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Questions for Meredith Greene, MD: Managing HIV Infection
in Older Adults....Aging Clinic at UCSF
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"None of the guidelines recommend specific antiretroviral therapy regimens for older adults, so these are the same regimens that would be recommended to anyone as the first line antiretroviral regimen. However for older adults, choice of regimen may depend on other co-morbid conditions, and liver and renal function in particular. A provider also has to consider the other medications someone is taking and drug-drug interactions......increased risk for social isolation......a geriatrics approach can be useful. When I say that, it means specific things like asking about someone's functional ability-how well are they managing daily activities? Are they having limitations with walking? Do they need help managing medications?.....Thinking through functional status.....You can't think of HIV in isolation anymore. As far as management ... For example with heart disease, is someone on antiretroviral medications that might potentially be increasing their cholesterol? ... older adults with HIV have higher rates of smoking and substance use compared to HIV negative adults--so you also have to take that into context of the management plan......HIV alone increases the risk of heart disease. There's a context of HIV infection when you are managing the other conditions......common age-related co-morbidities (e.g., hyperlipidemia, hypertension, osteoporosis, diabetes) in HIV+"
Slide talk:http://www.giaging.org/documents/Greene_GIA_Fellows_10-13_final_(2).pdf
UCSF & San Francisco General Hospital - The Silver Project - See more at:
http://informingchange.com/areas-of-expertise/health/over-50-hiv-access#sthash.SgzS7suY.dpuf
Questions for Meredith Greene, MD: Managing HIV Infection in Older Adults....Aging Clinic at UCSF.....http://360.ucsf.edu/content/silver-project
http://www.medpagetoday.com/resource-center/HIV-10-Questions/Meredith-Greene/a/54338
Take Note
⋅ "It's quoted that by 2015, half of all people living with HIV in the United States will be age 50 or older. We're in 2015 now! Some estimates say it'll be closer to 2017. But certainly here in the city of San Francisco, 58% of people living with HIV are now age 50 or over." --Meredith Greene, MD
Meredith Greene, MD, is Assistant Professor in the Department of Medicine, Division of Geriatrics at UCSF, where her research and clinical care focus on the intersection of HIV and geriatric medicine. She has done research on the management of HIV infection in older adults, and has studied polypharmacy and geriatric conditions in older HIV-infected adults. (References below) Dr. Greene received her MD from Wayne State University School of Medicine and completed her residency in Internal Medicine-Primary Care at UCSF. She completed both geriatrics and HIV research fellowships at UCSF.
Dr. Greene recently answered some questions from MedPage Today about the management of HIV in older patients. What follows is a lightly-edited transcript of the interview.
1. Are the numbers of HIV-infected older adults increasing, and if so, why?
The number of older adults living with HIV is increasing. A large part is because the antiretroviral therapies we have now are better and are allowing people to live longer, and now people are actually aging with HIV. The main reason the older adult population is increasing is that people are growing older with HIV infection, but new infections of HIV also occur in people who are age 50 and older. In particular, there are a disproportionate number of African American women who are newly diagnosed with HIV after age 50. A lot of times it's quoted that by 2015 half of all people living with HIV in the United States will be age 50 or older. We're in 2015 now! Some estimates say it'll be closer to 2017. But certainly here in the city of San Francisco, 58% of people living with HIV are now age 50 or over. So we've already passed that estimate for several years now.
2. Why is the diagnosis of HIV in older patients often delayed, and how does this affect prognosis?
New diagnoses of HIV in older adults are definitely delayed, and I think there are multiple reasons for that. Some are at the level of the health care system and some are at the level of the health care providers. There's still a lot of ageism and bias that older adults don't have sex anymore—so they're not perceived as being at risk. There are national studies that have shown that after age 50, most men and women aren't talking about sexual activity with their healthcare providers. Some of it is that. Many older adults might not perceive themselves to be at risk. We've had the HIV and AIDS epidemic for 30+ years. If you were in school before that time, and that's when you had sexual education, you may not have learned a lot about HIV transmission. There are still some misconceptions that may exist, so people might not perceive themselves to be at risk. Certainly older women, if they are postmenopausal and not worried about being pregnant anymore and may be divorced, it may have been a while since they've had to have conversations about condom use, for example. Also, people aren't getting routinely screened because they're outside of the age cutoff, which is age 64.
