A Website & Smart Phone App to Promote Healthy Aging with HIV

A Website & Smart Phone App to Promote Healthy Aging with HIV Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthca...
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A Website & Smart Phone App to Promote Healthy Aging with HIV Amy C. Justice, MD, PhD Section Chief, General Internal Medicine VA Connecticut Healthcare System Professor, School of Medicine and Public Health Yale University

Why Do We Need A Risk Index for HIV?

Projected Proportion of those Living With HIV in United States 50+ Years* 2001-2017 Projected

US VA in 2003 As of 2008: •San Francisco •NY City

33% 25%

17%

19%

21%

27%

27%

35%

37%

39%

41%

44%

45%

47%

50%

29%

22%

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 *Data from 2008, onward projected based on 2001-2007 trends (calculated by author), 2001-2007 data from

CDC Surveillance Reports 2007. New York and San Francisco data from their Departments of Public Health

Where Ever ART Available, People with HIV are Ageing • An estimated 14% of adults with HIV infection in Sub Saharan Africa are >50 years • AIDS is leading cause of death among >50 yrs. in Nyanza Providence, Western Kenya • As prevalence increases, incidence will rise

Projected HIV Prevalence by Age in Hlabisa Sub-district of KwaZulu-Natal, South Africa

What Drives Patient Outcomes Among those Aging with HIV? Not AIDS Defining Events Not Only “Immune Deficiency” Outcome Disparities Growing

AIDS Events Increasingly Rare

ART-CC, Archives Int Med 2005: 165 416-423

AIDS Events Variably Associated with CD4 and Survival By Median (IQR) CD4

ART-CC, CID 2009;48:1138-51

By Relative Hazard of Death

>50% of Deaths Attributed to Non-AIDS Events

Cumulative Mortality by COD Among Those on cART (1996-2006) ART-CC, CID 2010: 1387-1396

Death Rate Disparities by HIV, Race/Ethnicity and Age

HIV Epidemiology & Field Services Semiannual Report,

Strategies for Management of ART (SMART)

*More AIDS and “Non-AIDS” Events Among Rx. Sparing Arm (HR 1.7 in SMART) NEJM 2006;355:2283-96

General Observations on HANA • Multiple interacting HIV and non HIV causes – HIV typically not the most influential risk factor – cART appears to decrease risk (SMART)

• What is common and what has the greatest relative risk for HIV differ • Relative risk HIV+/- highly variable – Association with CD4 variable – Competing risk of death is changing and unmasking risk associated with HIV

Case: Routine Follow Up • 52 yr. old black male HIV+, on stable cART (2 yrs) • Undetectable HIV-1 RNA since starting cART • Hepatitis C infected, never treated

HIV Guideline Care Screening: – Behaviors • Adherence • Risk of transmission

Findings: – No difficulty with cART – 1 partner, no condoms

– – Measurements – • HIV-1 RNA – • CD4 count – • Electrolytes, glucose • CBC – • ALT, AST, T. Bilirubin – • Fasting lipids – • Urinalysis – • Anal Ca. screen

HIV-1 RNA 135/80) http://www.uspreventiveservicestaskforce.org/recommendations.htm

Pertinent Positives Behaviors • Smoking cessation? • Lung ca. screening? • Alcohol reduction? • Antidepressant? • Partner notification? • Exercise prescription? • Nutrition counseling?

Treatment Issues • Hepatitis C – Treatment? Risk reduction? – Liver ca. screening?

• Cardiovascular Risk – Aspirin? Statins?

• Colonoscopy? • Antihypertensives? • Erectile dysfunction? • Toxicity? 6 Possible additional medications --before considering HCV treatment

Decision to Screen and Treat a Balancing Act

Favors Screening/Treatment

Risk

Benefits of Treatment

Against Screening/Treatment Short Life Expectancy

Harms of Screening/Rx

Sigel K. et al. Cancer Screening in Patients Infected with HIV, Curr HIV/AIDS Rep (2011) 8:142-152

Polypharmacy • Typically defined as >5 drugs • Associated with – Nonadherence – Cognitive compromise – Organ system toxicities

• Risk of adverse events in uninfected subjects approximates 100%

Comedications % of participants

Swiss Cohort

100

No comedication One comedication Two comedications Three comedications Four or more comedications

80 60 40 20 0

Comorbidities % of participants

100

No comorbidity One comorbidity Two comorbidities Three comorbidities Four or more comorbidities

80 60 40 20 0

1x105

0 11 25

0 7 14

Hemoglobin g/dL

> 14 12 to 13.9 10 to 11.9 < 10

0 10 22 38

FIB-4

< 1.45 1.45 to 3.25 > 3.25

0 6 25

eGFR mL/min

> 60 45 to 59.9 30 to 44.9 < 30

0 6 8 26

Age

HIV Specific Biomarkers

Biomarkers of General Organ System Injury

Index Score Restricted VACS

Hepatitis C Infection

5

Accuracy of VACS Index for All Cause Mortality in NA-ACCORD Discrimination Subgroup

VACS Index

Restricted Index

p**

Overall Male Female

0.80 0.81 0.81

0.75 0.75 0.77