Managing older people with HIV: What are the challenges and what can we do about it Jaime Vera MD PhD Senior Lecturer in HIV and Consultant Progress towards ending the HIV epidemic in the United Kingdom: 2018 report 1. The UNAIDS 90:90:90 targets The continuum of HIV care illustrates key measures of the HIV patient pathway and provides an opportunity to assess progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90:90:90 targets of 90% of people living with HIV being diagnosed, 90% of people diagnosed receiving ART and 90% of people on treatment virally suppressed and unable to pass on the infection [15]. The UK met the UNAIDS targets in 2017; 92% (Credible interval (Crl) 88 to 94%) of the estimated 101,600 (CrI 99,300 to 106,400) people living with HIV infection in the UK were diagnosed, 98% of people diagnosed were receiving treatment and 97% of people receiving treatment were virally suppressed (Figure 1). Overall, 87% of people living with HIVUK in the UKcascade were estimated of to have HIV an undetectable care viral load and therefore unable to pass on the infection. Figure 1: Continuum of HIV care, UK: 2017 UNAIDS 90:90:90 target 100% 92% 100% 90% 87% 99% 90% 81% 73% 50% 93%92% 99%98% 99%97% 0% People living with People diagnosed On treatment Virally suppressed HIV with HIV PHE 2018 report UK 17 People livingPeople with HIV with HIV aged 50 and over 1. People aged 50 and over living with HIV Data available from: http://aidsinfo.unaids.org/ (last accessed September 2017). Progress towards ending the HIV epidemic in the United Kingdom: 2018 report 3. People living with diagnosed HIV In 2017, 93,385xxiii people (64,472 men and 28,877 women) living with diagnosed HIV infection received HIV care in the UK. This is a 54% increase on the number a decade ago (60,737 in 2008) and is due to effective treatment for HIV prolonging life, as well as ongoing new diagnoses. The median age of people receiving care increased over the past decade, from 40 years in 2008 to 46 years in 2017. In 2017, more than a third (39%; 36,288/93,385) of people receiving HIV specialist care were aged 50 years and above (Figure 9a). In 2017, 14% (6,029/42,739) of gay and bisexual men receiving HIV care were from BAME groups, similar to 2008 (12%; 2,994/25,806) (Figure 9b). Among heterosexuals, black African men and women accounted for the greatest proportion of those receiving care (57%; 24,548/42,668), whileHIV 26% (11,058) demographics were of white ethnicity compared to 21% (6,429/30,631) in 2008 (Figure 9c). In 2017, 123 trans people were receiving HIV care in the UK; 62% were from white ethnic groups and 42% were aged between 35-49 years. Figure 9: People diagnosed with HIV receiving specialist care, UK, 2008 to 2017 a) By age group 15-24 25-34 35-49 50-64 ≥65 100,000 90,000 80,000 70,000 60,000 50,000 Median age 40,000 now 45 years 30,000 20,000 10,000 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 14% 34% xxiii The overall total includes people who identify in another way and those with gender identity not reported. https://www.gov.uk/government/publications/hiv-in-the-united-kingdom 30 2019 (n=2500; 52% >50 years old) Lawson unit management team Age-related chronic diseases rises exponentially with age HIV+ HIV- INCIDENCE Age related chronic diseases Challenges facing people ageing with HIV Social isolation Cognitive Medications difficulties (ART and others) Physical challenges (chronic pain) Age Comorbidities Mental health Current models of care Stigma Frailty Cardiovascular Cancer Cognitive decline disease Geriatric Polypharmacy Chronic kidney disease syndromes Chronic liver disease Chronic obstructive pulmonary disease Diabetes mellitus Impact of comorbidity and ageing on health-related quality of life in HIV-positive and HIV-negative individuals Nienke Langebeeka,b, Katherine W. Kooijc, Ferdinand W. Witc,d, Ineke G. Stoltee, Mirjam A.G. Sprangersb, Peter Reissc,d,f, b Pythia T. Nieuwkerk , on behalf of the AGEhIV Cohort Study Group Background: HIV-infected individuals may be at risk for the premature onset of age- associated noncommunicable comorbidities. Being HIV-positive, having comorbidities and being of higher age may adversely impact health-related quality of life (HRQL). We investigatedØ HIV-positive the possible status contribution was of significantly HIV infection, comorbidities and independently and age on HRQL and depression. associated with worse physical and mental HRQL and Methods: HIV-infected individuals and uninfected controls from the AGEhIV Cohort Studywith were an screened increased for the presence likelihood of comorbidities. of depression. They completed the Short Form 36-item Health Survey to assess HRQL and the nine-item Patient Health Questionnaire to assess depression. Linear and logistic regression were used to investigate to which extentØ higher comorbidities, number aging of and comorbidities HIV infection were was independently