I think part of the reason for delayed diagnosis in older adults is that the symptoms of HIV can be more vague, so maybe there's fever, maybe there's been a little bit of weight loss, people can also present with cognitive decline or fatigue. A lot of times those things are dismissed as you are getting older, so these things are going to start happening to you, when in reality it's not necessarily normal, and we should be thinking about HIV as a possible explanation for the symptoms.
We know that older adults are more likely to be diagnosed with an AIDS diagnosis compared to an HIV diagnosis. So people are getting diagnosed much later, starting at a lower CD4 count where they're at risk for opportunistic infections that occur when the CD4 count is that low. There are some articles that have shown that older adults may not have quite as robust a response to antiretroviral therapy as far as recovering their immune function. But some of that may actually be because they are diagnosed later, so they are starting at a much lower point [in terms of CD4 count] to begin with.
Interestingly, we actually see that older adults, compared to younger adults with antiretroviral therapy, are more likely to have an undetectable viral load. We don't know entirely why that is. As we just discussed, the CD4 count response may be blunted [in an older adult] compared to a younger person, but older adults are more likely to obtain an undetectable viral load and that usually relates directly to the ability to take and adhere to the medication.
3. What do current guidelines recommend about HIV testing in older adults?
The CDC guideline for routine testing of everyone for HIV infection actually ends at age 64, so 65 and older were left out. The USPSTF [United States Preventive Services Task Force] guidelines that came out in 2013 recommend routine screening for everyone age 15-65. There is a sentence about people who are younger and older adults who are at increased risk should also be screened. So they do add a statement about it, but they still have a cut point of age 65. The American Geriatric Society, the American Academy of HIV Medicine and the AIDS Community Research Initiative of America, when they published the HIV and Aging Consensus Project, recommended routine screening regardless of age. There was another study that showed routine screening up to at least age 75 was likely to be cost effective, especially in places where there's higher HIV prevalence. In part, I think the guidelines that recommend screening regardless of age reflect that we know providers are not good about talking about sex and are probably underestimating the risk in some of their older patients.
4. What factors influence the choice of antiretroviral drugs in older HIV-positive adults?
All the major organizations are recommending that everyone, regardless of CD4 count, should be started on antiretroviral therapy. So regardless of age, a person who is newly diagnosed with HIV should be started on antiretroviral therapy as soon as possible. None of the guidelines recommend specific antiretroviral therapy regimens for older adults, so these are the same regimens that would be recommended to anyone as the first line antiretroviral regimen. However for older adults, choice of regimen may depend on other co-morbid conditions, and liver and renal function in particular. A provider also has to consider the other medications someone is taking and drug-drug interactions.
5. How should common age-related co-morbidities (e.g., hyperlipidemia, hypertension, osteoporosis, diabetes) be managed in HIV-positive adults?
I think the main thing is that very few people as they are older and living with HIV are just going to be dealing with HIV alone. [For] patients that are being seen in HIV clinics, HIV providers really need to take care of all the different conditions. You can't think of HIV in isolation anymore. As far as are there specific management things... it's not that different than someone who's HIV negative, but you still have to take into context their HIV infection. For example with heart disease, is someone on antiretroviral medications that might potentially be increasing their cholesterol? Those are known side effects of some of the HIV drugs. We also know that older adults with HIV have higher rates of smoking and substance use compared to HIV negative adults--so you also have to take that into context of the management plan. You have to keep in mind some of the HIV specific things because we know that HIV alone increases the risk of heart disease. There's a context of HIV infection when you are managing the other conditions.
6. Are the risks of polypharmacy and drug-drug interactions higher in older HIV-infected compared to HIV-unaffected adults, and if so, how should this be managed?
In a study we did here at UCSF of HIV positive adults who were all 60 and older, there was a higher degree of polypharmacy and drug-drug interactions compared to a small HIV-negative group we compared to. There aren't a lot of big studies that have specifically compared polypharmacy in HIV positive to HIV negative [adults]. A lot of studies have looked at HIV positive older adults [compared] to HIV positive younger adults, and maybe not surprisingly, the older adults are on more medications and are more at risk for polypharmacy. Another review suggested that HIV positive patients may be more at risk from polypharmacy potentially because of the increased risk of certain co-morbid conditions, like having more renal or liver problems, so they might be more susceptible to having complications.
