The Medical and Social Challenges of Aging with HIV

1. Alison Moore, MD, MPH, FACP Professor of Medicine and PsychiatryDavid Geffen School of Medicine at UCLADivision of Geriatric Medicine Homero E. del Pino, PhD Assistant Professor Charles R. Drew University Psychiatry and Human Behavior Adjunct Assistant Professor David Geffen School of Medicine Division of Geriatric Medicine & Psychiatry and Biobehavioral Sciences The Medical and Social Challenges of Aging with HIV African American HIV University Science and Treatment College Black AIDS Institute September 9, 2014

2. Objectives By the end of this session, you will be able to • Explain the medical and psychosocial challenges of aging with HIV • List two challenges for African-Americans aging with HIV • List two consequences of at-risk drinking for older people with HIV • Think about qualitative research analysis

3. What is aging? • Video (http://bit.ly/ZfkEA5)

4. Agenda • Aging and HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

5. Agenda • Aging and HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

6. HIV in Older Populations • CDC estimates that 15% of new HIV cases occur in people 50 years old and older • By 2015, half of people living with HIV will be 50 years old and older  • Rates of HIV/AIDS among 50+ • Whites 4.2/100K • Hispanics 21.4/100K (5 x Whites) • Blacks 51.7/100K (12 x Whites)

7. Aging with HIV • 50 years of age is considered “older” because: • HIV infection may “accelerate” the aging process • Evidence of earlier onset of age-related disease states. • HIV associated with non-AIDS comorbidities such as diabetes mellitus and coronary heart disease, depression, non-AIDS cancers, etc. • Complex cases of cognitive impairment

8. Agenda • Aging with HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

9. Aging with HIV Bridelee Gittens, 48 Living with HIV: 22 years “AIDS is different than before. It’s not Kaposi’s sarcoma and PCP. Now it’s more diabetes and heart disease, high blood pressure and cancers. That’s what’s going on now. The disease has evolved.” http://www.nytimes.com/interactive/2013/06/02/nyregion/faces-of-hiv.html?_r=0

10. Aging comorbidities Neurodegeneration, memory loss Osteoporosis Macular degeneration, hearing loss Heart disease Vascular disease Sarcopenia, frailty Diabetes, metabolic syndrome Decreased lung, kidney, etc function Slide adapted from Judith Campisi, PhD

11. How HIV Impacts Successful Aging Vance, et. al. Successful Aging and the Epidemiology of HIV. Clinical Interventions in Aging. 2011:6 181-192

12. Agenda • Aging with HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

13. Prevention and Screening Challenges • Many older adults do not practice safe sex • Impact of ageism, discrimination, & stigma • Healthcare professionals may underestimate risk

14. Initiating and Maintaining Care • Better medication adherence • With increased number of comorbidities, higher risk for polypharmacy and drug-drug interactions. • Higher risk for social isolation

15. Implications for African-Americans • Little data on issues specific to aging in African-Americans but given higher rates of HIV infection in younger age groups, this emerging population will pose challenges and successes.

16. Agenda • Aging with HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

17. Low Risk Drinking Guidelines for Healthy Adults 1 drink= 12 oz. of beer, 5 oz. of wine, 1.5 oz. spirits Low risk drinking Men aged < 65 years: No more than 14 drinks per week and no more than 4 drinks on any single day. Women aged < 65 years: No more than 12 drinks per week and no more than 3 drinks on any single day. Women and Men aged >65 years: No more than 7 drinks per week and no more than 3 drinks on any single day.

18. Alcohol Use and Aging • Increased brain sensitivity to alcohol and increased blood alcohol levels for a given dose compared to younger persons • Alcohol, even at “low risk” levels, may adversely affect a variety of medical and psychiatric conditions and impact negatively with a variety of medications

19. Alcohol Use and HIV • Alcohol use associated with nonadherence • Alcohol use decreases survival • Lifetime prevalence of alcohol use disorder two to three times higher than the general population

20. Agenda • Aging with HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

21. Qualitative Research • Emphasis on “meaning” that participants place on behaviors • Tries to answer “why” people do what they do • Cannot be generalized

