Kevin Fenton, MD, PhD, FFPHDirector

National Center for HIV/AIDs, Viral Hepatitis, STD and TB PreventionCenters for Disease Control and Prevention

HIV Prevention Programs Among Older Adult

Populations

AIDS 2012HIV and Aging Satellite Session

July 25, 2012

1. HIV among older adults in the U.S.

2. Prevention challenges3. Improving care and treatment

of older adults with HIV

Overview

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

Sexual Health Needs of Aging Adults

Source: Lindau et al, NEJM, 2007; 2008 National Survey of Sexual Health and Behavior

CDC estimates 33% of all persons living with HIV in 46 states are 50 and older; by 2020 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

HIV/AIDS Among Older Adults in the U.S.

Prejean PlosOne 2011; Linley et al., American Journal of Public Health, 2012; Brooks et al., American Journal of Public Health, 2012.

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

Prevention ChallengesHIV Health Disparities and Older Adults

Source: Linley, American Journal of Public Health, 2012

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

Prevention ChallengesOlder Adults and Late HIV Diagnosis

Source: Linley, et al., American Journal of Public Health, 2012

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

Prevention ChallengesGreater Risk of Chronic Illness

Brooks et al., American Journal of Public Health, 2012

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 stigma of HIV can be more severe for older adults, leading them to hide their diagnosis from family and friends, and missing social support

HIV Prevention for older adultsChallenges for the affected community

CDC, HIV/AIDS among Persons Aged 50 and Older

Resource limitations and need to prioritize and target groups where HIV incidence is increasing, or access is especially challenging.

Limited advocacy by 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.

HIV Prevention for older adultsChallenges for public health agencies and CBOs

Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc. have not been included – this is focused on reducing sexual transmission

Behavioural Intervention- Abstinence- Be Faithful

HIV Counselling and TestingCoates T, Lancet 2000

Male Condoms

Female Condoms

Treatment of STIs

Grosskurth H, Lancet 2000

Male circumcision

Auvert B, PloS Med 2005 Gray R, Lancet 2007 Bailey R, Lancet 2007

Microbicidesfor women

Abdool Karim Q, Science 2010

Treatment for prevention

Donnell D, Lancet 2010Cohen M, NEJM 2011

Behavioural positive prevention

Fisher J, JAIDS 2004

Grant R, NEJM 2010 (MSM)Baeten J , 2011 (Couples)Paxton L, 2011 (Heterosexuals)

Oral pre-exposure prophylaxis

Post Exposure prophylaxis (PEP)Scheckter M, 2002

VaccinesRerks-Ngarm S, NEJM 2009

HIV PREVENTION

TOOL-KIT

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

Integrating Healthy Aging and HIV Prevention

Source: The Healthy Aging Research Network Writing Group. Prev Chronic www.cdc.gov/pcd/issues/2006/jan/05_0054.htm.

Incorporate generational concernsTarget high risk groups such as older

gay men and older womenInvolve older adults as peer

educatorsEducate about HIV riskAddress ageism Provide HIV education and training for

service providers of elderly populations

Enhancing HIV prevention programs for older adults

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

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

Structural interventions and Policy Implications for Older HIV Population

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

Learn from, and disseminate, best and promising practices

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 limitations in 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

Summary

Thank YouKevin A. Fenton, MD, PhD, FFPH

Centers for Disease Control and Prevention404-639-8000

Email: kif2@cdc.gov Twitter: CDC_DrFenton

Web: www.cdc.gov/nchhstp