Optimal Wellness

December 13, 2012

For Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

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Welcome & Overview- 5 mins Optimal Wellness for People

Living with HIV: The Challenges of Success – 30 mins

Panel Discussion on Optimal Wellness, 20 mins

Wrap-up & Evaluation, 5 mins

Michael Hagerin+care Campaign ManagerNational Quality CenterNew York, NYmichael@nationalqualitycenter.org

Conversation opportunities throughout webinar

Agenda

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For more information: www.incarecampaign.org

This Partners in+care webinar is offered as part of the in+care Campaign.

The in+care Campaign is a national effort to improve retention in HIV care.

Webinars are one of many Partners in+care activities designed to engage people living with HIV/AIDS and their allies in the in+care Campaign.

Welcome & Overview

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This is a “public event.” If you have confidentiality concerns: Your names appear on-line in the list of webinar

registrants -consider just listening to the audio or to viewing the webinar at a later time, after it is posted at www.incarecampaign.org. Or, consider using an alias when entering as a guest

All webinars are recorded - do not use identifying information when asking questions

Participation Guidelines

For Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

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Actively participate and write your questions into the chat area during the presentation; we will also have a “pop up” question exercise, and will pause for conversation during the webinar

Do not put us on hold Mute your line if you are not speaking (press

*6, to unmute your line press #6) The slides and recording of this and other

Partners in+care webinars are available for playback and group presentations at www.incarecampaign.org – “Resources” tabFor Audio: Dial-in#: 866.394.2346 Participant Code: 397 154 6368#

Participation Guidelines

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Learning Objectives

At the end of this webinar you will know:

Wellness concerns for aging people living with HIV

Emerging trends for this population related to wellness and HIV

Tools and Resources for supporting aging persons living with HIV

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Visit www.incarecampaign.org

Pop-up Question

YesNo

I am not HIV+

The Aging Community

Is your clinic seeing a rise in the number of Persons Living with HIV over 50 years

old?

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Visit www.incarecampaign.org

Pop-up Question

YesNo

I don’t know

Optimal Wellness

Do you think your clinic is adequately

addressing the needs of Aging Persons Living with HIV?

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Optimal Wellness for People Living with HIV; The Challenges of Success

Purpose of today’s webinar

• Review the epidemiology of aging with HIV

• Provide information about the impact of comorbid physical and mental health conditions among those aging with HIV

• To relate this information to the care needs of this population with a focus on optimal wellness

Mark Brennan-Ing, PhDSenior Research Scientist

AIDS Community Research Initiative of America (ACRIA): ACRIA Center on HIV & AgingNew York University College of

Nursing

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ACRIA IS A CENTER OF EXPERTISE (COE)

• The New York State Dept. of Health AIDS Institute Funds ACRIA to serve as a COE on Aging and HIV, STD’s and Hepatitis

• COES are designated as experts in a specific topic and travel throughout New York State to offer specialized trainings

• ACRIA develops training programs that: Build HIV and Aging Service Providers skills to

improve the clinical status of people living with HIV Delivers trainings for human service providers Provides on-line distance learning opportunities Offers capacity building and technical assistance

opportunities

EPIDEMIOLOGY

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Why is the HIV Population Graying?

• With the advent of successful anti-retroviral therapies, adults 50 and older will be the majority of people living with HIV in the U.S. by 20151

• However, part of this growth is new infections, with adults 50+ accounting for approximately 11% of all new HIV infections

1 United States Senate Special Committee on Aging. HIV over Fifty: Exploring the New Threat. [Web cast]. May 12, 2005. Available at http://aging.senate.gov/hearing_detail.cfm?id=270655&.2 Brooks et al. (2012). (Am J Public Health. Published online ahead of print June 14, 2012: e1–e11. doi:10.2105/AJPH. 2012.300844.

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Mortality (x 1000)

HAART

Impact of HAART

Source: NYC Dept of Health & Mental Hygiene, 2004

PLWHA(x 10,000)

0

1

2

3

4

5

6

7

8

9

81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02

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Persons Living with HIV/AIDS By Age, New York State, end of year, 2002 and 2008*

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

12 & under 13-19 20-24 25-29 30-39 40-49 50-59 60+

2002 2008

* 2008 data are provisional

Source: NYSDOH BHAE

2002 N=102,464 2008 N=124,782

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0%10%20%30%40%50%60%70%80%90%

100%

2008

12 & under 13-19 20-24 25-29

30-39 40-49 50-59 60+

Persons Living with HIV/AIDSBy Age, New York State, end of 2008*

Source: NYSDOH BHAE

(N=124,782)

74.8% of PLWHA are 40

and older(93,426)

* 2008 data are provisional

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% of People with HIV Age 50 and Older 2009-2010

19 % and less20-29 %30-39 %

40 % and more

A National Trend

The Challenges of Success; Aging, HIV & Multimorbity

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Background• People with HIV on HAART are being treated

successfully as evidenced by viral suppression• However, those who are ageing with the virus are

experiencing a variety of non-HIV/AIDS conditions• AIDS-defining conditions are becoming less

common• CD4 t-cell counts are still related to morbidity and

mortality in this population i.e., those with low CD4 counts and high viral load

more likely to experience both AIDS-defining and non-AIDS defining health problems

