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 medicationsNo perceived need for condom usePhysiological changes in older womenIV drug use – 8% over 50 yoa in 1988, currently more than 17%Lack of education about HIVBlood transfusions received prior to 1985Herndobler, 2006; Resnick, 2003; Linsk, 2000

Contributing Factors

Absence of education and prevention campaignsSocial and Professional biasesLack of screening and testingResource AllocationOmission from research

Linsk 2000; NAHOF

New HIV testing recommendations

In Sept. 2006, the CDC released revised recommendations for HIV testingRoutine screening between the ages of 13-64Routine Screening of high risk patients at least once a yearDoes 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

FatigueAnorexia and Weight LossSkin rashesChronic PainIncreased infectionsIncreased 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 medicationsFailure of multi-drug rescue regimensDecrease effectivity of medications used against opportunistic infectionsPlethora of physiological disturbancesManfredi, 2002; Dore & Cooper, 2006; Valcour, et al., 2005

Treatment Challenges

Patient non-complianceAppropriate use of Available drugsPreserve ability to use future tx optionsAppropriate use and interpretation of resistance testingExploitation of drug interactionsPrevent adverse effects and toxicityManfredi, 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, fearDolder, 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-S42Harris, 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?