Nelson Vergel, long term survivor, founder of www.PoWeRUSA.org and author of health books speaks about what he has learned as he ages with HIV.

1. Older, Wiser, and Stronger
Nelson Vergel
Program for Wellness Restoration (PoWeR)
ExcelMale.com
DiscountedLabs.com
Author, Built to Survive
Testosterone: A Man’s Guide

2. To Get Copies of These Slides:
Email
NelsonVergel@gmail.com

3. This information (and any accompanying printed material) is not intended to
replace the attention or advice of a physician or other health care professional.
Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle
change intended to prevent or treat a specific disease or condition should first
consult with and seek clearance from a qualified health care professional.

4. Resources
 ExcelMale.com
 DefyHIV.com
 PoWeRUSA.org
 DiscountedLabs.com
 Yahoo group: Subscribe by sending an
email to pozhealth-
subscribe@yahoogroups.com
 Facebook Group: Pozhealth
 Subscribe to Nelson’s Aging with HIV
Newsletter: http://bit.do/HIVAging

7. The success of ART
Source: UNAIDS, gap report. Adapted from Lohse et al, 2007; Hoog et al. 2008; May et al, 2011; Hogg et al. 2013
Expected survival of a 20-year-old person living with HIV in a high
income country
Era before ART Era of ART

8. Top Lessons I Have Learned From Aging with HIV
 Life sucks sometimes. But nothing lasts. Mindfulness is the
strongest muscle I have to overcome adversity.
 My survival skills and resilience are useful for others who may not
be HIV+. We are all anti- stigma activists. Created my
ExcelMale.com platform and told my story. Share your resilience
skills!
 Not all tests are part of standard of care. The squeaky wheel gets
the grease. Anoscopies, DEXA, hormone tests, cardiovascular
tests, STI tests, etc, are sometimes difficult to access for non-
privileged and are also missed in standard of care.
 Being afraid of getting off disability took a lot of my energy. We
can all reinvent ourselves and jump in!

9. Main Lessons I Have Learned
 Life is short. I learned how to value my time and
focus.
 I have learned to be the cookie guy at my doctor’s
office.
 Learning to have compassion for myself took a lot of
effort but it saved me from going crazy through cancer,
multi-drug resistant HIV, multi-drug resistant H-
Pylori, back surgeries, IBS, depression and
autoimmune nerve disease. What does not kill you
makes you stronger.
 I never allow the “I will do it tomorrow” voice to
take over unless physically impaired.

11. Long Term HIV Survivors:
Are We Facilitators of
Vicarious Resilience?

12. Every Aging HIV+ Person and Their Physician Needs
to Read This Document!
http://www.aahivm.org/hivandagingforum

13. HIV Aging - Access and Coverage Issues
 DEXA scan
 Lipodystrophy therapies
 Hormone testing and replacement
 High resolution anoscopies
 Mental health counseling
 Back to work retraining. Disability counseling
 No-stigma retirement facilities
 Little funding for patient education
 Centralized online support group
 Formulary restrictions/ lack of copay assistance info for
polypharmacy
 Polypharmacy interactions

14. ROAH1: 1000 HIV+ NYC Residents Age 50 and Older

15. Average Number of Comorbidities
ROAH1: 1000 HIV+ NYC Residents Age 50 and Older
0
1
2
3
4
5
Elderly 70+
ROAH
1.1
3.3
Average Age= 55 Years
Brennan et al., 2009 n=1000 NYC HIV+ Over 50

16. Need for Caregiving:
PLWHA 50+ in the U.S.
Currently
Need
Care
19%
Needed
Care in
Past
19%
Have Not
Needed
Care
62%
Brennan, M., Karpiak, S. E., London, A. S., & Seidel, L., (2010). A Needs Assessment of Older
GMHC Clients Living with HIV. http://www.acria.org/files/GMHCFinal.pdf
•Average Age= 55.5 Years
•Average Number Comorbid
Conditions = 3.4
•46% reported difficulty with
at least one Instrumental
activities of daily living- ADL
•22% reported difficulty with
at least one Personal ADL