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Prevalence of Co-morbidities

• Data obtained from Research on Older Adults with HIV (ROAH) Adults 50 and older living with HIV (n = 914) Average age of 55.5 years Approximately one-third are women Fifty-percent African-American/Black, 33% Latino

• Living with HIV 12.6 years on average• 85% on HAART• 51% with AIDS diagnosis• 67% identified as heterosexual

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Comorbidities in ROAH

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ROAH: Distribution of Comorbidity

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Comorbidity Comparison: ROAH & Older Adults

Elderly 70+ ROAH

00.5

11.5

22.5

33.5

44.5

5

1.1

3.3

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Depression (52%)

• The most frequently reported comorbid condition

• Depression is often related to:• Prior history of depression• Presence of physical illness• Comorbid psychiatric and substance

use issues• Chronic stress• History of trauma/abuse• HIV stigma• Loneliness and Social Isolation

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Depression Assessment in ROAH

• Depressive symptomatology measured with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977)

• CES-D: 20-item self-report scale referring to symptoms experienced in the previous week; 4 items are reverse coded to prevent response-bias

• Responses scored on a 4-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time)

• Items are summed to obtain a total score with range of 0 to 60; higher scores indicate greater level of depressive symptoms (α = .90 for ROAH sample)

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CES-D Symptoms of Depression

Severe (23+)43%

Moderate (16-22)20%

Not De-

pressed (1 to

15)37%

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Depression in ROAH vs. Other Older Adults

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Depressive Symptoms and Conditions

Source: Havlik, R. J., Brennan, M., & Karpiak, S. E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8(4), 551-559. DOI:10.1071/SH11017

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Depression Predicts Comorbidity

Source: Havlik, R. J., Brennan, M., & Karpiak, S. E. (2011). Comorbidities and depression in older adults with HIV. Sexual Health, 8(4), 551-559. DOI:10.1071/SH11017

Treatment and Care Issues

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Multi-Morbidity Management

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Treatment Strategies for Older Adults with HIV

http://www.aahivm.org/Upload_Module/upload/HIV%20and%20Aging/AAHIVM%20Executive%20Summary%20FINAL%202.pdf

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What is Patient Retention• Retention in care is

typically measured in three ways: A) Missed appointments B) Medical visits at

regular intervals C) Combination of A & B

Horstman, E., Brown, J., Islam, F., Buck, J., & Agins, B. D. (2010). Retaining HIV-infected patients in care: Where are we? Clinical Infectious Diseases, 50, 752-761.

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Why is Care Retention Important?

• HIV patients in regular care are more likely to adhere to HAART Non-adherence to HAART linked to poor health

outcomes as well as the development of treatment-resistant strains of HIV

• High prevalence of multi-morbidity warrants regular engagement with health providers and screening to detect conditions early

• Keeping HIV-patients engaged in care is cost effective due to fewer emergency room visits and hospitalizations

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Are HIV+ Patients in Care?• Missed appointment rates are 25% to 30%

regardless of which types of appointments are included

• Proportion of HIV patients missing at least one appointment is 25% to 44% depending on time frame

• Average rate of retention in New York State was 72%, ranging from 20% to 100% in ambulatory clinics based on self-report (NYS DOH)

• Continuum Engagement Model research finds: Regular users (25%) Sporadic users (32%) Non-engagers (43%)

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Clinical Retention Factors:• Poorer retention is associated with:

1. Higher CD4 cell counts2. Not having an AIDS diagnosis (i.e., CD4 < 200

or presence of opportunistic infection)3. Detectable Viral Load and AIDS defining CD4

count• While seemingly contradictory, patients may

skip appointments if they are feeling well (1 & 2) or if they are ill (3)

• Poor health may be due to missed appointments in a reciprocal manner

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Other Retention Factors• Other factors related to poor retention:

History or current injection drug use Low perceived social support Less engagement with health care provider Shorter follow-up after initial appointment Unemployment Mental/psychiatric illness Child care Transportation Hospitalization “Other” (i.e., forgot, last minute social engagement,

etc.)

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Benefits of Care Retention

• Keeping HIV+ Patients in Care has been found to: Increase access to ARVs Improve Treatment Adherence Suppression of Viral Load Improved Immune Function Less Drug Resistance Reduced Health Care Costs (i.e., fewer ER and

Inpatient visits) Less Risky Sexual Behavior Improved Survival Rates

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National Minority AIDS Council's Model for HIV prevention and care *

• Model is to move PLWHA along the treatment cascade so that 81% of people living with HIV in the U.S. know their HIV status and have a suppressed viral load

• This model asks Health Departments and Community Based Organizations (CBOs) to: Identify people who do not know they are HIV positive

Increase linkage to and retention of PLWHA in high-quality care

Improve treatment adherence among PLWHA to achieve a suppressed viral load* based on modeling done by Dr. David Holtgrave

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Current Treatment Cascade

Source: Dr. Ronald Valdiserri, Centers for Disease Control (CDC) U.S.A.

