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Transcript of HIV and Aging: Shaping A Relevant Health System Response Wafaa El-Sadr, MD, MPH ICAP at Columbia...
HIV and Aging:Shaping A Relevant Health
System Response
Wafaa El-Sadr, MD, MPHICAP 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• Shaping a health system for older
PLWH
Mil
lio
ns
2.0
4.0
6.0
8.0
10.0
12.0
14.0
2002 2003 2004 2005 2006 2007 2008 2009 2010 20122011 2013
UNAIDS 2014
Scale-up of HIV Treatment
Optimal Models Study
Optimal Models is supported by tPEPFAR through the CDC under Cooperative Agreement 5U62PS223540 and 5U2GPS001537
Adults enrolled*
Children enrolled* Sites**
Ethiopia 113,096 9,057 32
Kenya 75,163 15,194 83
Rwanda 33,027 4,153 52
Mozambique 159,862 19,740 45
Tanzania 78,552 5,617 56
Total 459,700 53,761 268
*Total ever enrolled **Sites ever reporting
About 10% of PLWH enrolled in care are >50 years old and increasing proportion
initiated 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
2005
2005-32006
2006-32007
2007-32008
2008-32009
2009-32010
2010-30%
4%
8%
12%
16%
Perc
enta
ge o
f adu
lts w
ho a
re
50 y
ears
of a
ge o
r old
er
Newly enrolling in HIV careNewly initiating ART
Active in HIV careActive on ART
p = 0.33
p < 0.001
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
15-24 years 25-39 years 40-49 years 50+ years0%
10%
20%
30%
40%
50%
Newly enrolling in HIV care Newly initiating ART
Perc
ent m
ale
0
200
400
600
Enrollment into HIV care ART initiation
Med
ian
(IQR)
CD
4 ce
ll co
unt,
cells
/mm
3Lower CD4+ count at enrollment
into HIV care for 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
15-24 years 25-39 years 40-49 years 50+ years
Older PLWH have higher CD4+ cell loss during
follow-up in pre-ART care (CD4>600 at enrollment)
Enrollment 6 months 12 months 18 months 24 months600
650
700
750
800
850
15-40 years >40 years
• 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)
CD
4+
cou
nt
cell
s/m
m3
Teasdale CROI 2014, #913
Less robust CD4+ cell response after ART initiation 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
All patients
Men Women
15-49 years
50+ years
Table 3. Loss to follow-up and death one year after enrollment into care and ART initiation, by age group
Cumulative incidence of loss to follow-up and recorded death one year after enrollment into HIV care
n = 392,131
% Loss to follow-up % Recorded Dead
Age Group (years) Overall Males Females Overall Males Females
>50 33.1 35.9 30.5 6.0 7.3 4.7
40-49 32.6 36.5 29.4 5.0 6.5 3.9
25-39 40.5 46.1 38.0 4.1 5.9 3.3
15-24 56.3 58.5 55.9 2.8 4.3 2.5
Cumulative incidence of loss to follow-up and recorded death one year after ART initiation
n = 184,689
% Loss to follow-up % Recorded Dead
Age Group (years) Overall Males Females Overall Males Females
≥ 50 16.1 17.8 14.5 6.0 7.1 4.8
40-49 15.3 17.5 13.6 5.1 6.4 4.1
25-39 19.3 24.1 17.2 4.5 6.6 3.6
15-24 28.0 32.9 26.9 4.4 5.6 4.1
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
Less risk of loss to follow-up but increased risk of death in older
PLWHHIV Care
ART
Age of PLWH and Risk of NCD
Age and Risk of Diabetes in PLWH
Petoumenos et al. JIAS 2012
Age and Risk for Hypertension in PLWH
Thiebaut et al. Antiviral Therapy 2005
Predictors of MI in PLWH
0.1 1 10 100
Relative rate of myocardial infarction (95% CI)Uni- and multivariable Poisson modelAdjusted for family history, BMI, HIV risk, cohort, calendar year and race
CART per additional year
Age per 5 year older
Male sex
Previous CVD
Smoking
Family history
1.00.1 10 100
Age and Risk of MI in PLWH
El-Sadr et al. CROI 2005
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
Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics , standardized diagnostic protocols
Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support
Multidisciplinary family-focused care
A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient
Longitudinal monitoring Health information systems have standardized and easily retrievable data
Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community
Self management An informed, motivated patient is an effective manager of his/her own health
Community linkages and partnerships
Need functional partnerships between health facility-based providers and community-based groups that facilitate access to services across the care continuum
Health System Strategies
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
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)
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
HIV Care Continuum
ART Eligible
Link
McNairy et al AIDS 2012
HIV Care Continuum
McNairy et al AIDS 2012
Screen and manage NCD risk factors and NCD
Early Diagnosis Careful monitoringOf disease progression
Monitor response To ART
Monitor for side effects
link
Health System Challenges:Models of Care for HIV and NCD
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
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
and retention in both HIV and CVD care • 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
Participant has > 40% 10-year risk
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
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