17. The Problem:
Fragile Social Networks!
• The social networks of older adults living with HIV
are fragile – lack of family involvement and reliance
on friends, many who are also HIV+
• Fragile social networks result from:
– Stigma
• Self-Protective Withdrawal (Emlet, 2006)
• Rejection due to stigmatized behaviors (e.g., drug use,
homophobia) (Flowers et al., 2006; Lichtenstein et al., 2002; Mayers & Svartberg, 2001; Trzynka & Erlen, 2004)
– MSM are much less likely to have
partner/spouse/children to rely on in times of need

18. Proportion Living Alone:
ROAH vs. Community-Dwelling NYC Elderly
39%
70%
0% 10% 20% 30% 40% 50% 60% 70% 80%
NYC Elderly 65+
ROAH
1 Brennan, M., Karpiak, S. E., Shippy, R. A., & Cantor, M. H. (2009). Older adults with HIV: An in-depth examination of an
emerging population. New York: Nova Science Publishers.

19. Polypharmacy Interactions

20. % on Non-ART Medication by Age
Swiss Cohort N = 8575
<50 >65 p -value
Anti-Hyper not ACE 5.6 31.3 <0.001
ACE Inhibitors 11.1 32.9
<0.001
Lipid-Lower 12.7 41.8
<0.001
Oral Anti-diabetics 2.1 9.1
<0.001
Insulin 1.4 5.8
<0.001
Anti-platelet 5.8 28.9
<0.001
Anti-depressant 10 7.8 0.659
Hasse et al., ..Swiss HIV Cohort, 2011 CID53:1130-1139

21. Nelson’s Pill Box

22. hiv-druginteractions.org

23. Treatment Considerations for Older Patients with Comorbidities

25. Slide credit: clinicaloptions.com
Key Interactions: Integrase Inhibitor-
Containing ART Regimens
 Consider www.hiv-druginteractions.org to assist with
identifying potential interactions for all regimens
References in slidenotes.
Regimen Key Drug–Drug Interaction Considerations
All[1-8]  Use caution with/avoid polyvalent cation-containing
antacids
DTG/3TC/ABC[1]
DTG + FTC/TDF or FTC/TAF[2-4]
 Avoid dofetilide (antiarrhythmic)
 Dose adjust metformin (diabetes medication)
EVG/COBI/FTC/TDF[5]
EVG/COBI/FTC/TAF[6]
 Avoid lovastatin, simvastatin (lipid-lowering
agents), salmeterol (asthma/COPD medication)
 Dose adjust metformin
 Use caution with hormonal contraceptives
RAL + FTC/TAF or FTC/TAF[7,8]  No notable comedications to avoid for RAL aside
from aluminum/magnesium antacids

26. Slide credit: clinicaloptions.com
Key Interactions: Boosted PI- or NNRTI-
Containing ART Regimens
References in slidenotes.
Regimen Key Drug–Drug Interactions
ATV/RTV + FTC/TDF or
FTC/TAF[1,3-6]
DRV/RTV + FTC/TDF or
FTC/TAF[2,3-6]
 Avoid lovastatin, simvastatin, atorvastatin*(lipid-lowering
agents), simeprevir, elbasvir/grazoprevir (HCV agents),
salmeterol (asthma/COPD medication)
 Use caution with/avoid specific antiarrhythmics (eg,
amiodarone)
 Avoid PPIs (eg, omeprazole) with ATV
 Use caution with/avoid specific glucocorticoids (eg,
budesonide, fluticasone)
 Use caution with hormonal contraceptives
RPV/FTC/TDF[7]
RPV/FTC/TAF[8]
 Avoid PPIs (eg, omeprazole, pantoprazole),
dexamethasone
*ATV/RTV only.