Optimal Wellness Through Care Retention: Federal and

State Efforts

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in+care (http://www.incarecampaign.org)• National campaign for Ryan White grantees

supported by HRSA HIV/AIDS Bureau in coordination with the National Quality Center

• Goal is to support and provide resources to providers seeking to improve care retention: Data collection and reporting Webinars One-on-one coaching Local retention groups led by local quality

champions Partners in+care consumer education

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NY Links

• Supported by a Special Project of National Significance award to New York State to address system linkages and care access for those with HIV Goal is to develop and disseminate effective

linkage and retention models Community-level improvement approach Outcome of better health for people with HIV

and reduced HIV transmission• Other SPNS Grantees for this project

Pennsylvania, Virginia, Massachusetts, North Carolina, Louisiana, and Wisconsin

The Importance of Mental Health

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Over 2/3 of the study group had moderate to severe

depression

Depression Causes Non-Adherence to ALL Medication

including HIV Meds

Although in Medical Care their Depression Remains Unmanaged

Depression, Treatment Adherence & Care

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Co-occurence1

• A triple diagnosis (HIV + mental illness + substance use) impairs a person’s well-being and quality of life significantly

• Patients with triple diagnosis often have higher levels of distress and physical impairment compared to individuals with no diagnosis, or a psychiatric, or a substance use disorder alone (Lyketsos, et al., 1994)

• The interaction between the mental health and substance abuse problems escalate both the level of risk, and the severity of HIV (Stoff et al., 2004)1 HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx

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Substance Use Complicates HIV Care• Substance and alcohol use among persons

living with HIV is associated with: other mental health issues like depression

(Pence et al.) poor adherence to antiretroviral therapy

(Chesney, 2000; Ware et al., 2005) greater risk for HIV infection (Leigh & Stall, 1993;

Semaan et al., 2002)• Alcohol and substance use can decrease the

efficacy of antiretroviral therapy (Michel, Carrieri, Fugon et al., 2010)

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Substance Use in ROAH• ROAH respondents

were asked about current and lifetime use of tobacco, alcohol and other substances

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ROAH: Tobacco Use

• Tobacco use is associated with increased rates of cardiac disease, respiratory conditions, and cancers

• Smoking cessation efforts are needed to insure optimal wellness for those who use tobacco and are aging with HIV

Current History

57 % 84 %

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AlcoholMarijuana

Pain KillersCocaine

CrackHeroin

PoppersLSD/PCP

Crys MethEcstasy

KetamineGHB

0 10 20 30 40 50 60 70 80 90

PresentLife Time

80%0% 40%

Alcohol and Substance Use: ROAH

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Treat the Person, Not the Disease• Successful care of those with triple diagnosis requires a

holistic approach provided by an interdisciplinary, culturally sensitive clinical team (i.e., case managers, social workers, medical providers, counselors or therapists, and psychiatrists)

• Optimally, medical, dual diagnosis, and psychosocial services should be easily accessible at the same location.

• Integrated care should include: Access to ancillary services; Deliver multidisciplinary provider collaboration; Client-centered approach; and, Incorporates substantial efforts to connect patients to case

management services to address a variety of psychosocial needs (homelessness, poverty, and treatment adherence)

1 HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx

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Achieving Optimal Health Outcomes Must Address…

Client’s priorities

Psychosocial characteristics

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NYS DOH AI COEOlder Adults with HIV Webinar

Series• Thursday January 24th, 2013:

Social Isolation and Social Supports

• Wednesday, March 6th, 2013: Sex and Prevention Burnout

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Thank You!

For Further Information Please Contact:

Mark Brennan-Ing, PhDSenior Research Scientist

AIDS Community Research Initiative of America575 Eighth Avenue, Suite 502

New York, NY 10018(212) 924-3934 ext 131mbrennan@acria.org

www.acria.org

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Stigma and Retention in CarePanel Discussion - Introduction

Mark Brennan-Ing, PhDSenior Research ScientistAIDS Community Research

Initiative of America (ACRIA): ACRIA Center on HIV & AgingNew York University College of

Nursingmbrennan@acria.org

Carolyn Massey, MHS(c)Executive DirectorOlder Women Embracing Life

(OWEL) Inc.masseyc2002@yahoo.com

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Let us know your experiences in the chat room!

What is the greatest challenge facing retention efforts for Aging Persons Living With

HIV?

Speaking from Experience:Optimal Wellness: Aging with HIV

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Let us know your experiences in the chat room!

What change is needed to ensure that we are adequately addressing the needs of Aging

Persons Living with HIV?

Speaking from Experience:Optimal Wellness: Aging with HIV

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Visit www.incarecampaign.org

Pop-up Question

More likely than before I watched this programNo more or less likely than before I watched this

programLess likely than before I watched this program

Adapting to our Success

How likely are you to reevaluate the way you address the wellness

needs of Aging Persons Living with HIV?

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