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HIV and Aging: Shaping A Relevant Health System Response

HIV and Aging: Shaping A Relevant Health System Response. Wafaa El-Sadr, MD, MPH ICAP at Columbia University. Outline of Presentation. Characteristics of older PLWH Age as a risk factor for co-morbidities in PLWH Health system challenges for older PLWH

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HIV and Aging: Shaping A Relevant Health System Response

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  1. HIV and Aging:Shaping A Relevant Health System Response Wafaa El-Sadr, MD, MPH ICAP at Columbia University

  2. Outline of Presentation • Characteristics of older PLWH • Age as a risk factor for co-morbidities in PLWH • Health system challenges for older PLWH • Shaping a health system for older PLWH

  3. Scale-up of HIV Treatment 14.0 12.0 10.0 8.0 Millions 6.0 4.0 2.0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 UNAIDS 2014 UNAIDS, 2013

  4. Optimal Models Study *Total ever enrolled **Sites ever reporting Optimal Models is supported by tPEPFARthrough the CDC under Cooperative Agreement 5U62PS223540 and 5U2GPS001537

  5. About 10% of PLWH enrolled in care are >50 years old and increasing proportion initiated ART p < 0.001 p = 0.33 Active in HIV care Newly enrolling in HIV care Active on ART Newly initiating ART Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

  6. Men represent larger proportion of those enrolled in HIV care and initiate ART in older PLWH Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

  7. Lower CD4+ count at enrollment into HIV care for older PLWH 15-24 years 25-39 years 40-49 years 50+ years Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

  8. Older PLWH have higher CD4+ cell loss during follow-up in pre-ART care (CD4>600 at enrollment) • Patients >40 had lower median CD4+ at enrollment and during follow-up • Patients >40 lost 10 more CD4+ cells per year compared to 15-40 year olds (p<0.01) CD4+ count cells/mm3 Teasdale CROI 2014, #913

  9. Less robust CD4+ cell response after ART initiation in older PLWH 15-49 years 50+ years All patients Men Women Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

  10. Less risk of loss to follow-up but increased risk of death in older PLWH HIV Care ART Source: Eduardo et al, 2014, PLOS ONE (in press) Data from 391,313 patients enrolling in HIV care between 2005-2010 at 199 ICAP-supported HIV care and treatment clinics in Kenya, Mozambique, Rwanda, and Tanzania

  11. Age of PLWH and Risk of NCD

  12. Age and Risk of Diabetes in PLWH Petoumenos et al. JIAS 2012

  13. Age and Risk for Hypertension in PLWH Thiebaut et al. Antiviral Therapy 2005

  14. Predictors of MI in PLWH Age and Risk of MI in PLWH CART per additional year Age per 5 year older Male sex Previous CVD Smoking Family history 10 100 1.0 0.1 Relative rate of myocardial infarction (95% CI) Uni- and multivariable Poisson model Adjusted for family history, BMI, HIV risk, cohort, calendar year and race El-Sadr et al. CROI 2005

  15. Health Systems Challenges for Older PLWH • Early diagnosis of HIV • Careful follow-up during pre-ART period and after initiation of ART • Screening for and management of risk factors for NCDs and for NCD • Continuity care models attentive to the characteristics of HIV disease and co-morbid conditions

  16. Health System Strategies

  17. Health Systems Challenges:Diagnosis and Enrollment in Care • Patients and providers may be unaware of HIV risk in older individuals • Messaging regarding HIV and importance of HIV testing largely targeted at younger individuals • Current testing venues may be not suitable (e.g. ANC) or not “elder friendly” • HIV testing tailored to reach older persons e.g. PICT in inpatient settings and HTC in chronic disease clinics, family-focused testing

  18. Health Systems Challenges:Monitoring, Retention and Adherence • Retention in pre-ART and after ART initiation critical for monitoring disease progression (frequency?) • Monitoring for side effects of ART and other medicines for management of co-morbidities • Adherence counselling may be complicated by polypharmacy for non-HIV conditions (co-morbidities)

  19. Health Systems Challenges:Monitoring, Retention and Adherence • Peer educators may not be peers (tend to be young) • Family-focused care may be targeted at younger families • Innovative methods needed to screen and manage CVD, diabetes, hypertension, mental illness etc. among older PLWH

  20. HIV Care Continuum HIV Care Continuum ART Eligible Link link Monitor response To ART Careful monitoring Of disease progression Monitor for side effects Early Diagnosis Screen and manage NCD risk factors and NCD McNairy et al AIDS 2012 McNairy et al AIDS 2012

  21. Health System Challenges:Models of Care for HIV and NCD

  22. Opportunities for Implementation Research • A missed opportunity for screening? • PLWH enrolled in care are rarely screened for CVD risk factors, despite their frequent contacts with the health system • A missed opportunity for management? • Chronic care systems developed for HIV can theoretically be leveraged to manage chronic CVD risk factors (HTN, DM, high cholesterol) Rabkin, Goosby, El-Sadr Scientific American 2014 Rabkin, Nishtar JAIDS 2011 Rabkin, El-Sadr Global Pub Health 2011

  23. Relevant ICAP Studies • HEART study in South Africa • Feasibility of integrating CVD risk factor screening and risk stratification for PLWH on ART • Link4Health CVD study in Swaziland • Phase 1: Feasibility, acceptability, cost and time for CVD RF screening • Phase 2: Participants with CVDRF randomized to management • in HIV clinic versus OPD clinic • Outcome: Combined linkage to CVDRF management • andretention in both HIV and CVD care Participant has > 40% 10-year risk • ARTIC Study in Kenya • Prevalence of NCD risk factors and NCD • Cohort of HIV-infected ART naïve, initiating ART • Storage of samples for biomarker analyses

  24. Conclusions • Substantial, and likely increasing, proportion of PLWH enrolled in HIV care and initiating ART at older ages • Enhanced efforts needed for earlier diagnosis of HIV in older persons and engaging them in programs that address their unique needs with regards to HIV and co-morbid conditions • Research urgently needed to characterize older PLWH and to identify effective models of care for such individuals

  25. Acknowledgements • ICAP colleagues: Matt Lamb, Eduard Eduardo, Chloe Teasdale and Miriam Rabkin • Patients and staff at health facilities • Ministries of Health and partner organizations • Funding from PEPFAR, NIH and Medtronic

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