Optimal Wellness

1. Optimal Wellness December 13, 2012 For Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

2. Welcome & Overview- 5 mins Optimal Wellness for People Living with HIV: The Challenges of Success – 30 mins Panel Discussion on Optimal Wellness, 20 mins Wrap-up & Evaluation, 5 mins Agenda Michael Hager in+care Campaign Manager National Quality Center New York, NY michael@nationalqualitycenter.org Conversation opportunities throughout webinar

3. Welcome & Overview • This Partners in+care webinar is offered as part of the in+care Campaign. • The in+care Campaign is a national effort to improve retention in HIV care. • Webinars are one of many Partners in+care activities designed to engage people living with HIV/AIDS and their allies in the in+care Campaign. For more information: www.incarecampaign.org

4. This is a “public event.” If you have confidentiality concerns: Your names appear on-line in the list of webinar registrants -consider just listening to the audio or to viewing the webinar at a later time, after it is posted at www.incarecampaign.org. Or, consider using an alias when entering as a guest All webinars are recorded - do not use identifying information when asking questions Participation Guidelines For Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

5. Actively participate and write your questions into the chat area during the presentation; we will also have a “pop up” question exercise, and will pause for conversation during the webinar Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) The slides and recording of this and other Partners in+care webinars are available for playback and group presentations at www.incarecampaign.org – “Resources” tab Participation Guidelines For Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

6. Learning Objectives At the end of this webinar you will know: • Wellness concerns for aging people living with HIV • Emerging trends for this population related to wellness and HIV • Tools and Resources for supporting aging persons living with HIV

7. The Aging Community Pop-up Question Is your clinic seeing a rise in the number of Persons Living with HIV over 50 years old? Yes No I am not HIV+ Visit www.incarecampaign.org

8. Optimal Wellness Pop-up Question Do you think your clinic is adequately addressing the needs of Aging Persons Living with HIV? Yes No I don’t know Visitwww.incarecampaign.org

9. Optimal Wellness for People Living with HIV; The Challenges of Success • Purpose of today’s webinar • Review the epidemiology of aging with HIV • Provide information about the impact of comorbid physical and mental health conditions among those aging with HIV • To relate this information to the care needs of this population with a focus on optimal wellness • Mark Brennan-Ing, PhD • Senior Research Scientist • AIDS Community Research Initiative of America (ACRIA): • ACRIA Center on HIV & Aging • New York University College of Nursing

10. ACRIA is a CENTER OF EXPERTISE (COE) • The New York State Dept. of Health AIDS Institute Funds ACRIA to serve as a COE on Aging and HIV, STD’s and Hepatitis • COES are designated as experts in a specific topic and travel throughout New York State to offer specialized trainings • ACRIA develops training programs that: • Build HIV and Aging Service Providers skills to improve the clinical status of people living with HIV • Delivers trainings for human service providers • Provides on-line distance learning opportunities • Offers capacity building and technical assistance opportunities

11. EPIDEMIOLOGY

12. Why is the HIV Population Graying? • With the advent of successful anti-retroviral therapies, adults 50 and older will be the majority of people living with HIV in the U.S. by 20151 • However, part of this growth is new infections, with adults 50+ accounting for approximately 11% of all new HIV infections 1 United States Senate Special Committee on Aging. HIV over Fifty: Exploring the New Threat. [Web cast]. May 12, 2005. Available at http://aging.senate.gov/hearing_detail.cfm?id=270655&. 2 Brooks et al. (2012). (Am J Public Health. Published online ahead of print June 14, 2012: e1–e11. doi:10.2105/AJPH. 2012.300844.

