HIV & Aging:The Greying of the HIV Pandemic

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HIV & Aging:The Greying of the HIV Pandemic Version date_092021 1 Conflict of interest disclosure statement Douglas A. Drevets MD, DTM&H, FIDSA Has no relevant financial relationships or affiliations with commercial interests to disclose. This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Under grant number U1OHA33225 (South Central AIDS Education and Training Center). It was awarded to the University of New Mexico. No percentage of this project was financed with non-governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government. 2 Gap 1: There are gaps in understanding the changing demographics of people with HIV Gap 2: There are gaps in understanding the impact of aging on co-morbidities in people with HIV. Professional practice gaps Learning objectives Review clinical vignettes and data illustrating key points of aging and HIV. Review the current epidemiology of HIV. Identify the impacts of changing demographics of HIV. 4 Clinical vignettes Acquisition of HIV infection after 55yrs of age Effective antiretroviral therapy (ART) and prolonged lifespan Clinical Vignette 1 60 yo man referred for HIV infection History Found to be HIV positive at age 59 on HIV screening prior to ureteral stent for nephrolithiasias Reported having 19units of blood 20yrs earlier after gunshot wound Multiple female sexual partners Denied IDU but some sex partners might have engaged in IDU CD4 244 cells/ml /8%, HIV VL 123,972 copies/ml Encounter Presented to the IDI as new patient with girlfriend who has HIV Refused to fill out paperwork to access HDAP due to fear of being reported to the IRS for not paying taxes IDU=injection drug use; IDI=infectious disease institute Clinical Vignette 1 Clinical Course 12 months later Febrile illness with malaise CD4 67 cells/ml /3%, HIV VL 302,000 copies/ml Serum Cryptococcal Ag 1:32, CSF neg Diagnosis catalyzed drug assistance and he was started on ART 2 months later CD4 93 cells/ml /4%, HIV VL <400 copies/ml Subsequently The next year started on a statin for hyperlipidemia 4 years later developed type 2 diabetes, mild hypertension, arthritis 20 years later CD4 504/21% with tweaks to ART and other meds Clinical Vignette 2 64 yo man presented to OSH with weight loss and confusion Illness leading to diagnosis Diagnosed with HIV/AIDS Cryptococcal meningitis CSF CrAg 1:256, culture C. neoformans CD4 33 cells/ml /4%, HIV VL 97,750 copies/ml Recent Medical History Dermatomal shingles 3 years prior Failing health, sinusitis and thrush after antibiotics Social History Married, heterosexual, denied high risk sexual behavior Had a mid-life crises in late 50's, turned to IDU meth and cocaine OSH=outside hospital Clinical Vignette 2 Seen in the IDI as a new patient 3 months later Clinical Noted nausea, and a rash on hairline, face, neck, and upper body BMI 26.0 Meds Tenofovir/emtricitabine/elvitegravir/cobicistat Trimethoprim-sulfamethoxazole (TMP/SMX) Fluconazole Azithromycin Labs CD4 82/6% HIV VL 22 copies/l Clinical Vignette 3 Clinical 69 yo man; generally well, self-cath, BMI 31.6 Meds Abacavir/lamivudine/dolutegravir, fluconazole, cetirizine, pregabalin, trazodone, ondansetron, finasteride, docusate Labs CD4 276/17%, HIV not detected by PCR Summary Stable on ART with good HIV VL suppression but delayed CD4 reconstitution Main difficulty is with urinary issues The greying of global HIV:People aged 50+ living with HIV by sex https://aidsinfo.unaids.org/ Number Females 50+ est. Males 50+ est. Numbers of people over the age of 50 living with HIV in 2020 >23,000 8,100 - 23,000 1,900 - 8,100 <1,900 No data Not reported here https://aidsinfo.unaids.org/ Demographic data in the USA, 2018 People with HIV 1,039,680 35.3% aged 55+ New HIV diagnoses 37,864 10.1% aged 55+ Mortality 15,819 56.2% aged 55+ https://aidsvu.org/local-data/united-states/ Rates of Persons, aged 55+, Living with HIV HIV+ over the age of 55 Proportion with a late HIV diagnosis Proportion linked to HIV care Proportion who received HIV care Proportion who were virally suppressed https://aidsvu.org/local-data/united-states/ A closer look at Texas, 2018 https://aidsvu.org/local-data/united-states/ Prevalence 91,764 people with HIV 24,317 (26.5%) 55+ yrs of age Incidence 4,388 new infections 338 (7.7%) 55+ yrs of age PrEP (Pre-exposure prophylaxis) 16,319 users of PrEP 1,294 (7.9%) 55+ yrs of age Mortality 1,308 deaths 590 (45.1%) 55+ yrs of age Rates of Persons, aged 55+, living with HIV Survival With HIV/AIDS: The Way It Was Median survival time of the first 505 patients diagnosed with HIV/AIDS in San Francisco was 11 months. Median survival time following AIDS onset in a prospective cohort of 2,647 men with HIV in Baltimore, Chicago, Los Angeles, and Pittsburgh. 