As far as drug-drug interactions, we know specifically that many HIV medications are notorious for their drug interactions so it always has to be considered with each new medication. An example we have commonly seen is in people who are on ritonavir; there is a severe interaction even with just inhaled or intranasal fluticasone. There have been case reports of people actually developing Cushing's syndrome because of that drug interaction-not even from an oral medication-but an intranasal, a small amount systemically. Certainly I think patients are at increased risk for drug interactions and other complications depending on what HIV medications and other medications they are taking.
7. How should clinicians address the risk for social isolation in older HIV-positive adults?
First, they have to ask about it. There may be a few patients who would openly talk about that, but I think just being aware that-especially people who have aged [with] HIV and survived the 80s and 90s--they may have lost a lot of friends and partners so there may be isolation or loneliness from that. Additionally, people may be estranged from family—whether through past drug use or because their family did not accept that they were gay—there are many reasons people might be at increased risk for social isolation. There is also still a lot of stigma from HIV infection. There are some studies to suggest that older adults [in general] may be at increased risk of stigma. So the first point for providers is just being aware and asking about isolation or stigma.
As far as what to do, there have been a few studies that have shown that a telephone intervention to help improve coping strategies can help decrease loneliness and isolation. Even an online support group--there was a study that looked at that and showed that that had positive impact.
Here in San Francisco and in other places, there are support groups for people who are 50 and over living with HIV where they can come together and discuss issues. Sometimes there are social activities that occur in that context, and people are able to create new relationships and help decrease some of the isolation that they might be feeling.
8. How should clinical care of older HIV-infected adults incorporate geriatric principles?
A lot of the things we've talked about-just thinking about polypharmacy, thinking about multi-morbidity (meaning people who have more than two or three different medical conditions) are areas in which geriatricians have expertise. When you are dealing with increased medical complexity or complex chronic illness-taking a geriatrics approach can be useful. When I say that, it means specific things like asking about someone's functional ability-how well are they managing daily activities? Are they having limitations with walking? Do they need help managing medications?
I think what HIV care does very well is taking a holistic approach to care, which geriatrics does as well. Thinking through functional status. Looking at all the medications and looking for drug interactions. I think we are still trying to understand what are the geriatric assessments that are going to be most useful for older, HIV positive adults. That's one of the projects we are working on now--trying to create a more formalized geriatric HIV clinic here at San Francisco General to try to understand how we can be doing this and what it should look like.
9. Should PrEP be considered in the older adult population?
Yes, I think it should be considered for some of the reasons we talked about earlier.
Again, there are stereotypes that older adults don't have sex or [don't] engage in risky behaviors. I am not aware of studies that have looked at PrEP specifically in older adults but there is no reason that just because of age, someone should be excluded from PrEP. You just have to consider it in the context of the existing PrEP guidelines, which include starting in persons who have normal renal function. You would have to make sure that the kidney function is OK, and although the current CDC guidelines don't recommend routine DEXA screenings, the guidelines do include that in someone who has known osteoporosis or who has ever had a fragility fracture, you have to think more carefully about whether PrEP is appropriate. Both impaired renal function and osteoporosis are more common in older adults living with HIV. But that is something that is very individualized. The main take home point would be that age should not be a reason to exclude someone from PrEP-you just have to think about some of the side effects a little bit more carefully.
10. Is there anything you would like to add about the management of HIV in older adults?
There are a couple resources I would point out. Thinking about prevention in older adults, in NYC, there's been a campaign called "Age is not a condom." They've had a series of billboards and posters encouraging older adults to get tested for HIV. They were actually fairly controversial because they featured older adults but I think it's been a successful campaign as far as getting older adults to think about being HIV tested.
HIV-age.org is the website where the American Geriatric Society and the American Academy of HIV Medicine and the ACRIA [AIDS Community Research Initiative of America] guidelines live, and they are constantly being updated so it's a useful resource for people who are looking for more information. There are case histories, and a lot of journal articles are stored there.
The other thing is that this is just an amazing time that we are actually talking about HIV and geriatrics. Overall, it's a positive thing, although there's still a lot of work to be done to figure out how we are really going to support the health and care for older adults who are dealing with HIV.
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