13. Impact of HAART 9 8 Mortality (x 1000) 7 6 5 4 3 PLWHA (x 10,000) 2 1 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 HAART Source: NYC Dept of Health & Mental Hygiene, 2004

14. Persons Living with HIV/AIDS By Age, New York State, end of year, 2002 and 2008* Source: NYSDOH BHAE * 2008 data are provisional 2008 N=124,782 2002 N=102,464

15. Persons Living with HIV/AIDSBy Age, New York State, end of 2008* 74.8% of PLWHA are 40 and older (93,426) * 2008 data are provisional (N=124,782) Source: NYSDOH BHAE

16. A National Trend % of People with HIV Age 50 and Older 2009-2010 40 % and more 30-39 % 20-29 % 19 % and less

17. The Challenges of Success; Aging, HIV & Multimorbity

18. Background • People with HIV on HAART are being treated successfully as evidenced by viral suppression • However, those who are ageing with the virus are experiencing a variety of non-HIV/AIDS conditions • AIDS-defining conditions are becoming less common • CD4 t-cell counts are still related to morbidity and mortality in this population • i.e., those with low CD4 counts and high viral load more likely to experience both AIDS-defining and non-AIDS defining health problems

19. Prevalence of Co-morbidities • Data obtained from Research on Older Adults with HIV (ROAH) • Adults 50 and older living with HIV (n = 914) • Average age of 55.5 years • Approximately one-third are women • Fifty-percent African-American/Black, 33% Latino • Living with HIV 12.6 years on average • 85% on HAART • 51% with AIDS diagnosis • 67% identified as heterosexual

20. Comorbidities in ROAH

21. ROAH: Distribution of Comorbidity

22. Comorbidity Comparison: ROAH & Older Adults

23. Depression (52%) • The most frequently reported comorbid condition • Depression is often related to: • Prior history of depression • Presence of physical illness • Comorbid psychiatric and substance use issues • Chronic stress • History of trauma/abuse • HIV stigma • Loneliness and Social Isolation

24. Depression Assessment in ROAH • Depressive symptomatology measured with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) • CES-D: 20-item self-report scale referring to symptoms experienced in the previous week; 4 items are reverse coded to prevent response-bias • Responses scored on a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time) • Items are summed to obtain a total score with range of 0 to 60; higher scores indicate greater level of depressive symptoms (α = .90 for ROAH sample)

25. CES-D Symptoms of Depression

26. Depression in ROAH vs. Other Older Adults

27. Depressive Symptoms and Conditions Source: Havlik, R. J., Brennan, M., & Karpiak, S. E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8(4), 551-559. DOI:10.1071/SH11017

28. Depression Predicts Comorbidity Source: Havlik, R. J., Brennan, M., & Karpiak, S. E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8(4), 551-559. DOI:10.1071/SH11017

29. Treatment and Care Issues

30. Multi-Morbidity Management

31. Treatment Strategies for Older Adults with HIV http://www.aahivm.org/Upload_Module/upload/HIV%20and%20Aging/AAHIVM%20Executive%20Summary%20FINAL%202.pdf

32. What is Patient Retention • Retention in care is typically measured in three ways: • A) Missed appointments • B) Medical visits at regular intervals • C) Combination of A & B Horstman, E., Brown, J., Islam, F., Buck, J., & Agins, B. D. (2010). Retaining HIV-infected patients in care: Where are we? Clinical Infectious Diseases, 50, 752-761.

33. Why is Care Retention Important? • HIV patients in regular care are more likely to adhere to HAART • Non-adherence to HAART linked to poor health outcomes as well as the development of treatment-resistant strains of HIV • High prevalence of multi-morbidity warrants regular engagement with health providers and screening to detect conditions early • Keeping HIV-patients engaged in care is cost effective due to fewer emergency room visits and hospitalizations

34. Are HIV+ Patients in Care? • Missed appointment rates are 25% to 30% regardless of which types of appointments are included • Proportion of HIV patients missing at least one appointment is 25% to 44% depending on time frame • Average rate of retention in New York State was 72%, ranging from 20% to 100% in ambulatory clinics based on self-report (NYS DOH) • Continuum Engagement Model research finds: • Regular users (25%) • Sporadic users (32%) • Non-engagers (43%)

35. Clinical Retention Factors: • Poorer retention is associated with: • Higher CD4 cell counts • Not having an AIDS diagnosis (i.e., CD4 < 200 or presence of opportunistic infection) • Detectable Viral Load and AIDS defining CD4 count • While seemingly contradictory, patients may skip appointments if they are feeling well (1 & 2) or if they are ill (3) • Poor health may be due to missed appointments in a reciprocal manner

36. Other Retention Factors • Other factors related to poor retention: • History or current injection drug use • Low perceived social support • Less engagement with health care provider • Shorter follow-up after initial appointment • Unemployment • Mental/psychiatric illness • Child care • Transportation • Hospitalization • “Other” (i.e., forgot, last minute social engagement, etc.)