11.6 months in 1984-1985 19.5 months in 1988-1989 17.2 months in 1990-1991 Bacchetti et al. J Infect Dis. 1988;157(5):1044-7 Jacobson et al Am J Epidemiol. 1993;138(11):952-64 Annual age-adjusted rates of death with HIV infection as the underlying cause, 19872018, United States https://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-surveillance-mortality-2018.pdf Changing demographics in our outpatient clinic IDI, OUHSC Data courtesy of M. Salvaggio % Patients in age group No Satisfaction: The effect of age + mileage Rolling Stones logo by John Pasche Keith & Mick: Then Keith & Mick: More recently Charlie Watts 1941-2021 Rising numbers of medical co-morbidities in an urban Ryan White-funded clinic 20 % Patients with condition Hypercholesterolemia Hypertension Diabetes Renal disease Coronary artery disease Vance et al., JANAC Vol. 22, No. 1, January/February 2011 Chronic disease onset among people with HIV in a large private insurance claims dataset Evaluated the magnitude of association of HIV infection on developing chronic conditions Controlled for: demographics, behavioral risk factors, chronic comorbidities Compared chronic disease risks between those with and without HIV for: Yang et al. Scientific Reportsvolume9, Articlenumber:18514(2019) Diabetes Hypertension Stroke Cancers Lung diseases Cardiovascular diseases Cognitive impairment Chronic disease onset among people with HIV and in a large private insurance claims dataset Interval Diabetes Hyper-tension Stroke Cancer Lung Disease Cardio-vascular Disease Cognitive Impairment/Dementia 2-year 1.30 1.13 1.28 1.44 1.26 1.30 1.66 (1.191.42) (1.061.20) (1.161.40) (1.311.58) (1.191.34) (1.201.40) (1.481.86) 5-year 1.44 1.22 1.43 1.44 1.25 1.38 1.56 (1.331.57) (1.131.31) (1.301.57) (1.311.58) (1.171.34) (1.281.49) (1.401.72) 10-year 1.45 1.36 1.45 1.37 1.33 1.37 1.73 (1.241.70) (1.171.58) (1.221.73) (1.151.64) (1.161.52) (1.191.58) (1.442.08) Yang et al. Scientific Reportsvolume9, Articlenumber:18514(2019) Chronic disease onset among people with HIV in a large private insurance claims dataset Conclusions HIV is statistically significantly associated with higher levels for all chronic illnesses examined Results were robust to multiple model specifications and duration of analysis (2, 5, and 10 years from enrollment) Yang et al. Scientific Reportsvolume9, Articlenumber:18514(2019) Prevalence of medical co-morbidities in Italian age-matched cohorts of PWH on ART and those without HIV https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0118531 Prevalence's of Co- & Multi-morbidities PWH 20.6 yrs (n= 404) PWH <11.3 yrs (n= 404) HIV negative (n= 2424) Association of HIV infection and cognitive impairment in older adults: A meta-analysis Deng et al. https://doi.org/10.1016/j.arr.2021.101310 Results from the meta-analysis of cognitive domain impairment Domain K (n of studies) Participants MD (95 % CI) p I2(%) Executive function 5 646 0.42 [-0.72, -0.11] 0.01 32 Processing speed 6 712 0.33 [-0.59, -0.08] 0.01 16 Verbal 5 666 0.29 [-0.48, -0.10] < 0.01 0 Recall 6 1010 0.24 [-0.38, -0.10] < 0.01 0 Working memory/Attention 6 1309 0.17 [-0.46, 0.22] 0.24 83 Motor/Psychomotor 5 967 0.38 [-0.59, -0.16] < 0.01 31 Visuospatial 3 449 0.31 [-0.88, 0.27] 0.30 88 Deng et al. https://doi.org/10.1016/j.arr.2021.101310 Conclusions: HIV & Aging Increasing numbers of older people with HIV with more medical co-morbidities Patients with HIV >55 yrs of age tend to be diagnosed later, but respond well to ART HIV infection accelerates / potentiates development of several common age-associated medical co-morbidities including cognitive impairment Resources National Clinical Consultation Center http://nccc.ucsf.edu/ HIV Management Perinatal HIV HIV PrEP HIV PEP line HCV Management Substance Use Management Present case on ECHO http://echo.unm.edu AETC National HIV Curriculum https://aidsetc.org/nhc AETC National Coordinating Resource Center https://targethiv.org/library/aetc-national-coordinating-resource-center-0 Additional trainings [email protected] www.scaetc.org https://hsc.unm.edu/scaetc/local-partners/ouhsc.html 28 Find an HIV TeleECHO clinic in your area: https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/ AETC National HIV Curriculum: 6 core modules for self study; regularly updated; CME, CNE 28