28. Poor CD4 T Cell Recovery Despite HIV Suppression
Linked to Increased Morbidity and Mortality
 These patients are called “immunological non-responders” (INRs).
 As yet, there is no universally accepted definition of INRs (e.g. persistently
below 200, 250 or 350 cells despite 3+ years of HIV suppression).
 Depending on the definition, estimates of the proportion of people starting ART
who can be categorized as INRs are typically around 5-20%.
 In studies conducted to date, the most consistently reported risk factors for this
outcome are low CD4 T cell counts at the time of ART initiation and older
age.
 Several published studies have also reported that INRs have a greater risk of
morbidity and mortality compared to HIV-positive individuals with more
robust CD4 T cell gains.

29. Immunotherapy in HIV infection: Past and
Current Challenges
 IL- 2
 IL-2 was extensively studied in several phase II and two large phase III
studies. Results from these studies showed that IL-2 significantly increases
CD4 counts in the long term. However, this biological effect did not
translate into clinical benefit.
 IL- 7
 Cytheris had ambitious plans to conduct a phase III clinical endpoint trial in
INRs, but went out of business in 2015. The rights to pursue IL-7 as a therapy
for HIV-related immune impairment are reportedly now being directed by a
collaboration involving the French National Agency for Research on AIDS
and Viral Hepatitis (ANRS) and Cognate BioServices. At best, this will
certainly delay evaluation of the ability of IL-7 to reduce morbidity and
mortality in INRs.
 SB-728-T (ZFN-CCR5-gene modification)
 Research continues into the use of the Sangamo BioSciences technology to
genetically modify CD4+ T cells ex vivo. Like other small companies,
Sangamo has not been able to move a product near FDA approval and has
shown no interest in pursuing an INR indication after receiving letter
from community members advocating for it.

30. Top Supplements for HIV+ People
 Vitamin D (decrease in parathyroid hormone)
 Whey Protein (increased CD4 cells)
 Multivitamin (with selenium) (survival)
 Neuropathy:
 Acetyl-L-Carnitine
 Alpha lipoic acid
 SAMe (S-adenosyl-L-methionine) (mood, joint pain,
endogenous glutathione)
 Coenzyme Q-10 (heart protective. Muscle myopathy
protective specially for statin users)

31. Frailty Prevention
 Exercise
 Adequate protein intake
 Testosterone Replacement
 Thyroid Replacement
 Growth Hormone Replacement
 Creatine monohydrate
 Whey protein
 Vitamin D supplementation + calcium intake
 Anabolic agents (nandrolone and oxandrolone)
 Carnitine and Coenzyme Q10

32. Commonly Used Medications for Improved
Quality of Life in Aging with HIV
 Testosterone gels, injections, etc (mood, low libido, fatigue, etc)
 Thyroid medications (Cytomel, Synthroid, Armour) (fatigue, weight gain)
 Modanifil (fatigue)
 Nandrolone decanoate (muscle loss)
 Oxandrolone (muscle loss, visceral fat?)
 Egrifta (abdominal fat)
 B-12 Injections (stamina?)
 Trimix (erectile function)
 PDE5 Inhibitors (erectile function)
 Testosterone and Thyroid formulations
 Zolpidem and other sleep aids.
 Losartan and other ACE and ARB blood pressure meds.
 PMMA (facial and buttock wasting)
 IV Nutrients (lack of data but some doctors prescribe them)
 Metformin (glucose control, abdominal fat?)

34. (binds testosterone)

35. Production and Regulation
of Testosterone
T = testosterone
Only 2% is free
testosterone
and 98% is bound
Free T
2%
SHBG-bound T
60%
Albumin-
bound T
38%
Adapted from Bagatell CJ, Bremner WJ. N Engl J Med.
1996;334:707-715.
GnRH
LH FSHTestosterone
Testosterone
Sperm
Hypothalamus
Pituitary
Testis
Adapted from Braunstein GD. In: Basic & Clinical Endocrinology.
5th ed. Stamford, Conn: Appleton & Lange; 1997:403-433.

