Download HIV infection in the older population

New On-Set HIV Among the
Older Population
Shelley Irving PA-S
Advised by Dr. Grimes
Terms
“older” and “elderly” in HIV/AIDS
literature refers to anyone 50 years of age or
older.
2 Reasons:
Lack of significant numbers
 Did not typically live past 50

The Problem
1991-1996 AIDS cases rose twice as fast
2004 saw a 7.3% increase from 2003 and a
9.2% increase from 2002.
Currently 10-15% of HIV/AIDS
National Association of HIV over fifty tip sheet; CDC Surveillance Reports
It is estimated that 24-27% of HIV cases go
unreported.
Limited research shows that the average age
of Dx is increasing over time.
Risk factors lead researchers to believe that
infection in the over 50 population will
increase.
Rhodes, 2005; Manfredi, 2002
Specific Risk Factors
Impotence medications
No perceived need for condom use
Physiological changes in older women
IV drug use – 8% over 50 yoa in 1988,
currently more than 17%
Lack of education about HIV
Blood transfusions received prior to 1985
Herndobler, 2006; Resnick, 2003; Linsk, 2000
Contributing Factors
Absence of education and prevention
campaigns
Social and Professional biases
Lack of screening and testing
Resource Allocation
Omission from research
Linsk 2000; NAHOF
New HIV testing
recommendations
In Sept. 2006, the CDC released revised
recommendations for HIV testing
Routine screening between the ages of 1364
Routine Screening of high risk patients at
least once a year
Does not recommend prevention counseling
at time of testing.
CDC
If Undiagnosed and Untreated
HIV will progress rapidly to AIDS and may
appear very much like:
Atherosclerotic Dementia
Alzheimer’s Disease
Parkinson’s Disease
Manfredi, 2002
Diseases Common in both Aging
and HIV infection
Peripheral Neuropathy
Herpes Zoster
Pneumonia
Any Opportunistic Infections
Manfredi, 2002
Signs and Symptoms common in
aging and HIV infection
Fatigue
Anorexia and Weight Loss
Skin rashes
Chronic Pain
Increased infections
Increased viral illnesses
Manfredi, 2002
When Should HIV be included in
the Differential Dx?
Anytime a patient presents with signs and
symptoms of Alzheimer’s or Parkinson’s
Disease with no family history.
Anytime an older patient presents with
psychotic symptoms or a mental illness with
no family history and no prior history.
Diagnostic Tools
The Gold Standard is the enzyme
immunoassay
Must confirm with a Western Blot test
before a diagnosis of HIV can be given
General Treatment Options
Standard Treatment is HAART regimen – a
min of three drugs from a min of two drug
classes:
Nucleoside Analogues
 Protease Inhibitors
 Non-nucleoside reverse transcriptase inhibitors


Manfredi, 2002
Treatment Goals
Maximize prolonged viral suppression
Improve immune system competence
Reduce complications and death
Improve quality of life
Manfredi, 2002
Benefits of HAART
Reduction in Opportunistic Infections
Reduction in Morbidity and Hospitalization
Reduction in Cost of Care
Reduction in Dementia
Manfredi, 2002; Dore & Cooper, 2006; Dolder, et al, 2004
Adverse Effects of HAART
Immunoreconstitution Syndrome
Non-Compliance causes resistance
Toxicity when used with other medications
Failure of multi-drug rescue regimens
Decrease effectivity of medications used
against opportunistic infections
Plethora of physiological disturbances
Manfredi, 2002; Dore & Cooper, 2006; Valcour, et al., 2005
Treatment Challenges
Patient non-compliance
Appropriate use of Available drugs
Preserve ability to use future tx options
Appropriate use and interpretation of
resistance testing
Exploitation of drug interactions
Prevent adverse effects and toxicity
Manfredi, 2002
Treatment Debate
Currently it is unknown if treatment is the
best choice for older individuals.
Research is ongoing to help provide an
answer to this debate
Pro-Treatment
Wellons, et al. 2002