37. Benefits of Care Retention • Keeping HIV+ Patients in Care has been found to: • Increase access to ARVs • Improve Treatment Adherence • Suppression of Viral Load • Improved Immune Function • Less Drug Resistance • Reduced Health Care Costs (i.e., fewer ER and Inpatient visits) • Less Risky Sexual Behavior • Improved Survival Rates

38. National Minority AIDS Council's Model for HIV prevention and care * • Model is to move PLWHA along the treatment cascade so that 81% of people living with HIV in the U.S. know their HIV status and have a suppressed viral load • This model asks Health Departments and Community Based Organizations (CBOs) to: • Identify people who do not know they are HIV positive • Increase linkage to and retention of PLWHA in high-quality care • Improve treatment adherence among PLWHA to achieve a suppressed viral load * based on modeling done by Dr. David Holtgrave

39. Current Treatment Cascade Source: Dr. Ronald Valdiserri, Centers for Disease Control (CDC) U.S.A.

40. Optimal Wellness Through Care Retention: Federal and State Efforts

41. in+care(http://www.incarecampaign.org) • National campaign for Ryan White grantees supported by HRSA HIV/AIDS Bureau in coordination with the National Quality Center • Goal is to support and provide resources to providers seeking to improve care retention: • Data collection and reporting • Webinars • One-on-one coaching • Local retention groups led by local quality champions • Partners in+care consumer education

42. NY Links • Supported by a Special Project of National Significance award to New York State to address system linkages and care access for those with HIV • Goal is to develop and disseminate effective linkage and retention models • Community-level improvement approach • Outcome of better health for people with HIV and reduced HIV transmission • Other SPNS Grantees for this project • Pennsylvania, Virginia, Massachusetts, North Carolina, Louisiana, and Wisconsin

43. The Importance of Mental Health

44. Depression, Treatment Adherence & Care • Over 2/3 of the study group had moderate to severe depression • Depression Causes Non-Adherence to ALL Medication • including HIV Meds • Although in Medical Care their • Depression Remains Unmanaged

45. Co-occurence1 • A triple diagnosis (HIV + mental illness + substance use) impairs a person’s well-being and quality of life significantly • Patients with triple diagnosis often have higher levels of distress and physical impairment compared to individuals with no diagnosis, or a psychiatric, or a substance use disorder alone (Lyketsos, et al., 1994) • The interaction between the mental health and substance abuse problems escalate both the level of risk, and the severity of HIV (Stoff et al., 2004) 1 HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx

46. Substance Use Complicates HIV Care • Substance and alcohol use among persons living with HIV is associated with: • other mental health issues like depression (Pence et al.) • poor adherence to antiretroviral therapy (Chesney, 2000; Ware et al., 2005) • greater risk for HIV infection (Leigh & Stall, 1993; Semaan et al., 2002) • Alcohol and substance use can decrease the efficacy of antiretroviral therapy (Michel, Carrieri, Fugon et al., 2010)

47. Substance Use in ROAH • ROAH respondents were asked about current and lifetime use of tobacco, alcohol and other substances

48. ROAH: Tobacco Use Current History 57 % 84 % • Tobacco use is associated with increased rates of cardiac disease, respiratory conditions, and cancers • Smoking cessation efforts are needed to insure optimal wellness for those who use tobacco and are aging with HIV

49. Alcohol and Substance Use: ROAH 0% 40% 80%

50. Treat the Person, Not the Disease • Successful care of those with triple diagnosis requires a holistic approach provided by an interdisciplinary, culturally sensitive clinical team (i.e., case managers, social workers, medical providers, counselors or therapists, and psychiatrists) • Optimally, medical, dual diagnosis, and psychosocial services should be easily accessible at the same location. • Integrated care should include: • Access to ancillary services; • Deliver multidisciplinary provider collaboration; • Client-centered approach; and, • Incorporates substantial efforts to connect patients to case management services to address a variety of psychosocial needs (homelessness, poverty, and treatment adherence) 1 HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx