Transcript No Slide Title

Optimal
Wellness
December 13, 2012
For Audio: Dial-in#: 866.394.2346
Participant Code: 397 154 6368#
Agenda
Michael Hager
in+care Campaign Manager
National Quality Center
New York, NY
[email protected]
 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
Conversation opportunities throughout webinar
2
Welcome & Overview
 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.
For more information: www.incarecampaign.org
3
Participation Guidelines
 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
For Audio: Dial-in#: 866.394.2346
4
Participant Code: 397 154 6368#
Participation Guidelines
 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” tab
For Audio: Dial-in#: 866.394.2346
5
Participant Code: 397 154 6368#
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
6
The Aging Community
Pop-up Question
Is your clinic seeing a rise in
the number of Persons
Living with HIV over 50
years old?
Yes
No
I am not HIV+
Visit www.incarecampaign.org
7
Optimal Wellness
Pop-up Question
Do you think your clinic is
adequately addressing the
needs of Aging Persons
Living with HIV?
Yes
No
I don’t know
Visit www.incarecampaign.org
8
Optimal Wellness for People Living with HIV; The
Challenges of Success
Purpose of today’s webinar
• Review the epidemiology of aging with HIV
Mark Brennan-Ing, PhD
Senior Research Scientist
AIDS Community Research Initiative of
America (ACRIA):
ACRIA Center on HIV & Aging
New York University College of Nursing
9
• 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
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
10
EPIDEMIOLOGY
Why is the HIV Population Graying?
• With the advent of successful antiretroviral 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.
12
Impact of HAART
9
8
Mortality
(x 1000)
7
6
5
4
3
PLWHA
(x 10,000)
2
1
0
81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
Source: NYC Dept of Health & Mental Hygiene, 2004
13
HAART
Persons Living with HIV/AIDS
By Age, New York State, end of year, 2002 and 2008*
50000
45000
Source: NYSDOH BHAE
40000
* 2008 data are provisional
35000
30000
25000
20000
15000
10000
5000
0
12 & under
2002 N=102,464
14
13-19
20-24
2008 N=124,782
25-29
2002
30-39
2008
40-49
50-59
60+
Persons Living with HIV/AIDS
By Age, New York State, end of 2008*
* 2008 data
are provisional
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
74.8% of
PLWHA are 40
and older
(93,426)
2008
(N=124,782)
Source:
NYSDOH
BHAE
15
12 & under
13-19
20-24
25-29
30-39
40-49
50-59
60+
A National Trend
% of People with HIV Age 50 and Older 2009-2010
40 % and more
30-39 %
20-29 %
19 % and less
16
The Challenges of Success; Aging, HIV
& Multimorbity
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
18
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
•
•
•
•
19
Living with HIV 12.6 years on average
85% on HAART
51% with AIDS diagnosis
67% identified as heterosexual
Comorbidities in ROAH
20
ROAH: Distribution of
Comorbidity
21
Comorbidity Comparison:
ROAH & Older Adults
5
3.3
4
3
1.1
2
1
0
Elderly 70+
22
ROAH
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
23
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)
24
CES-D Symptoms of Depression
Moderate
(16-22)
20%
Severe (23+)
43%
25
Not
Depressed
(1 to 15)
37%
Depression in ROAH vs. Other Older Adults
26
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
27
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
28
Treatment and Care Issues
Multi-Morbidity Management
30
Treatment Strategies for Older Adults with HIV
http://www.aahivm.org/Upload_Module/upload/HIV%20and%20Aging/AAHIVM%
20Executive%20Summary%20FINAL%202.pdf
31
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.
32
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
33
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%)
34
Clinical Retention Factors:
• Poorer retention is associated with:
1.
2.
3.
Higher CD4 cell counts
Not having an AIDS diagnosis (i.e., CD4 < 200 or presence of
opportunistic infection)
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
35
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.)
36
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
37
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
38
Current Treatment Cascade
Source: Dr. Ronald Valdiserri, Centers for Disease Control (CDC) U.S.A.
39
Optimal Wellness Through Care
Retention: Federal and State Efforts
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
41
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
42
The Importance of Mental Health
Depression, Treatment Adherence & Care
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
44
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
45
HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx
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)
46
Substance Use in ROAH
• ROAH respondents were
asked about current and
lifetime use of tobacco, alcohol
and other substances
47
ROAH: Tobacco Use
Current
History
57 %
84 %
• 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
48
Alcohol and Substance Use: ROAH
GHB
Ketamine
Ecstasy
Crys Meth
LSD/PCP
Poppers
Heroin
Crack
Cocaine
Pain Killers
Marijuana
Alcohol
Present
Life Time
0%
49
40%
80%
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
50
HIV Integrated Care at: http://www.apa.org/pi/aids/programs/bssv/integration.aspx
Achieving Optimal Health
Outcomes Must Address…
Client’s priorities
Psychosocial characteristics
51
NYS DOH AI COE
Older Adults with HIV Webinar Series
• Thursday January 24th, 2013:

Social Isolation and Social Supports
• Wednesday, March 6th, 2013:

52
Sex and Prevention Burnout
Thank You!
For Further Information Please Contact:
Mark Brennan-Ing, PhD
Senior Research Scientist
AIDS Community Research Initiative of America
575 Eighth Avenue, Suite 502
New York, NY 10018
(212) 924-3934 ext 131
[email protected]
www.acria.org
53
Stigma and Retention in Care
Panel Discussion - Introduction
Mark Brennan-Ing, PhD
Senior Research Scientist
AIDS Community Research Initiative of
America (ACRIA):
ACRIA Center on HIV & Aging
New York University College of Nursing
[email protected]
Carolyn Massey, MHS(c)
Executive Director
Older Women Embracing Life (OWEL) Inc.
[email protected]
54
Speaking from Experience:
Optimal Wellness: Aging with HIV
What is the greatest challenge
facing retention efforts for
Aging Persons Living With
HIV?
Let us know your experiences in the chat room!
55
Speaking from Experience:
Optimal Wellness: Aging with HIV
What change is needed to
ensure that we are adequately
addressing the needs of Aging
Persons Living with HIV?
Let us know your experiences in the chat room!
56
Adapting to our Success
Pop-up Question
How likely are you to
reevaluate the way you address
the wellness needs of Aging
Persons Living with HIV?
More likely than before I watched this program
No more or less likely than before I watched this program
Less likely than before I watched this program
Visit www.incarecampaign.org
57
Partners in+care Resources
Visit Web / Open the Toolkit
www.incarecampaign.org - “Partners” tab
Sign up for Partners in+care Network
www.incarecampaign.org – “Partners” tab
Join Facebook
Send email to
[email protected] –
“Facebook” in subject line
58
Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730