR of mortality in women with
0.6 chronic depressive symptoms
(2.0; 95% CI:
P = .0001
0.4 1.0-3.8) vs those with limited or
no symptoms
 Mortality in patients with CD4+ < 200
0.2
HIV-Related Mortality
1.0
Cumulative Survival
or
s
ad
Cumulative Survival
HIV-
2
0.9
0.8
Limited depression
Intermittent depression
Chronic depression
–
Chronic depression: 54%( RR: 4.3; 95%
CI: 1.6-11.6) vs limited depression
0 – Intermittent depression: 48% (RR: 3.5;
95% 20
CI: 1.1-10.5)
limited
0 10
30 40vs 50
60depression
70
– Limited depression: 21%
Time on HAART (Mos)
Ickovics JR, et al. JAMA. 2001;285:1466-1474.
clinicaloptions.com/hiv
0.7
0
1
2
3
4
5
6
7
Total Time in Study (Yrs)
clinicaloptions.com/hiv
64
1. Bangsberg DR et al (2001) ICAAC, Chicago, USA
2. Ickovics JR et al (2001) JAMA
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
65
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
66
1. Bayon et al (2012) 2nd International Workshop on HIV and Women, Abst 0_1
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
Insomnia
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
69
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
70
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
71
Family and parenting
issues
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
Support
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
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
75
Alleviate
concerns/fears
around their health
Additional community
or healthcare support
Information and
support on caring
and bereavement
Supporting women with HIV as they age
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
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
Community groups, and
sharing experiences with
others ageing with HIV, can
offer essential support and
encourage women to take
on meaningful duties and
tasks
76
Enriquez M et al (2008) J Assoc Nurses AIDS Care
Peer support and peer education
•
•
Allows sharing of feelings, experiences and information
Provides mutual support
•
•
•
•
Many opportunities for women with HIV to provide support and
encouragement to others
•
•
•
•
•
Helps women to realise they are not alone
Acceptance of HIV
Disclosure to family or loved ones
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
Existing peer support initiatives
for women living with HIV
78
Case studies
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
80
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?
81
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
82
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
83
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
84
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
85
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
86
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
87
Summary
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories
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
89
Thank you for your
attention
Any questions?
Women for Positive Action is an educational program
funded and initiated by Abbott Laboratories