Download Slide 1

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 followup 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 followup 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

www.aetcnmc.org

www.capitolregiontelehealth.org
Howard University HURB 1
1840 7th Street NW, 2nd Floor
Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
www.capitolregiontelehealth.org
www.aetcnmc.org