Дискуссии о здоровом старении с ВИЧ Узнайте о медицинских и немедицинских проблемах, с которыми сталкиваются стареющие пациенты с ВИЧ, включая дополнительные проблемы, с которыми сталкиваются пожилые женщины и пожилые люди, живущие в условиях ограниченных ресурсов.

1. Conversations on Healthy Aging With HIV
Supported by an educational grant from ViiV Healthcare.

2. About These Slides
 Please feel free to use and share some or all of these slides in your
noncommercial presentations to colleagues or patients
 When using our slides, please retain the source attribution:
 These slides may not be published, posted online, or used in
commercial presentations without permission. Please contact
permissions@clinicaloptions.com for details
Slide credit: clinicaloptions.com

3. Melanie Reese
Subject Matter Expert, Older Women
Living and Aging with HIV, HIV North
America Health Resources and Services
Administration HIV/AIDS Bureau
Executive Director, Older Women
Embracing Life
Board Secretary, International Community
of Women Living With HIV
Baltimore, Maryland
Co-Chairs
Jonathan Appelbaum, MD,
FACP, AAHIVS
Laurie L. Dozier Jr, MD, Education Director
Professor of Internal Medicine
Chair, Department of Clinical Sciences
Florida State University College of
Medicine
Tallahassee, Florida

4. Dorothy Onyango
Chief Executive Officer,
Women Fighting AIDS in Kenya
Founding Member, International Community
of Women Living With HIV
Former Chair, Pan African Women’s Coalition
Former Board Member, Kenya National AIDS
Council
Nairobi, Kenya
Marc Thompson
Director, The Love Tank
Co-Founder, Prepster
London, England
Faculty
Lydia Mungherera, MBChB
Executive Director, The Mama’s Club Uganda
Co-Founder, The Global Athena Network
Member, The International Community of
Women Living With HIV
Commissioner, Uganda AIDS Commission
Kampala, Uganda
Cristina Mussini, MD
Head of Department of Infectious Diseases and
Tropical Medicine
Full Professor of Infectious Diseases
Infectious Diseases Clinics, University Hospital
University of Modena and Reggio Emilia
Modena, Italy

5. Faculty Disclosures
Jonathan Appelbaum, MD, FACP, AAHIVS: consultant/advisor/speaker: Merck,
Theratechnologies, ViiV Healthcare.
Cristina Mussini, MD: consultant/advisor/speaker: AbbVie, Angelini, Gilead Sciences,
Janssen, MSD, Pfizer, Roche, ViiV Healthcare; researcher: Gilead Sciences, Janssen,
MSD, ViiV Healthcare.
Lydia Mungherera, MBChB, has no relevant financial relationships to disclose.
Dorothy Onyango has no relevant financial relationships to disclose.
Melanie Reese has no relevant financial relationships to disclose.
Marc Thompson has no relevant financial relationships to disclose.

6. Outline
 Living as an Older Person With HIV
 Medical Care Considerations for Older Patients
 Spotlight on Older Women With HIV
 Spotlight on Older Patients in Resource-Constrained Settings

7. Living as an Older Person With HIV
Marc Thompson

8. Slide credit: clinicaloptions.com
PWH Older Than 50 Yr of Age: The “Silver Tsunami”
 UNAIDS 2014 Gap Report1
‒ 13% of adult PWH are >50 yr of age overall
‒ 4.2 million PWH are >50 yr of age
‒ >2 million PWH >50 yr of age in sub-Saharan
Africa
 In 2018, 51% of PWH in US were ≥50 yr of
age and 17% of newly diagnosed PWH were
≥50 yr of age2
 Model based in Netherlands estimated that
~70% of PWH will be ≥50 yr of age by 20303
1. unaids.org/sites/default/files/media_asset/12_Peopleaged50yearsandolder.pdf. 2. hiv.gov/hiv-basics/living-well-with-hiv/
taking-care-of-yourself/aging-with-hiv. 3. Smit. Lancet Infect Dis. 2015;15:810. 4. Autenrieth. PLoS One. 2018;13:e0207005.
No. of PWH ≥50 Yr by Region in 20164
Eastern
and
Southern
Africa
Western
and Central
Europe and
North
America
Western
and
Central
Africa
Asia
and the
Pacific
Latin
America
and the
Caribbean
Eastern
Europe and
Central Asia
Middle
East and
North
America
350,000
300,000
250,000
150,000
100,000
0
50,000

