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New On-Set HIV Among the Older Population
Shelley Irving PA-S
Advised by Dr. Grimes
Terms
“older” and “elderly” in HIV/AIDS literature refers to anyone 50 years of age or older.
2 Reasons: Lack of significant numbers Did not typically live past 50
The Problem
1991-1996 AIDS cases rose twice as fast
2004 saw a 7.3% increase from 2003 and a 9.2% increase from 2002.
Currently 10-15% of HIV/AIDS
National Association of HIV over fifty tip sheet; CDC Surveillance Reports
It is estimated that 24-27% of HIV cases go unreported.Limited research shows that the average age of Dx is increasing over time.Risk factors lead researchers to believe that infection in the over 50 population will increase.Rhodes, 2005; Manfredi, 2002
Specific Risk Factors
Impotence medicationsNo perceived need for condom usePhysiological changes in older womenIV drug use – 8% over 50 yoa in 1988, currently more than 17%Lack of education about HIVBlood transfusions received prior to 1985Herndobler, 2006; Resnick, 2003; Linsk, 2000
Contributing Factors
Absence of education and prevention campaignsSocial and Professional biasesLack of screening and testingResource AllocationOmission from research
Linsk 2000; NAHOF
New HIV testing recommendations
In Sept. 2006, the CDC released revised recommendations for HIV testingRoutine screening between the ages of 13-64Routine Screening of high risk patients at least once a yearDoes not recommend prevention counseling at time of testing. CDC
If Undiagnosed and Untreated
HIV will progress rapidly to AIDS and may appear very much like:
Atherosclerotic Dementia
Alzheimer’s Disease
Parkinson’s Disease
Manfredi, 2002
Diseases Common in both Aging and HIV infection
Peripheral Neuropathy
Herpes Zoster
Pneumonia
Any Opportunistic Infections
Manfredi, 2002
Signs and Symptoms common in aging and HIV infection
FatigueAnorexia and Weight LossSkin rashesChronic PainIncreased infectionsIncreased viral illnesses
Manfredi, 2002
When Should HIV be included in the Differential Dx?
Anytime a patient presents with signs and symptoms of Alzheimer’s or Parkinson’s Disease with no family history.
Anytime an older patient presents with psychotic symptoms or a mental illness with no family history and no prior history.
Diagnostic Tools
The Gold Standard is the enzyme immunoassay
Must confirm with a Western Blot test before a diagnosis of HIV can be given
General Treatment Options
Standard Treatment is HAART regimen – a min of three drugs from a min of two drug classes: Nucleoside Analogues Protease Inhibitors Non-nucleoside reverse transcriptase inhibitors
Manfredi, 2002
Treatment Goals
Maximize prolonged viral suppression
Improve immune system competence
Reduce complications and death
Improve quality of life
Manfredi, 2002
Benefits of HAART
Reduction in Opportunistic Infections
Reduction in Morbidity and Hospitalization
Reduction in Cost of Care
Reduction in Dementia
Manfredi, 2002; Dore & Cooper, 2006; Dolder, et al, 2004
Adverse Effects of HAART
Immunoreconstitution Syndrome Non-Compliance causes resistance Toxicity when used with other medicationsFailure of multi-drug rescue regimensDecrease effectivity of medications used against opportunistic infectionsPlethora of physiological disturbancesManfredi, 2002; Dore & Cooper, 2006; Valcour, et al., 2005
Treatment Challenges
Patient non-complianceAppropriate use of Available drugsPreserve ability to use future tx optionsAppropriate use and interpretation of resistance testingExploitation of drug interactionsPrevent adverse effects and toxicityManfredi, 2002
Treatment Debate
Currently it is unknown if treatment is the best choice for older individuals.
Research is ongoing to help provide an answer to this debate
Pro-Treatment
Wellons, et al. 2002 Similar therapeutic interventions (HAART)
yielded similar outcomes regardless of age at HIV infection
Anti-Treatment
Knobel, et al. 2001 Compared effectiveness of HAART between
patients 60 yoa and 40 yoa and younger After 24 months found no difference in
mortality, HIV-RNA levels, CD4 counts Higher rates of lipodystrophy in 60 yoa Older patients may be more prone to negative
side effects
Specific Treatment Considerations
Life Expectancy
Patient’s desired Quality of Life
Ex: zidovudite and efavirenz have CNS side effects of nightmares and hallucinations
Assess need for atypical antipsychotic
Psychosocial interventions – isolation, rejection, fearDolder, et al. 2000
What Can We Do – Tips from NAHOF
Educate patients about transmission and prevention of the disease.
Open up dialogue and assess risk – History!!!
Promote safe sexual and drug use practices.
Support research efforts.
Stay current on research results and recommendations for screening and treatment.
Become aware of services in the community that may offer support to older patients.http://www.hivoverfifty.org/index.html
References
Centers for Disease Control and Prevention. (n.d.). CDC surveillance reports. Retrieved October 14, 2006, from, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2004report/table1.htm Dolder, C. R., Patterson, T. L., Jeste, D. V. (2000). HIV, psychosis and aging: past, present and future. AIDS, 18(suppl 1), S35-S42Harris, M.J., Jeste, D.V., Gleghorn, A., Sewell, D.D. (1991). New-onset psychosis in HIV-infected patients. Journal of Clinical Psychiatry, 52, 369-376.Herrndobler, K. (2006, August 27). Sex medications fuel HIV in the elderly. The Beaumont Enterprise. Retrieved August 30, 2006, from http://www.southeasttexaslive.com Knobel, H., Guelar, A., Valldecillo, G. Carmona, A, Gonzalez, A., Lopez-Colomes, J.L.,et. al. (2001) Response to highly active antiretroviral therapy in HIV infected patients age 60 years or older after 24 months of follow-up. AIDS, 15, 1591-1593. Linsk, N. L. (2000). HIV among older adults: age-specific issues in prevention and treatment [Electronic version]. AIDS Read, 10(7), 430-440. Manfredi, R. (2002). HIV disease and advanced aging: An increasing therapeutic challenge [Electronic version]. Drugs Aging, 19(9), 647-669.National Association on HIV Over Fifty. (Last Revised February 6, 2007). Educational Tip Sheet: HIV/AIDS and Older Adults. Retrieved February 10, 2007, from http://www.hivoverfifty.org/tip.html Resnick, Barbara. (2003). Risky behaviors in older adults. Highlights of the National Conference of Gerontological Nurse Practitioners. Retrieved September 5, 2006, from http://www.medscape.com/viewarticle/464727.Wellons, M.F., Sanders, L., Edwards, L.J., Bartlett, J.A., Heald, A.E., Schmader, K.E. (2002). HIV infection: Treatment outcomes in older and younger adults. Journal of American Geriatric Society, 50, 603-607.
References Continued
Valcour, V.G., Shikuma, C.M., Shiramizu, B.T., Williams, A.E. Grove, J.S., Seines, O.A., et al. (2005). Diabetes, Insulin Resistance, and Dementia Among HIV-1-Infected Patients. Journal of Acquired Immune Deficiency Syndromes, 38(1), 31-36.
Dore, G. J., & Cooper, D. A. (2006, August 5). HAART’s first decade:success brings further challenges. The Lancet, 368, 427-428.
National HIV Prevention Conference (2005, June). Estimated HIV prevalence in the United States at the end of 2003 (Abstract 595). Atlanta, GA: Glynn M. & Rhodes P.
Questions?