Post-Congress Activity Expert Review on the EACS, HIV & Aging and the AASLD Meetings, 2011

Post-‐Congress Ac.vity Expert Review on the EACS, HIV & Aging

and the AASLD Mee.ngs

With Dr. Mark Wainberg (moderator) and Dr. Fred Crouzat, Dr. Alice Tseng, and

Dr. Stephen Shafran

2nd Interna.onal Workshop on HIV and Aging

October 27-‐28, 2011

Bal3more, Maryland

Immune Dysfunction

and Senescence.

Microbial Translocation “Leaky Gut”

Chronic Inflammation and Platelet

Hypercoagulability

HIV and Non-HIV Treatment

Toxicity Oxidative Stress.

Associated Comorbid Disease

Incremental Depletion in Organ

System Reserve

Death

Presenting Conditions

Interacting Pathophysiologic Processes

Organ System Injury

Advanced Clinical Disease

AG

ING

VACS Risk Index

Health Care Outcomes

Repeated Hospitalization/ Nursing Home

Placement

Functional Decline

Organ System Failure

Conceptual Model for Aging with HIV Infec.on

HIV

Viral Hepatitis

Alcohol and Other

Substance Abuse

Adapted from Jus3ce A et al. Alcohol Res Health 2010;33:258-‐66.

Guaraldi G, et al. Clin Infect Dis. 2011;53(11):1120-‐6. Epub 2011 Oct 13.

Untreated Cerebrovascular Disease May Have Implica.ons for Cogni.ve Impairment (CI) in HIV

MACS cohort: – n = 207 HIV-‐ & 428 HIV+ men, median ~50 yo, CD4 535, no history of CVD

– ↑ caro3d in3ma media thickness (IMT) and fas3ng glucose were predictors of poor psychomotor speed performance (p=0.04 & 0.037)

– AIDS, detectable VL and CD4 were not significant predictors

SMART study: – n=292, median CD4 536, 88% VL<400, 92% on cART

– Risk of cogni3ve impairment higher in pts with pre-‐exis3ng CVD (OR 6.2, CI 1.4–26.4); use of HTN agents, ↑ cholesterol & HBV also risk factors

– Current/nadir CD4, CPE scores not associated with impairment

Results suggest that risk of CI more strongly related to CV & metabolic disease profiles than HIV serostatus or disease

Becker JT, et al. Neurology 2009;73:1292-‐9. Wright EJ, et al. Neurology 2010 ;75:864-‐73.

Treatment of Vascular Risk Factors Impacts Neurocogni.ve Func.on in HIV

• n=98 HIV+ adults – mean 44 yo, 81% male, 70%

AA, 62% prior AIDS

• 23 pts with CVS risk factors (DM, HTN) – 13 treated, 10 untreated

• Pts with untreated CVS risk demonstrated ↓ processing speed, learning/memory and execu3ve func3oning vs. those on medica3on (p=0.01, 0.04, 0.09)

Foley J, et al. Clin Neuropsychol 2010;24:265-‐85.

Strategies to Improve Cogni.on

• Mindfulness-‐Based Cogni.ve Therapy (MBCT) – 40 HIV+ subjects randomized to par3cipate in MBCT (2-‐hr class/wk x 8)

or con3nue with rou3ne care • mean 50 yo, 20 yrs since HIV Dx, 16 yrs on ART, current CD4 527, VL<25 in 39 subjects

– MBCT group reported significant ↑ in quality of life vs. controls (energy, pain, emo3onal reac3ons, sleep, social isola3on, mobility)

• Visualiza.on/Mental Imagery – 70 HIV+ pts assigned prospec3ve memory (PM) medica3on task;

randomized to visualiza3on exercise vs. repea3ng instruc3ons • 83% male, mean 56 yo, 70% Caucasian, 91% cART, 93% CD4 >200,

85% VL undetectable

– visualiza3on significantly improved ability to complete PM task (55% vs. 30%, p<0.05)

Fumaz et al. [#O_09]. Presented at the 2nd Interna3onal Workshop on HIV & Aging, October 27-‐28, 2011, Bal3more, USA. Woods et al. Ibid, #O_10.

