Special Concerns About HIV Infection in the Older Adult

Special Concerns About HIV Infection in the Older Adult Joseph S. Cervia, M.D., FACP, FAAP Associate Professor of Clinical Medicine and Pediatrics, Department of Medicine, Albert Einstein College of Medicine

The Problem • Prevalence of HIV infection and AIDS in older individuals (those over age 50) continues to grow • This phenomenon is felt to be related to both: 1. The longer survival of younger HIV-infected individuals, and 2. New infections of older individuals who do not appreciate their risk.

Epidemiology • The cumulative number of patients over age 50 with AIDS quintupled from 16,288 in 1990 to 90,513 by the end of December 2001. • Currently more than 60,000 persons over 50 living with AIDS in the U.S. • More than 50,000 have died in this age group since the beginning of the epidemic. Mack, K. et al. JAIDS 2003; 33(2):S68-S75

Why the Concern? • Despite engaging in behavior which puts them at risk for HIV, older adults are less likely to perceive themselves at risk and to adopt safer sexual and needle-sharing behavior. • Older adults are more likely to be diagnosed late in disease, experience progression more quickly, and survive for a shorter period than younger counterparts. Goodroad, B. J Gerontol Nurs. 2003; 29(4):18-24

What is the extent of the problem? • 11-15% of AIDS cases in the U.S. are in persons >50

Risk Behaviors • Despite myths and stereotypes, many older individuals remain sexually active, and homosexual contact remains the most common reported risk behavior in those over 50. • Intravenous drug use is the second most common risk factor, and receipt of blood products is third. • Many older individuals report no identified risk. This may reflect heterosexual transmission from at risk partners.

Sexual Risk • Americans over 50 are 1/6 as likely to use condoms during sex, and 1/5 as likely to have been tested for HIV as a comparison group of individuals in their 20’s. • Postmenopausal women are perceived to be at greater risk due to the increased likelihood of thinning and dryness of vaginal mucosa.

HIV Among Older MSM • HIV prevalence=19% for men in their 50’s and 3% for men in their 60’s • Prevalence for older African-American men=30% • High-risk sex between serodiscordant partners=4-5%

Immunological Risk • Naïve CD8+ cell depletion, • Diminished CD28 expression on CD8+ cells, and • Reduced thymic volumes are possible correlates of the interaction of age and HIV disease. Kalayjian, R. J Infect Dis. 2003;187(12):1924-33

Natural History • HIV infection progresses more rapidly in older individuals, and survival times are shorter. • 37% of persons >80 die within a month of AIDS diagnosis. Zaidi, S. Cervia, J. NY Chapter ACP-ASIM Newsletter 2002;2(2):4

Reasons for Poor Outcomes • Comorbid disease • Immunosenescence • Delay in diagnosis by unsuspecting providers and patients

Causes of Diagnostic Delay • Older individuals may not admit or even be asked about risk behaviors • HIV may go undiagnosed as the evaluation for more common conditions causing similar symptoms (such as cancer, infection, or organic brain syndrome) are pursued.

Immunological Factors • CD4+ cell counts decline more rapidly among persons >40 than among younger individuals. • Thymic activity begins to decline from about the fourth decade perhaps accounting for a more gradual recovery of CD4+ lymphocytes observed in some older individuals. • Nutritional deficiencies are also more common in older individuals, perhaps contributing to immunosuppression.

HAART in Older Adults • Recent studies indicate that age may not have a significant impact on the outcome of HAART. • This would strongly argue for an approach in which therapy in the older adult should be individualized according to the patient’s health status rather than age, per se.

Opportunistic Infections in Older Adults • The characteristic AIDS-defining opportunistic infections have similar prevalence rates regardless of age.

HIV-Related Metabolic Abnormalities in Older Adults • Higher risk of lipodystrophy, perhaps reflecting the role of age dependent modifications of lipid metabolism and insulin sensitivity in response to HAART.

Clinical Events More Common in the Older HIV-Infected Adult • Older age has been identified as an independent risk factor for severe hepatic injury in naïve patients beginning HAART. • HIV infection has been identified as a major risk factor for CVA, and is more frequent among older individuals. • Cognitive decline associated with HIV infection may also be noted more frequently in older patients.

Neurocognitive Morbidity • Most common is a diffuse, subacute encephalitis that causes progressive dementia (AIDS Dementia Complex, ADC) • ADC is manifested in 8.5% of those >50 compared to 5.2% of those 13-49 • ADC in the older individual must be differentiated from Alzheimer Disease or Parkinson Disease

ADC: Rapidly progressive Subcortical dementia Cognitive impairment may improve with HAART Alzheimer Disease: More gradual progression Cortical dementia No improvement with HAART ADC vs Alzheimer Disease

Case Presentation • 52 year-old computer technologist is hospitalized with progressive weakness and confusion over the past several weeks • 2 weeks ago visited a local ER and was diagnosed as “anemic” • Yesterday, he showed up for work on his day off. • He has been afebrile, and without headache, photophobia, or neck stiffness. No history of travel, pets or insect bites • He is oriented to person and place, but believes that it is “February” in June. • Examination is significant only for 3 well-defined perianal ulcerations.

Laboratory Data • MRI of head revealed multiple white matter signal abnormalities • CD4+=17

Diagnosis • HIV infection with Progressive Multifocal Leuko-encephalopathy (PML)

Denouement • The assessment of a newly demented patient or a patient with a clinical course that more rapid or less typical of a recognized primary neurodegenerative disorder may warrant serological testing for HIV. Zaidi, S. Cervia, J. NY Chapter ACP-ASIM Newsletter. 2002; 2(2):4

Clinical Pharmacology • Drug therapy for HIV infection is more challenging in older individuals due to: • Polypharmacy/Drug-drug interactions • Higher incidence of adverse effects • Altered pharmacokinetics with age

Addressing the Needs of the Older HIV-Infected Patient • Characteristics and care needs of the older HIV-infected population are very diverse and vary by exposure route: • Older gay men: Predominantly white, more likely to have health insurance, 38% employed, 48% with incomes >$25,000, good physical functioning and emotional support • Older IDUs: Predominantly African-American, 11% employed, 74% with income <10,000, low physical functioning and emotional support Crystal, S. JAIDS 2003; 33:S76-S83

Addressing Emerging Risk Factors • Finding sex partners on-line (34 million older internet users) • Late-onset crack use • Increasing travel and tourism among older adults

Resources • Seniors in a Gay Environment (SAGE) provides information and referrals • AARP Social Outreach and Support (SOS) offers programs on HIV/AIDS • Social Security Administration provides benefit programs

Recommendations • Providers must become educated on HIV risk behaviors and associated symptoms, and should offer HIV counselling and testing irrespective of a patient’s age. • Policy makers may need to consider expansion of recommendations for HIV counseling and testing to include elderly hospitalized patients, especially in high seroprevalence areas.

Recommendations (Continued) • Outreach workshops and training should should be implemented for older individuals and their caregivers in order to inform them about transmission risk and prevention of HIV. • Media and social marketing campaigns may be helpful in raising awareness and reinforcing the need for educational programs.

Recommendations (Continued) • Further research on HIV in older adults should be supported.

Special Concerns About HIV Infection in the Older Adult