9. My 5 Key Points
1. The impact of HIV on aging
2. Continued concerns about stigma and discrimination
3. Persistence of loneliness and social isolation
4. Threats to the continuity of care
5. Increase need for support services

10. Slide credit: clinicaloptions.com
Intersectionality
1. Jackson-Best. BMC Public Health. 2018;18:919. 2. Cole ER. Am Pyschol. 2009;64:170.
AGE
People
with HIV
Race
Culture
Gender
identity
Sexual
orientation
Migration
Socio-
economic
status

11. Slide credit: clinicaloptions.com
Second Annual State of Aging With HIV National Survey
 Survey consisting of 102
questions distributed online
‒ Data collected from
15 March - 16 June, 2021
 Included in report analysis
(N = 479)
‒ PWH aged ≥50 yr
‒ PWH aged <50 yr but living with
HIV for ≥15 yr
 Discrimination remains a barrier
to care
‒ Stigma: 28%
‒ Homophobia: 19%
‒ Ageism: 17%
‒ Racism: 10%
healthhiv.org/wp-content/uploads/2021/07/HealthHIV_Second_Annual_State_of_Aging_with_HIV.pdf

12. Slide credit: clinicaloptions.com
Impact on Mental Health
 Aging PWH are more likely than younger PWH to experience:
Social isolation2
Loneliness
and
rejection2
Depression2
Lower status
disclosure1,4
Adverse clinical
outcomes3
1. Emlet. Gerontologist. 2013;53:963. 2. Bogart. AIDS Behav. 2008;12:244.
3. Logie. AIDS Care. 2009;21:742. 4. Emlet. AIDS Patient Care and STDs. 2006;20:350.

13. Slide credit: clinicaloptions.com
Second Annual State of Aging With
HIV National Survey: Mental Health
healthhiv.org/wp-content/uploads/2021/07/HealthHIV_Second_Annual_State_of_Aging_with_HIV.pdf
39%
have been diagnosed
with a mental health
condition
27%
reported being in
substance abuse
recovery
25%
have been diagnosed
with posttraumatic
stress disorder
~60%
reported memory loss issues, of which
only 64% had HCPs discuss memory
loss with them
32%
went 24 hr without
interaction with
another person in
the past week
~50%
reported having support when
sick or injured

14. Medical Care Considerations for Older Patients
Jonathan Appelbaum, MD, FACP, AAHIVS

15. Slide credit: clinicaloptions.com
HIV and Aging Health Issues
Medical1
 Late diagnosis
 Polypharmacy
 Multimorbidity
 Other geriatric syndromes
‒ Cognitive impairment3
‒ Falls3
‒ Frailty4
Psychosocial2
 Mental health
 Substance use
 Stigma
 Loneliness
 Social support systems
1. hiv.gov/hiv-basics/living-well-with-hiv/taking-care-of-yourself/aging-with-hiv. 2. Rueda. Curr Opin HIV AIDS.
2014;9:325. 3. Greene. JAIDS. 2015;69:161. 4. Brothers. Eur Geriatr Med. 2019;10:219.

