HIV and the Older Patient Part 2

1. I. Jean Davis, PhD, PA, AAHIVS Howard University College of Medicine HIV and the Older PatientPart 2

2. Howard University CMEAccreditation Sponsor Accreditation: Howard University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credits for Physicians: Howard University College of Medicine, Office of Continuing Medical Education, designates this live activity for a maximum of 0.5 AMA PRA Category I Credit(s)TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. Funded by Health Resources Services Administration (HRSA) Grant #H4AHA24081 Goulda A. Downer, PhD, RD, LN, CNS – Principal Investigator/Project Director

3. CME Disclosures: Planning Committee and Speaker AETC-Capitol Region Telehealth Project  Planning Committee : The following committee members have nothing to disclose in relation to this activity: Keith W. Crawford, RPH, PhD I. Jean Davis, PhD, PA, AAHIVS Goulda A. Downer, PhD, RD, LN, CNS John I. McNeil , MD  Denise Bailey, MEd   Marjorie Doulas-Johnson, BA Speaker: The following speaker has nothing to disclose in relation to this activity: I. Jean Davis, PhD, PA, AAHIVS

4. Howard University CMEAccreditation Requirements for Internet Viewers Intended Audience: Low volume clinicians (i.e. those with fewer than 25 patients in their case load who are HIV positive): Physicians, Physician Assistants, Nurse Practitioners, Pharmacists, Dentists Webinar Requirements: A computer with Internet accessibility and a telephone line • Your presence on the call must be acknowledged at the start of each session. Please announce your name loud and clear, as well as sign in on the computer for the attendance list • You will not be able to receive CME credit if you leave the call early • At the end of the Webinar, please send an email to email: mdouglas@howard.edu and the Training Coordinator will send you the CME Evaluation Survey to fill in. • You must fill out the emailed survey at the end of each session in order to receive CME credit. It can be scanned and emailed back to mdouglas@howard.edu , or it can be faxed to: AETC-Capitol Region Telehealth Project (FAX#: 202.667.1382) • ATTN: Training Coordinator

5. I. Jean Davis, PhD, PA, AAHIVS Howard University College of Medicine HIV and the Older PatientPart 2

6. Objectives At the end of this webinar the participating providers will have an enhanced ability to: • Describe the epidemiology of HIV in the population over 50 • Explain the Delays in diagnosis due to unsuspected HIV infection • Describe the Age-related differences in immune responses to HIV antigens • Understand the Special Consideration Involving the Care of this Population • Identify behavioral health challenges that can put older Americans at greater risk for HIV infection, co-occur with HIV infection, and hinder access to treatment and maintenance in care

7. Clinical Case Study #1 Mr. Ray Singles is a 70 year old mixed race male who appears to be younger than stated age. He is a retired attorney. He was born in California. He moved to the DC Area 28 years ago, where he met his third, fourth and fifth wife. He admits to sexual activity with other women throughout his marriages. He admits rare sexual activities with men while in California with increased activity when he moved to the DC Area. Mr. Singles presented 3 months ago with a 2 week history of penile discharge, oral, penile and anal lesions. Diagnosis was GC and HSV Type 2. Lab results positive for a VL of 94,000 copies/mL, CD4 cell count of 280 cells/mm3, estimated CrCl of 97mL/min and total cholesterol of 268. Co-morbidities: hypertension, diabetes, and obesity. Lifestyle considerations: multiple sex partners (male and female), long term smoker, family history of cardiovascular disease

8. Overview • Epidemiology • Prevalence of HIV increasing among older adults • HIV patients living longer, aging • Older adults are sexually activity • Prevention • Reduction in provider bias • Patient education and screening for all STDs • Biology • HIV patients age more rapidly than HIV negative controls • HIV and aging may share link with chronic inflammation • Treatment Considerations • Consider starting older patients on ART earlier • Attention to co-morbidities, vascular disease important

9. Overview • Secondary to the advancement in pharmacological therapies and a greater focus on patient centered care with a holistic point of view, including the importance of nutrition, physical activity and psychosocial issues, a greater prevalence of HIV-infected individuals over the age of 50 is projected • This epidemiologic trend is expected due to longer survival of HIV-infected patients on antiretroviral therapy, the sexual activity status of adults over 50 and to increased case findings due to wider HIV testing

