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1981-2013 - The Aging HIV Epidemic
New Strategies for a
Changing Demographic
Overview
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HIV Epidemiology Update
HIV Medical Update
HIV and Aging
National HIV Strategy
Minnesota’s HIV Services
Minnesota Program HH Eligibility
History of HIV
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June, 1981, the Center for Disease Control
reported clusters of an unusual illness
1982- This illness was labeled AIDS
1984- HIV was discovered
Initial medications were very expensive and
highly toxic
1996- The advent of highly active
antiretroviral therapy
Why Are We Here?
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Even with improvements to HIV care and
treatment, HIV remains a significant public
health threat
New infections on the rise
HIV is a chronic, lifelong condition
With more people living with HIV, the number
of new infections is likely to continue to rise
National HIV Strategy
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Reducing HIV incidence
Increasing access to care and optimizing
health outcomes
Reducing HIV-related health disparities
National Perspective
National Perspective
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The Center for Disease Control estimates 1.1
million people in the U.S. are living with HIV
– 1 in 5 (18.1%) of those people are unaware of
their infection
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Over 50,000 Americans become infected with
HIV each year
Nearly 636,000 people with AIDS have died in
the U.S. since the epidemic began
National Perspective
By Sub-Populations
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RISK GROUP
– MSM
• Although MSM represent 4% of the U.S. male
population, MSM accounted for 78% of new HIV
infections among males
• From 2008-2010 there was a 12% increase in new
infections among MSM
• The number of new HIV infections was greatest among
MSM in the youngest age group (13-24)
– Young, black, MSM most severely burdened
National Perspective
By Sub-Populations
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RISK GROUP
– Heterosexuals
• Accounted for 25% of estimated new HIV infections in
2010
– Injection Drug Users
• Represented 8% of new HIV infections in 2010, and
16% of those living with HIV in 2009
National Perspective
By Sub-Populations
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GENDER
– Women
• HIV infections among women are primarily attributed
to heterosexual contact or injection drug use
• Accounted for 20% of estimated new infections in 2010
and 20% of those living with HIV infection in 2008
• There was a 21% decrease from 2008-2010
– Men
• Accounted for approximately 80% of those living with
HIV infection in 2010
National Perspective
By Sub-Populations
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RACE
– Blacks continue to experience the most severe
burden of HIV
• Blacks represent approximately 12% of the U.S.
population, but accounted for an estimated 44% of
new infections in 2010.
– Latinos are also disproportionately affected by
HIV
• Latinos represented 16% of the U.S. population, but
accounted for 21% of new infections in 2009.
National Perspective
By Sub-Populations
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YOUTH
– Young people aged 13-24 accounted for 20% of all
new HIV infections in the U.S. in 2009
– HIV disproportionately affects young gay and
bisexual men and young African Americans
– Among young black MSM, new HIV infections
increased 48% from 2006-2009
Prevention Challenges for Youth
– Sexual Risk Factors
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Early age at sexual initiation
Unprotected sex
Older sex partners
Male-to-male sex
Sexual abuse
Sexually transmitted infections
– Substance use
– Lack of awareness
Younger Patients
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Based on a U.S. government report released
in August 2012
The least likely to be receiving medical care
and medications
– 15% of those aged 25-34 had an undetectable
viral load
• Compared to
– 36% of those aged 55-64
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Only 22% of young adults are taking HIV
medications
Transmission and Treatment Rates
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The same factors drive high transmission and
poor treatment rates among U.S. groups that
are disproportionately impacted
– Poverty
– Lack of access to medical care
– Lack of education about what causes HIV and
what people can do about it
Minnesota Perspective
Minnesota HIV/AIDS Surveillance
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As of December 31, 2012, a cumulative total of
10,112 persons have been diagnosed and
reported with HIV infection in Minnesota.
Of these 10,112 persons, 3,459 are known to be
deceased
As of December 31, 2012, 7,516 persons are
assumed alive and living in Minnesota with
HIV/AIDS
– 3,974 living with HIV infection (non-AIDS)
– 3,452 living with AIDS
Geographical Distribution
HIV Infections† by County of Residence
at Diagnosis, 2012
Number of Infections
None
1-2
3-5
City of Minneapolis – 123
City of St. Paul – 44
Suburban# – 94
Greater Minnesota - 54
Total number = 315
6-14
15-53
54-180
*Counties in which a state
correctional facility is located
# 7-county metro area, excluding
the cities of Minneapolis and St.