16. Slide credit: clinicaloptions.com
Polypharmacy
 Definition: use of ≥5 medications1
 Increased medication use is associated with1:

 Polypharmacy is one of the strongest predictors of serious ADEs,2
drug–drug interactions,2 and fall risk3
 Dose–response association with all-cause and CVD mortality4
1. Back. J Int AIDS Soc. 2020;23:e25449. 2. Sharp. Crit Rev Clin Lab Sci. 2019;1.
3. Edelman. Curr Opin HIV AIDS. 2020;15:126. 4. Huang. J Gerontol A Biol Sci Med Sci. 2022;77:1002.
↓ adherence
and ↑ pill fatigue
↑ risk of adverse
drug events
↑ drug–drug and
drug–disease
interactions
Geriatric syndromes
(eg, falls, cognitive
impairment, frailty)
Mortality

17. Slide credit: clinicaloptions.com
Multimorbidity
 More common in older PWH due to intersection of disease, lifestyle
risk factors, polypharmacy, chronic inflammation and immune
activation1
 Associated with increased mortality and frailty2
 Treatment of one disease can impact outcomes of other
comorbidities3,4
‒ Holistic approach should be provided to manage multimorbidity
“The whole is greater than the sum of its parts” – Aristotle
1. Montano. Lancet Health Longevity. 2022;3:E194. 2. Guaraldi. AIDS. 2015;29:1633.
3. DHHS ART Guidelines. December 2019. 4. Sangarlangkarn. Pathogens. 2021;10:1332.

18. Slide credit: clinicaloptions.com
Frailty
 Frailty characterized by decline in
physiologic reserve and increase in
susceptibility to stressors1
 Fried’s frailty phenotype2,3:
‒ Weight loss
‒ Fatigue
‒ Low activity level
‒ Slow gait
‒ Weak grip
 Consequences of frailty
‒ Falls3
‒ Delayed recovery from illness4,5
and/or fall
‒ Greater functional impairment3
(eg, disabled or dependent)
‒ Hospitalization resulting in worse
outcomes3,4 (eg, dependency)
‒ Mortality3
1. Selman. JGEM. 2022;3:1. 2. Fried. J Gerontol. 2001;56A:M146. 3. Bloch. AIDS Res Ther. 2018;15:19.
4. Lees. J Infect Dis. 2020;222:428. 5. Hatheway. Age Aging. 2017;46:920.

19. Slide credit: clinicaloptions.com
Applying Best Practices to Aging PWH
1. Sangarlangkarn. Open Forum Infect Dis. 2020;7:ofaa485. 2. Wong. Clin Infect Dis. 2018;66:1230.
3. Falutz. Curr Opin HIV AIDS. 2021;16:133. 4. Saag. JAMA. 2020;324:1651
Health Issue Best Practices
Polypharmacy
 Medication review at every visit1
 Medication reconciliation at least yearly including prescription, OTC, topical, herbal medications1:
‒ Review for DDIs
‒ Discontinue unnecessary medications
‒ Simplify regimen
‒ Consider ADEs for potential new syndrome
‒ Consider nonpharmaceutical approaches
‒ Substitute medications with safer options if able (eg, Beers or STOPP criteria)
‒ Ensure appropriate dosing
Multimorbidity  Advance care planning (eg, prevention, multi-subspecialty management)1,2
Frailty
 Screen patients ≥50 yr of age, every 1-2 yr if frail/prefrail, less frequent in those who are robust*
 Address modifiable factors (smoking cessation, substance use counseling, physical activity, diet)3
 Comprehensive geriatric assessment4
 Management of polypharmacy4
*Fried’s frailty phenotype or FRAIL scale.1,3

20. Spotlight on Older Women With HIV
Cristina Mussini, MD
Melanie Reese

21. Slide credit: clinicaloptions.com
Challenges Faced by Aging Women With HIV
Menopause1
Low bone
mineral
density7
Neurocognitive
decline, mental
health issues2
Frailty8
Stigma,3
ageism,4
sexism, racism
Sexuality3
Lack of
self-care5
MEDICAL PSYCHOSOCIAL
Other diseases6
(eg, CVD, cancer)
1. King. Lancet HIV. 2021;8:e591. 2. Vance. Curr HIV/AIDS Rep. 2016;13:399. 3. Rubtsova. Curr HIV/AIDS Rep. 2017;14:17.
4. Interdiscip Top Gerontol Geriatr. 2017;42:234. 5. Durvasula. Behav Med. 2014;40:85. 6. thewellproject.org. 7. Andany.
Int J Womens Health. 2016;8:1. 8. Van Epps. Infect Dis Clin North Am. 2017;31:791.
Isolation
and
loneliness