Similar therapeutic interventions (HAART)
yielded similar outcomes regardless of age at
HIV infection
Anti-Treatment
Knobel, et al. 2001
Compared effectiveness of HAART between
patients 60 yoa and 40 yoa and younger
 After 24 months found no difference in
mortality, HIV-RNA levels, CD4 counts
 Higher rates of lipodystrophy in 60 yoa
 Older patients may be more prone to negative
side effects

Specific Treatment
Considerations
Life Expectancy
Patient’s desired Quality of Life
Ex: zidovudite and efavirenz have CNS side
effects of nightmares and hallucinations
Assess need for atypical antipsychotic
Psychosocial interventions – isolation,
rejection, fear
Dolder, et al. 2000
What Can We Do – Tips from NAHOF
Educate patients about transmission and prevention of the
disease.
Open up dialogue and assess risk – History!!!
Promote safe sexual and drug use practices.
Support research efforts.
Stay current on research results and recommendations for
screening and treatment.
Become aware of services in the community that may offer
support to older patients.
http://www.hivoverfifty.org/index.html
References
Centers for Disease Control and Prevention. (n.d.). CDC surveillance reports. Retrieved October 14, 2006, from,
http://www.cdc.gov/hiv/topics/surveillance/resources/ reports/2004report/table1.htm
Dolder, C. R., Patterson, T. L., Jeste, D. V. (2000). HIV, psychosis and aging: past, present and future. AIDS,
18(suppl 1), S35-S42
Harris, M.J., Jeste, D.V., Gleghorn, A., Sewell, D.D. (1991). New-onset psychosis in HIV-infected patients. Journal of
Clinical Psychiatry, 52, 369-376.
Herrndobler, K. (2006, August 27). Sex medications fuel HIV in the elderly. The
Beaumont Enterprise. Retrieved
August 30, 2006, from http://www.southeasttexaslive.com
Knobel, H., Guelar, A., Valldecillo, G. Carmona, A, Gonzalez, A., Lopez-Colomes, J.L.,et. al. (2001) Response to
highly active antiretroviral therapy in HIV infected patients age 60 years or older after 24 months of follow-up. AIDS,
15, 1591-1593.
Linsk, N. L. (2000). HIV among older adults: age-specific issues in prevention and treatment [Electronic version].
AIDS Read, 10(7), 430-440.
Manfredi, R. (2002). HIV disease and advanced aging: An increasing therapeutic challenge [Electronic version].
Drugs Aging, 19(9), 647-669.
National Association on HIV Over Fifty. (Last Revised February 6, 2007). Educational Tip Sheet: HIV/AIDS and
Older Adults. Retrieved February 10, 2007, from http://www.hivoverfifty.org/tip.html
Resnick, Barbara. (2003). Risky behaviors in older adults. Highlights of the National Conference of Gerontological
Nurse Practitioners. Retrieved September 5, 2006, from http://www.medscape.com/viewarticle/464727.
Wellons, M.F., Sanders, L., Edwards, L.J., Bartlett, J.A., Heald, A.E., Schmader, K.E. (2002). HIV infection:
Treatment outcomes in older and younger adults. Journal of American Geriatric Society, 50, 603-607.
References Continued
Valcour, V.G., Shikuma, C.M., Shiramizu, B.T., Williams, A.E. Grove, J.S., Seines, O.A., et al. (2005). Diabetes,
Insulin Resistance, and Dementia Among HIV-1-Infected Patients. Journal of Acquired Immune Deficiency
Syndromes, 38(1), 31-36.
Dore, G. J., & Cooper, D. A. (2006, August 5). HAART’s first decade:success brings further
challenges. The Lancet, 368, 427-428.
National HIV Prevention Conference (2005, June). Estimated HIV prevalence in the United States at
the end of 2003 (Abstract 595). Atlanta, GA: Glynn M. & Rhodes
P.
Questions?