Paul
†HIV or AIDS at first diagnosis
HIV Infections* in Minnesota
by Residence at Diagnosis, 2012
Total Number = 315
Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (except Minneapolis), Ramsey
(except St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties, outside the sevencounty
* HIV ormetro
AIDSarea.
at first diagnosis
Living HIV/AIDS Cases by
County of Residence, 2012
Number Living with HIV/AIDS
None
1-20
21-100
101-500
City of Minneapolis – 2,943
City of St. Paul – 1,025
Suburban# – 2,393
Greater Minnesota – 1,111
501-1000
1000-2000
2001-4190
Total number = 7,472
(44 people missing residence information)
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7-county metro area, excluding
the cities of Minneapolis and St.
Paul
Gender, Race and Ethnicity
Persons Living with HIV/AIDS in Minnesota
by Gender, 2012
5,771
(77%)
1,745 (23%)
HIV Infections* Diagnosed in Year 2012 and General
Population in Minnesota by Race/Ethnicity
HIV Diagnoses
(n = 315)
* HIV or AIDS at first diagnosis
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Population estimates based on 2010 U.S. Census
data.
Population†
(n = 5,303,925)
n = Number of persons
Amer Ind = American Indian
Afr Amer = African American (Black, not African-born
persons)
Afr born = African-born (Black, African-born persons)
Number of Cases and Rates (per 100,000 persons) of
HIV Infection* by Race/Ethnicity† – Minnesota, 2012
* HIV or AIDS at first diagnosis; 2010 U.S. Census Data used for rate calculations.
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“African-born” refers to Blacks who reported an African country of birth; “African American” refers to all other Blacks.
Estimate of 72,930 Source: Retrieved from MNCompass.org on 3/22/12. Additional calculations by the State Demographic Center.
^ Other = Multi-racial persons or persons with unknown race
Age
Average Age at HIV Diagnosis by Race/Ethnicity† :
2010-2012
Cases with unknown or multiple race or unknown age were excluded.
† “African-born”
Blacks.
refers to Blacks who reported an African country of birth; “African American” refers to all other
Persons Living with HIV/AIDS in Minnesota
by Age Group†, 2012
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Age missing for 8 people .
HIV Medical Update
What is the difference between HIV
and AIDS?
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HIV versus an AIDS diagnosis
How long does this progression take?
What is the average life expectancy of
someone with HIV?
Common Lab Counts
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CD4 Count
– A key measure of immune system health
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Viral load
– This test measures the amount of virus in the
body
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How do non-medical providers interpret these
numbers?
Medications
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AIDS drug cocktail vs. combination therapy
Adherence rates
Goal of medication
Medications as part of national HIV strategy
– Health of individual
– Public health approach
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Medications and Aging
– Drug resistance
HIV and Aging- Associated Diseases
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Illnesses typically associated with aging that
are elevated in persons with HIV and can
occur at a younger age
– Cardiovascular and lung disease
– Kidney and liver disease
– Bone loss, increased fracture risk and frailty
– Cognitive impairment
– Cancer
– Arthritis
– Diabetes and high blood pressure
Factors Associated with Accelerated
Aging-Related Illnesses
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Inflammation
Immune dysregulation
Polypharmacy
Long-term drug toxicities
Co-infections and comorbidities
– Hepatitis B or C
– Substance-use disorders
– Stress, depression
What do HIV and Aging have in
Common?
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Inflammation
Weakening immune system
High levels of depression and isolation
– Leads to skipping medication
– Which aggravates other maladies
Transmission
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What are the four fluids that transmit HIV?
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Blood
Semen
Vaginal fluid
Breast milk
What are the most common ways HIV is
transmitted today?
– Unprotected anal, vaginal and oral sex
– Sharing needles
– From mother to child
Transmission Considerations for
Older Adults
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Aging of the sex organs
– Lining of the vaginal and anal walls
– Decrease in natural lubrication
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The role of erectile dysfunction medications
Long term partner
– New partners after epidemic began
– Multiple partners, partner not monogamous
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HIV education
Sex Among Older Adults With HIV
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Some choose not to have sex at all
– Fears about infecting others
– Fears about exposure to STI’s
– Shifting priorities
– Disinterest in sex
– Negative body image
– Difficulty with sexual performance
– Fear of rejection
Prevention
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Universal precautions
Barrier methods
Syringe exchange and pharmacy access
Post-exposure prophylaxis
Pre-exposure prophylaxis
Prevention and Older Adults
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Condom use
– Only 18% of HIV negative and 58% of HIV positive
sexually active men ages 49-80 said that “always”
wear condoms.