22. Key Take-home Points
 Expansive landscape of medical and nonmedical challenges in aging
women with HIV
 Additional consideration of diversity may lend to added challenges
and stigma
 Opportunities exist to reduce barriers through:
‒ Self-advocacy in care
‒ Advocacy at the system level
‒ Increasing support in the community

23. Spotlight on Older Persons in
Resource-Constrained Settings
Lydia Mungherera, MBChB
Dorothy Onyango

24. Slide credit: clinicaloptions.com
Redefining Resource Constrained Settings
 “Low- to-middle-income countries” or “developing countries”: umbrella
terms often used to describe resource-constrained settings
 van Zyl and colleagues identified 9 themes to consider in any country:
Van Zyl. BMJ Glob Health. 2021;6:e005190

25. Slide credit: clinicaloptions.com
Barriers
to Care
Social/Behavioral
Perception of low risk
Low rates of HIV testing
Low rates of condom use
Adherence challenges
Engagement of risky behaviors
Lack of social support
Structural
Providers unaware of HIV risk
Limited availability of tailored HIV prevention and treatment services
Lack of access to services for non-HIV conditions
Limited mobility
Increased risk of poverty
Biological/Physiological
Suboptimal immunological response to ARV
ARV risk for ADRs (eg, cardiometabolic toxicities)
Increased risk of multimorbidity
Increase risk of polypharmacy
Challenges Faced by Resource Constrained Settings
Harris. AIDS. 2018;32:1563.

26. Slide credit: clinicaloptions.com
Reducing Late HIV Diagnosis in Older PWH in RCS
 Increase access to HIV self-testing
 Free medical checkups, including:
‒ Routine HIV testing
‒ Gynecologic follow-up
‒ Integration of sexual health counseling
‒ Offer prevention strategies (eg, condoms)
 Promote community engagement aimed at facilitating HIV testing
 Prioritize stigma reduction interventions and sexual health needs

27. Slide credit: clinicaloptions.com
What Can We All Do to Help Improve Healthcare Access
and Quality for Older PWH in RCS?
 Advocate for general awareness of rights of
older people
 Support livelihood and provide social protection
 Promote age-appropriate community awareness
of programs and campaigns
 Create support groups targeting special
populations (eg, women)
 Promote and model age-friendly health services,
including HIV and noncommunicable diseases
• Accessible and affordable HIV screening
 Prioritize geriatric training for healthcare workers
(eg, providers, nurses)
 Promote physical health to maintain/improve
motor control
 Create partnerships with local government, private sector, civil society, and other
stakeholders to promote a holistic approach in promoting healthy aging
‒ Ensure well-resourced (eg, skilled personnel)
‒ Ensure adequate technical capacity
‒ Include issues and rights of older people in their policies and programs
 Ensure rights of older people to age-friendly prevention, diagnosis, treatment and
home-based services, economic and social contributions

28. Slide credit: clinicaloptions.com
A Call to Action for Older PWH
 Prioritize interventions to reduce stigma and address sexual health needs
(regardless of HIV status)
 Provide a comprehensive public health response to encourage good health
and wellness (eg, engaging in physical/productive activities)
 Promote policy change to ensure rights of older PWH and include line-item
budget by governments to offer:
‒ Age-friendly prevention
‒ Diagnosis and treatment (eg, home-based services)
‒ Economic and social contributions
 Ensure resourced age-friendly community programs/interventions

29. Go Online for More CCO Information on
Aging with HIV
ClinicalThought commentaries addressing medical and non-medical challenges
Audio podcasts with perspectives from healthcare professionals and patient advocates
clinicaloptions.com/hiv