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HIV and Over 50
Kathleen M. Nokes, PhD,RN,FAAN Professor, Hunter College, CUNY, Hunter-Bellevue School of NursingChairperson, New York Association on HIV over Fifty (1995 – 2007)Clinical Consultant, Cicatelli Associates Inc
July 2007
HIV/AIDS and middle-aged and older adults
Objectives: Identify demographic picture of persons
50+ living with HIV/AIDS. Identify unique differences of middle-
aged/older persons living with HIV/AIDS applied to a specific case.
Analyze programmatic considerations in providing services to this population.
Resources
National Association on HIV over Fifty www.hivoverfifty.org – extensive bibliography.
New York Association on HIV over 50 www.nyahof.org
Public Health Library 455 First Ave. Room 1200 (nyc.gov/health)
Case Study
MV is a 62 year old Hispanic woman from the Dominican Republic who has been married for 30 years; she presents to the clinic with herpes zoster; health history reveals chronic fatigue, weight loss; physical examination reveals lymphadenopathy. Her husband has also been losing weight and vague about his health problems.
Risk Behavior
“TOO MANY UNKNOWNS” for both men and women living with AIDS aged 50 and older(Forlenza, 2002)
Epidemiology DataJanuary 1, 2004 - December 31, 2004
New York City DataNew York City HIV/AIDS Surveillance Statistics. New York: NYCDOHMH, 2005.
http://www.nyc/gov/html/doh/html/dires/hivepi.shtml
1st Quarter Report: NYC
“Between 1993 and 2003, the number of PWA age 50 and over increased almost six-fold, from 2,904 to 16,900”.
http://www.nyc.gov/html/doh/downloads/pdf/dires-dires-2005-report-Qtr1.pdf
Face of the epidemic in NYC: 2004
Men: (aged 50-59) 08.1%:dx with HIV 15.5%: dx with AIDS 23.9% of men living
with HIV/AIDS 34.1% of the deaths
Women: (aged 50-59) 11.7%:dx with HIV
17.1%: dx with AIDS 18.1% of women
living with HIV/AIDS 26.4% of the deaths
Stage of HIV diagnosis: Comparing persons aged 30-39 to persons aged
50-59 – 1/1/04 through 12/31/04
HIV, not AIDS (71.6% of total cases) 30-39: 33.3% 50-59: 9.3%
Concurrent with AIDS Dx (28.4% of total cases)
30-39: 29.1% 50-59: 16.0%
Three issues
Disclosure Physical functioning Co-morbidities
Disclosure
Increased social isolation Increased internalized homophobia (?),
socially marginalized due to: IDU and imprisonment
Decreased social support due to deaths; other losses, stigma
Possible decreased children in network due to decreased parenting; estranged from children
Case continued
MV hasn’t told her adult children of her fears. She is afraid of their reaction since their relationship with their father hasn’t been good.
She also hasn’t told her close friends or her church associates since she is embarrassed.
Decreased Physical Functioning (measured by SF- 36)
May get overwhelmed when asked to move from place-to-place
May feel physically tired from carrying heavy materials
May experience usual aging issues such as arthritis
Mortality from non-HIV/AIDS related causes
“Mortality from non-HIV-related causes is five times higher for PWA age 50 and over than for 25-34 year-olds”.
http://www.nyc/gov/html/doh/html/ah/hivtables2002.html
Co-morbidities
Cardiovascular – major causes: chronic ischemic health disease, hypertension, and cerebrovascular disease HIV meds – lead to increased cholesterol, triglycerides
Potential for strokes, heart disease – also higher risk in blacks/AA who are have higher rates of HIV disease in proportion to population rates.
Older age is associated with increased risk of cardiovascular disease including MI and stroke especially for clients on HAART
(The DAD Writing Committee (2004). Cardio-and cerebrovascular events in HIV-infected persons. AIDS 18: 1811-1817.)
Comorbidities (continued)
Diabetes Injection drug use and alcohol abuse
are associated with chronic pancreatitis
Some HIV meds cause pancreatitis
Cancer – all persons with HIV/AIDS
Lung cancer is the leading cause in both men & women
Breast cancer in women; liver cancer in men
Comorbidities (continued)
Hepatitis B/C Decreased liver function secondary to
hepatitis
Most drugs are detoxified by liver
Liver disease most commonly reported co-morbidity and clients aged 50 and older could not differentiate mild from moderate liver damage.
Comorbidities (continued)
Drug addiction/Alcohol abuse Methadone maintenance and liver
function
Methadone and HIV drug interactions
Comorbidities (continued)
Erectile dysfunction Sexuality and HIV – prevention issues
HIV drug interaction and drugs to treat erectile dysfunction such as viagra
Neuropsychological changes
Sanchez Rodriguez & Rodriguez Alvarez (2003) found remarkable similarity between the neuropsychological performance by the normal elderly and the much younger AIDS patients despite great age differences between the groups (70.5 vs. 29.9 years).
Implications for older persons living with AIDS….
No differences on MAT for older clients or on REALM.
Clinical Implications
Need clinical expertise in treatment modalities for multiple chronic illnesses
Need to consider risks inherent in polypharmacy – see chart by Ernst (2004) ACRIA Update Vol. 13 (3)– accessible on-line: www.acria.org
Need to carefully evaluate symptoms since older persons seem to underreport symptoms
Five sectors providing assistance to older adults
Source: Topolski, J., Gotham, H.,
Klinkenberg, WD., O’Neill, D., & Brooks, A. (2002). Older adults, substance use, and HIV/AIDS: Preparing for a future crisis. Journal of Mental Health and Aging 8(4) Winter, 349-363.
These five sectors need to interface
AIDS Service Organizations Health/Medical Behavioral Health Treatment Public Health Aging Services
Components of an integrated system
communication cross-training cross-disciplinary consultation coordinated treatment planning co-location of services integrated service teams integrated funding sources.
Think about your program
Is it integrated?
Is it meeting the needs of mid-life and older adults with HIV/AIDS?
If yes, how do you know.
If no, what will you do to find out.
Case summary
MV has diabetes and HTN; she agreed to HIV testing and was staged finding her CD4 cell count of 180 and viral load of 70,000.
How do you treat her considering her other co-morbidities?
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