Kevin Fenton, MD, PhD, FFPH Director

1. HIV Prevention Programs Among Older Adult Populations Kevin Fenton, MD, PhD, FFPH Director National Center for HIV/AIDs, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention AIDS 2012 HIV and Aging Satellite Session July 25, 2012

2. Overview • HIV among older adults in the U.S. • Prevention challenges • Improving care and treatment of older adults with HIV

3. Sexual Health Needs of Aging Adults • The majority of Americans aged 57 to 65 years, and a substantial fraction of those 66 and older, remain sexually active. • Older persons may have been in a long-term monogamous relationship and have poor understanding of HIV transmission • Minority of older patients discuss sexual activity with care givers • Few older Americans use condoms Source: Lindau et al, NEJM, 2007; 2008 National Survey of Sexual Health and Behavior

4. HIV/AIDS Among Older Adults in the U.S. • CDC estimates 33% of all persons living with HIV in 46 states are 50 and older; by2020 more than 50% of all persons living with HIV may be 50 and older • Approximately 11% of new HIV infections are among adults 50 and older • In 2001, 13% of new diagnoses of HIV infection were among persons 50 and older, while in 2009, 17% were among those over 50 Prejean PlosOne 2011; Linley et al., American Journal of Public Health, 2012; Brooks et al., American Journal of Public Health, 2012.

5. Prevention ChallengesHIV Health Disparities and Older Adults • Racial/ethnic disparities in HIV diagnosis rates are greater among persons aged 50 and older than among younger persons • Rates of HIV diagnosis among older (50 and older) blacks and Hispanics/Latinos for 2005-2008 were 13 times and 5 times, respectively, as high as those among older whites • Rates among younger blacks and younger Hispanics/Latinos were 8 times and 3 times as high as those for younger whites • By region, highest average rate of diagnosis per 100,000 among older persons was in Northeast (15.8),followed by the South (12.3) • There was a 3.4% annual increase in diagnosis rates for older persons, compared to a 2.3% increase for younger persons Source: Linley, American Journal of Public Health, 2012

6. Prevention ChallengesOlder Adults and Late HIV Diagnosis • Older persons were nearly twice as likely to receive a late diagnosis of HIV infection compared to younger persons (2005-2008). • Half of the older persons received their diagnosis late in course of infection—AIDS developed within 12 months Source: Linley, et al., American Journal of Public Health, 2012

7. Prevention ChallengesGreater Risk of Chronic Illness • HIV-infected older persons increasingly affected by chronic illnesses such as heart disease, bone fractures, and hepatic disorders that occur at rates greater than expected for age • Thus primary and preventive care is especially important Brooks et al., American Journal of Public Health, 2012

8. HIV Prevention for older adultsChallenges for the affected community • Older persons of minority races/ethnicities may face discrimination and stigma that can lead to later testing, diagnosis and reluctance to seek services • Health care professionals may underestimate their older patients’ risk for HIV and miss opportunities for HIV testing • Physicians may miss AIDS diagnosis because symptoms in older patients can mimic those of normal aging • The stigmaof HIV can be more severe for older adults, leading them to hide their diagnosis from family and friends, and missing social support CDC, HIV/AIDS among Persons Aged 50 and Older

9. HIV Prevention for older adultsChallenges for public health agencies and CBOs • Resource limitations and need to prioritize and target groups where HIV incidence is increasing, or access is especially challenging. • Limited advocacyby older adults to focus on HIV prevention and sexual health issues • Limited capacity and experience with programming for HIV and older adults • Limited surveillance, health needs assessment and other strategic information to inform program planning • Challenges with integrating sexual health and HIV prevention into other broad health programs for older adults due to stigma, ignorance.

10. Treatment of STIs Male circumcision Microbicides for women Grosskurth H, Lancet 2000 Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007 Abdool Karim Q, Science 2010 Female Condoms Treatment for prevention Behavioural positive prevention Donnell D, Lancet 2010 Cohen M, NEJM 2011 Fisher J, JAIDS 2004 Male Condoms HIV PREVENTION TOOL-KIT HIV Counselling and Testing Oral pre-exposure prophylaxis Coates T, Lancet 2000 Grant R, NEJM 2010 (MSM) Baeten J , 2011 (Couples) Paxton L, 2011 (Heterosexuals) Behavioural Intervention Post Exposure prophylaxis (PEP) Vaccines • Abstinence • Be Faithful Scheckter M, 2002 Rerks-Ngarm S, NEJM 2009 Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is focused on reducing sexual transmission

11. Integrating Healthy Aging and HIV Prevention • Healthy aging is the development and maintenance of optimal physical, mental, spiritual and social well-being and function in older adults. • It is most likely to be achieved by • individuals who live in safe and supportive physical environments and communities • the effective use of health services to prevent or minimize the impact of chronic disease • Draw upon principles of healthy aging and HIV prevention strategies for other populations Source: The Healthy Aging Research Network Writing Group. Prev Chronic www.cdc.gov/pcd/issues/2006/jan/05_0054.htm.

12. Enhancing HIV prevention programs for older adults • Incorporate generational concerns • Target high risk groups such as older gay men and older women • Involve older adults as peer educators • Educate about HIV risk • Address ageism • Provide HIV education and training for service providers of elderly populations Sources: http://caps.ucsf.edu/uploads/pubs/FS/over50.php; http://caps.ucsf.edu/uploads/pubs/FS/over50.php; http://www.aoa.gov/AoARoot/Press_Room/Products_Materials/fact/pdf/Seniors_and_HIV_AIDS.pdf

13. Structural interventions and Policy Implications for Older HIV Population • Need to promote healthy aging for those infected with HIV, ensuring preventive services, with emphasis on other health factors as well, such as mental health • Integrate HIV and Sexual Health programming into existing programs targeting older adults • Need for outreach in communities with higher numbers of HIV and STDs among older adults • Need to increase awareness about risk for HIV infection and importance of early diagnosis • Improving linkage to care so that older adults who are HIV infected can be treated earlier

14. Learn from, and disseminate, best and promising practices • U.S. Administration on Aging has developed materials aimed at risk reduction for older adults • Fact sheets, posters, Powerpoint templates, video • http://www.aoa.gov • Jurisdictions with large numbers of older adults have focused on prevention for over 50 year olds • Senior HIV Intervention Project in Broward County, FL • Gay Men’s Health Crisis, NY • AIDS Community Research Initiative of America, NY

15. Summary • Older people are at risk for HIV, and a growing proportion of people living with HIV are over 50, as people live longer lives with ART • Current efforts to focus on older adults reflect limitationsin epidemiological, programmatic, policy and fiscal assessment and response • There is a need for additional models of effective prevention, treatment and care programs for older adults • There is a need to raise awareness among older persons as well as their general practitioners about HIV

16. Thank You Kevin A. Fenton, MD, PhD, FFPH Centers for Disease Control and Prevention 404-639-8000 Email: kif2@cdc.gov Twitter: CDC_DrFenton Web: www.cdc.gov/nchhstp