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Reasons for not using condoms
– No need to worry about pregnancy
– Loss of sensation and erectile dysfunction
– Uncomfortable talking about safer sex
– Sex under the influence of drugs and alcohol
Testing
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How long does it take after an HIV exposure
to receive a definitive HIV test result?
– 3 months
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Testing options
– Rapid testing
– Home test
– Testing sites
Testing in Older Adults
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HIV testing guidelines- informed consent
Annual blood draws
Role of health care provider
Sexual health history
Stigma
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More than half of HIV positive people (50-65)
practice “protective silence”
– Not telling others to manage stigma
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Social Stigmatization
– Ageism and HIV-related stigma
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Health care and social service providers
– Infantilizing “elderspeak”
– Violation of patient confidentiality
– Exclusion of patient from provider/family
discussion of patient care
Burden in Older Adults With HIV
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Creating a new life after bracing for death
Changing community activism
Financial
Worries of growing older alone
Housing and senior centers
The Traditional Service System
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Medical Care
Case Management
Housing
Financial Assistance
Transportation
Food Assistance
Benefits Counseling
Legal
Social and Support Groups
Employment
What is the HIV/AIDS Program?
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Located at the Department of Human Services
and called Program HH
Ryan White Part B Grantee for Minnesota
– ADAP Program administration
Funded through state, federal, and rebate
dollars
Payer of last resort
NOT an entitlement program – limited funding
What is ADAP?
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ADAP – AIDS Drug Assistance Program
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Part of the Ryan White HIV/AIDS Treatment
Extension Act 2009 (formerly Ryan White
CARE Act)
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Provides access to health care including:
drugs, insurance, dental care, mental health,
nutritional supplements, and case
management
Minnesota’s Ryan White Funding
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Part A – for care and supportive services
– Funding is limited to the target area including 11 metro
counties in Minnesota and two counties in Wisconsin
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Part B – for care and supportive services
– Funding is for the entire state
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Part C – for primary care
Part D – services specifically for women and
children
Part F – MATEC (provider training), oral
health, and special projects of national
significance (SPNS)
Minnesota’s Ryan White Funding
For 2012
 Part B (Administered by DHS)
$7.9 million
 Part A (Administered by Hennepin County)
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Part C (administered by HCMC and RAAN)
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Part D (Administered by West Side Clinic)
Additional Program Funding
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State funding – the State appropriates $1.2
million to supplement the insurance program
Rebate funding – as the ADAP administrator
Program HH submits rebate requests to
pharmaceutical companies for drug purchases
made on behalf of program participants
What is Program HH?
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Drug
Insurance Continuation
Dental Care
Nutritional Supplements
Mental Health
Case Management
Outreach, advocacy, and special projects
Who Qualifies?
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Must be HIV positive
Must be a Minnesota resident
Less than 300% of federal poverty guideline
Assets less than $25,000
Program HH Specifics
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Drug Program
– Pays for cost of ADAP formulary drugs in the form
of co-pay or full pay
Program HH Specifics
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Insurance Program
– Pays COBRA premiums
– Pays Minnesota Comprehensive Health
Association (MCHA) Premiums
– Pays Federal High Risk Insurance Plan
– Pays Medicare Supplement Policies– for Part D
client with no subsidy
– Does not cover office co-pays
Program HH Specifics
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Dental Program
– Pays for services provided by a Minnesota
Health Care Providers
– Pays for routine Dental care
– When necessary, covers dental services not
approved by Medical Assistance that is
medically necessary
– May need a prior authorization for services
Program HH Specifics
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Nutritional Supplement Program
– Prescribed by a registered dietitian
– Covers up to $100/month in supplements
– Based on Medical Assistance nutritional
supplement formulary
Program HH Specifics
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Outpatient Mental Health Program
– Includes individual, family, and group
therapy
– May provide additional services beyond
individual insurance plans when benefits
have been exhausted
– DSM-IV diagnosis code required
Program HH Specifics
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Case Management Program
– Funds statewide HIV-specific case
management programs in conjunction with
Hennepin County funded programs
– Tiered service delivery – levels of care
specific to individual need
– Training for case managers provided in
accordance with Standards of Care
developed
Contact Information
Minnesota Department of Human Services
Program HH
P O Box 64972
St Paul, MN 55164-0972
Phone: 651-431-2414 or 800-657-3761
Fax: 651-431-7414
Website: www.dhs.state.mn.us/hivaids