Saturday, November 19th, 2011

Falls: A Geriatric Syndrome

Falls common in people ≥ 65 yrs of age – 30% rate per year, associated with significant morbidity (ER visits, nursing home placements, loss of independence)

Risk factors: – comorbidi3es (depression, HTN, arthri3s, DM, pain, urinary incon3nence)

– physical impairment (balance, strength, gait, cogni3on)

– polypharmacy (esp. psychoac3ve meds)

Erlandson KM, et al. [#O_05] Presented at the 2nd Interna3onal Workshop on HIV & Aging, October 27-‐28, 2011, Bal3more, USA.

Falls in HIV-‐Infected Persons: Prevalence and Risk Factors

• Cross-‐sec3onal study of 359 HIV+ pts 45-‐65 yo on cART for > 6 months with VL<48 copies/mL

• Verbally ques3oned about falls in past year – 70% no falls – 30% ≥ 1 fall – 18% frequent falls (≥ 2 falls)

• Current CD4, nadir CD4, dura3on of ART similar b/w frequent & non-‐fallers

• Risk factors for frequent falls: – female, smokers, comorbidi3es and

polypharmacy (p<0.01) • Frequent fallers:

– weaker grip strength, greater difficulty arising from a chair, greater difficulty with balance, slower gait speed over 400 m (all sta3s3cally significant)

– Frailty by Fried’s defini3on1 (OR 9.3, CI 3.6-‐24.3, p<0.001)

• Conclusions: – fall risk for middle-‐aged HIV+ persons is

consistent with rates in general popula3on ≥ 65 yo

– ↑ risk with comorbidi3es and meds


OR (CI)

3.0 (1.4-‐6.8)

5.6 (2.6-‐12.1)

3.2 (1.8-‐5.6)

8.2 (2.0-‐33.9)

3.2 (1.5-‐5.5)

4.6 (2.6-‐8.2)

3.7 (1.9-‐6.9)


Mul.ple Comorbidi.es are Associated with Greater Fall Risk in HIV-‐1 Infected Persons

OR (CI)

3.6 (1.8-‐7.3)

4.5 (2.6-‐8.1)

3.9 (1.9-‐8.1)

4.6 (2.6-‐8.1)

2.8 (1.4-‐5.3)

5.5 (3.1-‐9.8)

Polypharmacy is Associated with Greater Odds of Falling in HIV-‐Infected Persons


Frailty and Hospitaliza.ons in IDUs

Prospec.ve cohort of subjects with current/past IDU

– n=1206, median 48 yo, 4652 person visits – 28% HIV+ (n=345):

• median CD4 290, VL 3.1 log, CD4 nadir 138, 21.7% AIDS diagnosis, 51% on cART

Overall prevalence of frailty 8.3%, pre-‐frailty 59% – associated with age, female, socioeconomic class, depressive Sx, HIV status

– higher risk in advanced HIV with poor virologic control – frailty was an independent predictor of hospitaliza3on (adjusted HR 1.5, CI 1.01-‐2.17)

Piggot DA, et al. Frailty and Incident Hospitaliza3on among HIV+ and At Risk Injec3on Drug Users (IDUs). [#O_06]. Presented at the 2nd Interna3onal Workshop on HIV & Aging, October 27-‐28, 2011, Bal3more, USA.

Frailty and Hospitaliza.ons in IDUs

Frailty and HIV Clinical Status:

Prefrail Adj OR* (95% CI)

Frail Adj OR* (95% CI)

HIV nega3ve Ref Ref

HIV+, CD4≥350, VL UD 1.14 (0.81, 1.62) 1.13 (0.65, 1.97)

HIV+, CD4<350, VL UD 1.37 (0.97, 1.95) 1.75 (1.02, 2.98)

HIV+, CD4≥350, VL+ 1.14 (0.79, 1.63) 1.80 (1.00, 3.21)

HIV+, CD4<350, VL+ 1.49 (1.17, 1.89) 2.26 (1.51, 3.39)


Hospitaliza.on by Frailty Status in ALIVE


Current Reali.es/Challenges of Aging Well with HIV

Cure

• DNA repair • oxida3ve stress • telomere protec3on?

• HIV cure

Chronic Management

• medica3on adherence • exercise • risk modifica3on

• management of comorbidi3es

• cogni3ve-‐based tx • search for treatable factors

vs.

Adapted from Valcour V. Presented at the 2nd Interna3onal Workshop on HIV & Aging, October 27-‐28, 2011, Bal3more, USA.

Post-Congress Activity Expert Review on the EACS, HIV & Aging and the AASLD Meetings, 2011

Health & Medicine

Transcript of Post-Congress Activity Expert Review on the EACS, HIV & Aging and the AASLD Meetings, 2011