10. Overview • HIV infection in the older patient (age greater than 50 years) is associated with: • Delays in education or screening due to provider prejudgment • Delays in diagnosis due to unsuspected HIV infection • Age-related differences in immune responses to HIV antigens leading to a less robust clinical outcomes • Issues specific to an aging population, such as neurological, cardiovascular disorders, diabetes, low testosterone, osteoporosis need to be addressed in the older HIV-infected patient

11. cdc.gov

12. New diagnosis of HIV most common in 15-64 year old range • Significantly increased survival in persons with HIV in last 15 years • Large population of patients with HIV surviving to older age groups

13. 44,491 HIV infected patients in US/Canada • 1997-2007: proportion of pts > 50 years old presenting for HIV care increased from 17% to 27% • Median CD4 count lower in > 50 year olds than younger pts • AIDS diagnosis at or within 3 months of presentation • <50 years old: 10% • >50 years old 13% Althoff et al. AIDS Research and Therapy 2010 7:45.

14. Sex Not Only for the Young • Limited information on sexual behavior in older adults and how sexual activities change with aging and illness • Large market for medications/devices to treat sexual problems targets older adults • National sample of 1550 women, 1455 men ages 57-85 • Response rate 75% Lindau ST. NEJM 2007; 357:762.

15. Older adults often sexually active • Prevalence of sexual activity declined with age • Women less likely than men to report sexual activity • 14% men took medication to aid sexual activity • Poor health associated with decreased sexual activity, sexual problems Lindau ST. NEJM 2007; 357:762.

16. Why Older Persons Acquire STIs (including HIV) • Lack of awareness of STD/HIV risk factors • Recently divorced or widowed • Menopause • No pregnancy risk, little condom use • Increased vaginal mucosal trauma/risk • Unprotected intercourse: less condom use in this generation associated with birth control pill as their primary mode to prevent pregnancy • Viagra: increased sex among older adults • Lack of HIV prevention services for older persons • Healthcare providers don’t consider older adults at risk • Providers not recognizing that 60 is the new 40 and the prevalence of cross generational sexual activities

17. eRounds: Case Study Discussion

18. Clinical Case Study #1 Mr. Ray Singles is a 70 year old mixed race male who appears to be younger than stated age. He is a retired attorney. He was born in California. He moved to the DC Area 28 years ago, where he met his third, fourth and fifth wife. He admits to sexual activity with other women throughout his marriages. He admits rare sexual activities with men while in California with increased activity when he moved to the DC Area. Mr. Singles presented 3 months ago with a 2 week history of penile discharge, oral, penile and anal lesions. Diagnosis was GC and HSV Type 2. Lab results positive for a VL of 94,000 copies/mL, CD4 cell count of 280 cells/mm3, estimated CrCl of 97mL/min and total cholesterol of 268. Co-morbidities: hypertension, diabetes, and obesity. Lifestyle considerations: multiple sex partners (male and female), long term smoker, family history of cardiovascular disease

19. Clinical Case Study #1Let’s Talk • Mr . Ray Singles is a 70 year old; Appears to be younger than stated age; Retired attorney • Sexual activity with other women throughout his marriages • Admits to rare sexual activities with men while in California; Increased activity when he moved to the DC Area • Presenting symptoms: penile discharge, oral, penile and anal lesions • Initial diagnosis: GC and HSV Type 2 • Lab finding: Positive for GC, HSV2, Syphilis and anal pap HPV VL OF 94,000 copies/mL , CD4 cell count of 280 cells/mm3, estimated CrCl of 97mL/min , total cholesterol of 268, LDL 190 and HDL 78, A1c 4 • Co-morbidities: hypertension, diabetes, and obesity • Lifestyle considerations: multiple sex partners (male and female), long term smoker, family history of cardiovascular disease • Pt had a 2 week follow-up visit schedule but did not return due to travel to California and vacationing in South America.

20. Questions?

21. Resources • www.aetcnmc.org • www.capitolregiontelehealth.org

22. Howard University HURB 1 1840 7th Street NW, 2nd Floor Washington, DC 20001 202-865-8146 (Office) 202-667-1382 (Fax) At the end of the Webinar, please email Ms Douglas-Johnson at mdouglas@howard.edu and she will send you the CME Evaluation Survey to fill in. www.capitolregiontelehealth.org www.aetcnmc.org