36. How can one increase testosterone
naturally?
 Improve sleep quality and hygiene
 Nutrition/Weight loss
 Avoiding environmental toxins
 Improve glucose control
 Exercise
 Note: There is no effective over the
counter testosterone booster

37. FDA Approved Testosterone Replacement Products

38. Newest Testosterone Products
Long Acting

39. Injectable Testosterone Esters Approved in the U.S.

40. Compounded Products

41. Most Commonly Used TRT Regimens
 Testosterone Cypionate or Enanthate:
 200 mg every two weeks
 100-200 mg very week
 50-75 mg twice per week
 Testosterone Propionate:
 25-50 mg three times per week
 Aveed (testosterone undecanoate)
 1000 mg every 10 weeks
 Testopel pellets (14 pellets every 12 weeks)
 Adjunctive: HCG 500IU twice per week to preserve
testicular function and/or anastrazole (.5 mg/week) for
high estradiol.

42. Most Men on Androgel and Testim Stop Using Them
 Included were 15,435 hypogonadal men, from the Thomson
Reuters MarketScan® Database, who had an initial topical
testosterone prescription in 2009 and who were followed
for 12 months.

43. What are the health risks associated
with low testosterone?
 Higher Cardiovascular Risks/Mortality
 Low Fertility
 Cognitive
 Muscoloskeletal (low of lean mass)
 Increased risk for Diabetes and metabolic
syndrome
 Quality of life related

44. TRT Contraindications
 Absolute contraindications for TRT
include carcinoma of the prostate and the male
breast.
These cancers are androgen dependent for growth and
proliferation.
 TRT should be used with caution in older men
with enlarged prostates and urinary symptoms,
elevated hematocrit, and sleep-related breathing
disorders. (PSA should be under 4)

45. What are the potential side effects of TRT and
how can we prevent or manage them?
 Polycythemia (20-50% of patients)
 Blood donations/therapeutic phlebotomy
 Lipid changes (decreased HDL at higher TRT doses)
 Dose adjustment. NAC, Niacin?
 Edema (men with comorbidities)
 Dose adjustment. Anastrazole?, Diuretics
 Acne (age <40)
 Topical creams containing drying agents/antibiotics
 Hair loss (age < 40)
 Topical lotions containing monoxinil, lotanaprost, finasteride, etc
 Tachycardia (dose related- rare)
 Testicular atrophy and low fertility (over 50% of patients)
 Human chorionic gonadotropin (HCG)
 Gynecomastia (rare)
 Anastrazole
 High blood pressure
 Weight loss, ACE, ARBs
 BPH (rare)- Cialis, Flomax
 Sleep apnea- weight loss, CPAP

47. TRT Patient Blood Test Monitoring Schedule
 Initial Blood Test – New Patient
 Testosterone, Free & Total (If total T is under 150 ng/dL test for prolactin)
 PSA
 LH & FSH
 Lipids (LDL, HDL, triglycerides)
 Complete Blood Count ( CMP-white and red blood cells, platelets, etc)
 Comprehensive metabolic panel (CMP- electrolytes, liver and kidney function)
 TSH, free T3 (if high TSH, test for thyroid antibodies)
 6 or 8 wk Follow up – 6 or 8 weeks after initial RX
 CBC
 CMP
 Testosterone, Free & Total
 Estradiol, sensitive test
 TSH
 6 Month Follow up – 6 months after initial RX
 Testosterone, Free & Total
 PSA
 LH & FSH
 Lipids
 CBC
 CMP
 Estradiol, sensitive test
 Annual Blood Test – Same as 6 months
Lowest Cost Blood Tests Online:

48. Low
Desire
Obesity
StressMedications
Alcohol
&
Drugs
Heart
Disease
Diabetes
Cholesterol
Prolactin
Surgery
Injury
Organ
Failure
Low
Testosterone
High Blood
Pressure
Sleep
Courtesy of Dr Turek

49. Causes of Erectile Dysfunction

50. When TRT is not enough to fix ED

53. Free download on ExcelMale.com

54. Free Download at PoWeRUSA.org

56. THANK YOU!
QUESTIONS?