22. Research Background In the social world, some gay men experience: • Family rejection, stigma, and discrimination • Greater psychological distress and psychiatric morbidity • Alcohol used to cope

23. Significance & Aim • Stigma, stress, discrimination threaten recovery • Negative health outcomes • AIM: To describe how HIV+, middle-aged gay men in recovery cope with ongoing stigma and stress

24. Example “I just had this guilt… and shame because of the way I was brought up, and the prejudices of being, you know, my being Latino and being gay in Pasadena, California at that time.” Amino, Latino, 59 years old “I didn’t know that I was queer, gay, homosexual or any of those words. I just knew that I was attracted to guys from …a very young age. And… religion and people crippled me by things that they said and things that I’ve heard.” Junior, Latino, 51 years old

25. Questions Based on these men’s experiences, • What does it mean to feel stigmatized? • How do the men’s coping abilities change? • What programmatic changes should we consider to support middle-aged gay men in their recovery efforts?

26. Review Agenda • Aging and HIV • Aging comorbidities • Prevention and Care Challenges • Aging, Alcohol Use, and HIV • Current Research

27. Acknowledgements • National Institute on Aging: P30-AG021684. UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) • National Institute on Aging: P30-AG028748. UCLA Older Americans Independence Center • National Center for Research Resources/National Center for Advancing Translational Science: UL1TR000124. UCLA CTSI • National Institute for Minority Health and Health Disparities: U54MD007598. CDU-AXIS

28. Contact Information • Alison A. Moore, MD, MPH, FACP aamoore@mednet.ucla.edu • Homero E. del Pino, PhD hdelpino@mednet.ucla.edu

29. Resources • Administration on Aging website • http://www.aoa.gov/AoARoot/AoA_Programs/HPW/HIV_AIDS/ • Thebody.com

30. References • CDC. HIV/AIDS among Persons Aged 50 and Older. 2008 • Greene et. al. Management of Human Immunodeficiency Virus in Advanced Age. JAMA. 2013; 309(13):1397-1405 • Effros RB, Fletcher CV, Gebo K, et al. Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis. 2008;47(4):542-553. • Youle M and Murphy G. Coming of Age: a guide to ageing well with HIV. HIV Research and Training Institute. http://www.natap.org/2011/PDF/ComingAgeBook.pdf Accessed July 12, 2013. • Sankar A, Nevedal A, Neufeld S, et al. What do we know about older adults and HIV? A review of social and behavioral literature. AIDS Care. 2011;23(10):1187-1207. • Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health. 2013;103(3):e7-e15. • Rowe, et. al. Successful Aging. The Gerontologist. Vol. 37, #4, 433-440 • Moore AA, Blow FC, Hoffing M, et al. Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial. Addiction. 2011;106(1):111-120. • Weathermon R, Crabb DW. Alcohol and medication interactions. Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism. 1999;23(1):40-54. • Moore AA, Giuli L, Gould R, et al. Alcohol use, comorbidity, and mortality. J Am Geriatr Soc. 2006;54(5):757-762.

31. References • Vance, et. al. Successful Aging and the Epidemiology of HIV. Clinical Interventions in Aging. 2011:6 181-192 • Moore AA, Beck JC, Babor TF, et al. Beyond alcoholism: identifying older, at-risk drinkers in primary care. J Stud Alcohol. 2002;63(3):316-324. • Fink A, Morton SC, Beck JC, et al. The alcohol-related problems survey: identifying hazardous and harmful drinking in older primary care patients. J Am Geriatr Soc. 2002;50(10):1717-1722. • Barnes AJ, Moore AA, Xu H, et al. Prevalence and correlates of at-risk drinking among older adults: the project SHARE study. J Gen Intern Med. 2010;25(8):840-846. Effros RB, Fletcher CV, Gebo K, et al. Aging and infectious diseases: workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis. 2008;47(4):542-553. • Youle M and Murphy G. Coming of Age: a guide to ageing well with HIV. HIV Research and Training Institute. http://www.natap.org/2011/PDF/ComingAgeBook.pdf Accessed July 12, 2013. • Saag MS. HIV now firmly established in the Middle Ages. Clin Infect Dis. 2011;53(11):1140-1142. • Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health. 2013;103(3):e7-e15.