independently associated with HRQL and depression. Results:associatedHIV-infected with individuals worse (n physical541) reported quality significantly of life worse physical and ¼ mental HRQL and had a higher prevalence of depression than HIV-uninfected individuals (n 526). A higher number of comorbidities and HIV-positive status were each inde- ¼ pendently associated with worse physical HRQL, whereas HIV-positive status and younger age were independently associated with worse mental HRQL and more depres- sion. The difference in physical HRQL between HIV-positive and HIV-negative individ- uals did not become greater with a higher number of comorbidities or with higher age. Conclusion: In a cohort of largely well suppressed HIV-positive participants and HIV- AIDS. 2017;31:1471-1481. negative controls, HIV-positive status was significantly and independently associated with worse physical and mental HRQL and with an increased likelihood of depression. Our finding that a higher number of comorbidities was independently associated with worse physical HRQL reinforces the importance to optimize prevention and manage- ment of comorbidities as the HIV-infected population continues to age. Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved. AIDS 2017, 31:1471–1481 Keywords: ageing, cohort study, comorbidity, depression, health-related quality of life, HIV infection aDepartment of Internal Medicine and Infectious Diseases, Rijnstate Hospital Arnhem, Arnhem, bDepartment of Medical Psychology, Academic Medical Centre, cDepartment of Global Health, Academic Medical Centre and Amsterdam Institute for Global Health and Development, dDivision of Infectious Diseases and Centre for Infection and Immunity Amsterdam (CINIMA), eDepartment of Infectious Diseases, Public Health Service of Amsterdam, and fHIV Monitoring Foundation, Amsterdam, The Netherlands. Correspondence to Nienke Langebeek, MSc, Department of Internal Medicine and Infectious Diseases, Rijnstate Hospital Arnhem, PO Box 9555, 6800 TA Arnhem, The Netherlands. Tel: +31 88005 6780; e-mail: [email protected] Received: 21 November 2016; revised: 28 March 2017; accepted: 3 April 2017. DOI:10.1097/QAD.0000000000001511 ISSN 0269-9370 Copyright Q 2017 Wolters Kluwer Health, Inc. All rights reserved. 1471 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Geriatric syndromes in PWH • Average age of those with HIV not in the territory of true older age • But increasing problems seen in older adults including: – Cognitive impairment – Complex multimorbidity – Polypharmacy – Mobility decline – Falls – Functional impairment- difficulties of activities of daily living/self-care – Frailty Frailty Decline in multiple physiological systems resulting in: – An ‘at risk’ state – Vulnerability to minor stressor events (may trigger crisis) – Disproportionate changes in health status – An increased risk of adverse events • Falls, hospital admission, disability, mortality Physiological reserve Frailty in PWH: Brighton Number (N) % 95% CI Frailty Frail (scores 3-5) 48 19% 14.6-24.3 status Pre-frail (scores 1-2) 111 44% 37.8-50.1 Robust (scores 0) 94 37% 31.4-43.3 Median age 61 (55-79) 60 47% 39% 40 23% 20 10% 11% Prevalence (%) Prevalence 0 Low activity Exhaustion Weight loss Weak grip Slow walk Phenotypic criterion (Fried) Levett T et al , 2016,BHIVA Predictors Variable Risk of frailty AdjOR (95% CI) p-value Age (per year) 6% ↑ 1.06 (1.01-1.21) 0.018 Comorbidity count 58% ↑ 1.58 (1.28-1.95) <0.001 Moods/anxiety symptoms 17% ↑ 1.17 (1.10-1.24) <0.001 Not working 8-fold ↑ 8.43 (1.94-36.6) 0.004 Financial insecurity 3-fold ↑ 3.46 (1.54-7.77) 0.003 Current smoker 2-fold ↑ 2.35 (1.00-5.50) 0.049 COPD 4-fold ↑ 4.53 (1.11-18.6) 0.036 Arthritis 4-fold ↑ 3.69 (1.90-8.88) <0.001 Daily pain 3-fold ↑ 3.01 (1.30-7.01) 0.010 No regular exercise 4-fold ↑ 3.85 (1.68-8.84) <0.001 Adjusted for age, gender, comorbidity count and HADS score Levett T et al , 2016, BHIVA Falls but not frailty are common in people living with HIV using an mHealth platform: issues of ageing within the EmERGE cohort 1 1 1 1 2 3 4 5 3 5 2 6 EmERGE Project has received funding from the European Union’s Horizon 2020 Authors: T Levett , J Vera , C Jones , S Bremner , A Leon , J Begovac , L Apers , M Borges , S Zekan , E Teoflo , F Garcia , J Whetham on behalf of the EmERGE Consortium. [email protected] Research and Innovation Programme under Grant Agreement No: 643736 1Brighton & Sussex Medical School, Brighton, United Kingdom, 2Fundació Clínic per a la Recerca, Barcelona, Spain 3Klinika za Infektivne Bolesti, Zagreb, Croatia 4Instituut Voor Tropische Geneeskunde, Antwerp, Belgium 5Centro Hospitalar de Lisboa Central, Lisbon, Portugal 6Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom Introduction: Falls but not frailtyResults: are common in people living withFalls: HIV using Ageing of HIV cohorts globally brings new challenges Interim data is presented.