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Challenges associated with ageing in women living with HIV

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Title: Challenges associated with ageing in women living with HIV


1
Challenges associated with ageing in women living
with HIV
2
Contents
Introduction
Physical challenges of ageing in women with HIV
Emotional, psychological and psychiatric
challenges of ageing in women with HIV
Support
Case studies
Summary
3
Introduction
4
An ageing global population
  • By 2050, 25 of the global population will be
    60 years

Global population estimate
US Census Bureau International Data Base
5
The changing age distribution of people living
with HIV
  • People with access to ART can look forward to
    extended life spans, similar to the general
    population
  • Antiretroviral Therapy Cohort Collaboration
    (2008) Lancet
  • 2. Swiss HIV Cohort Study (May 2009)

6
Proportion of new HIV/AIDS cases in older people
  • The rate of HIV infection and new diagnoses among
    older people is increasing1-3
  • In Europe, the proportion of women aged 50 years
    accounting for new HIV/AIDS cases in women rose
    from 7.4 in 2004 to 12.5 in 20104
  • UK data show that new diagnoses among older
    adults more than doubled between 2000 and 2009,
    accounting for 13 of all diagnoses in 20095
  • In the UK, women represent 25 of all diagnoses
    in people 50 years6
  • However, true rates of infection in the
    population aged 50 years are often unknown due
    to poor testing rates7

1. EuroHIV End-year Report (2006) 2. Simone MJ
et al (2008) Geriatrics 3. Dougan S et al
(2004) Epidemiol Infect 4. WHO/ECDC (2010)
HIV/AIDS surveillance in Europe 2010 5.
http//www.hpa.org.uk/hpr/archives/2010/hpr4710.pd
f 6. Smith R et al (2010) HIV Medicine 7. Pratt
G et al (2010) Age and Ageing
7
Significance of age at diagnosis
  • HIV testing is often delayed in older
    individuals1
  • Older individuals may not perceive themselves as
    being at risk for HIV infection
  • HCPs may fail to consider HIV as a potential
    cause of illness
  • Delayed treatment and diagnosis may have more
    adverse consequences in older individuals
    compared with younger people2-4
  • Older patients diagnosed with a CD4 cell count
    lt200 cells/mm3 at the time of their diagnosis are
    14 times more likely to die than younger
    patients4
  • However, older patients derive a similar level of
    benefit form ART as younger patients5
  • Rotily M et al (2000) Int J STD AIDS
  • Kirk (2006) J Am Geriatr Soc
  • 3. COHERE Study Group (2008) AIDS
  • 4. Smith R et al (2010) Lancet
  • 5. Perez JL et al (2003) Clin Infect Dis

8
HIV in older woman
  • There is a lack of research on sexual activity in
    older individuals
  • The successful integration of sexual health care
    can decrease morbidity and mortality, and enhance
    well-being and longevity in the patient1
  • A considerable proportion of sexually active
    older adults with HIV practice unsafe sex2
  • Shorter time from diagnosis to onset of AIDS
    (age-related faster progression to AIDS, late
    diagnosis)3
  • HIV testing in older women is uncommon4
  1. AAHIVM (2011) 2. Golub SA et al (2010) Sex
    Transm Dis 3. CDC (2006) 4. The Wellness
    Project 5. Deeks SG (2011) Ann Rev Med

9
Consequences of ageing as a woman with HIV
  • Conditions with increased incidence in women
    living with HIV
  • Hormonal changes
  • Cardiovascular events
  • Non-AIDS-defining infections
  • Renal disease
  • Non-AIDS-defining malignancy
  • Muscular and skeletal changes
  • Non-AIDS neurocognitive and psychiatric events,
    mood and CNS disorders
  • Women living with HIV face all the challenges
    that the general population faces when growing
    older PLUS

The consequences of HIV
The consequences of longer exposure to HIV
treatment regimens
9
10
Research on ageing in those living with HIV is
ongoing
  • There is an emerging consensus that HIV and/or
    its treatment may affect
  • the process of ageing, and/or
  • the development of illnesses typically associated
    with advancing age
  • It is uncertain why people with HIV infection
    develop these conditions earlier in their life
    course, suggestions include
  • HIV speeds up the ageing process
  • HIV is an additive to other risk factors which
    increases the risk of various illnesses
  • Further research is required to understand the
    processes involved in HIV and ageing

11
Physical challenges of ageing in women with HIV
12
Menopause
13
The menopause
  • The menopause is marked by the ending of
    menstruation and ovulation
  • Falling levels of the female sex hormone,
    oestrogen
  • Onset of the menopause is associated with an
    increased risk of13
  • cardiovascular disease (CVD)
  • diabetes
  • osteopenia / osteoporosis
  • Early onset menopause (before 46 years)
  • increases the risk of these diseases46
  • may be linked to increased mortality7,8
  1. Santoro N et al (2009) Maturitas 2. Carr MC
    (2003) J Clin Endocrinol Metab 3. Isaia GC et al
    (1990) Exp Gerontol 4. Kritz-Silverstein D et al
    (1993) Am J Public Health 5. Lisabeth LD et al
    (2009) Stroke 6. Janssen I et al (2008) Arch
    Intern Med 7. Cooper et al (1998) Ann Epidemiol
    8. Jacobsen BK et al (2003) Am J Epidemiol 9.
    Conde DM et al (2009) Menopause

14
Onset of early menopause in women living with HIV
P0.04
n303
n268
  • US study 571 women (53 with HIV)
  • Women with HIV were 73 more likely to experience
    early onset of menopause, compared with
    HIV-negative women (P0.024)

14
Schoenbaum et al (2005) Clin Infect Dis
15
Onset of early menopause in women living with HIV
  • In the Italian DIDI study, the prevalence of
    early menopause (7.6) was comparable with the
    general population (7.1) however, a higher
    proportion of premature menopause was observed in
    women younger than 40 (5.2 vs. 1.8)1
  • Women with an earlier onset of menopause were
    more likely to
  • be at an advanced stage of HIV infection
  • have been diagnosed with HIV for a significantly
    longer time
  • have a history of drug misuse
  • Average age at onset of menopause in women with
    CD4 lt200 cells/mm3 is lower than in the general
    population2
  1. Cicconi P et al. EACS Congress 2011 Abstract
    PS2/5 2. de Pommerol M et al. Int J STD AIDS
    201122(2)67-72.

16
Impact of HIV on the symptoms of menopause
  • Menopause symptoms are common in women living
    with HIV1
  • The symptoms associated with the menopause are
    more frequent among women with HIV than
    HIV-negative women13
  • These include palpitations and insomnia in
    addition to vasomotor, psychological,
    genitourinary symptoms
  • Post-menopausal women living with HIV have lower
    BMD, increased bone turnover, and higher rates of
    bone loss than HIV negative women4
  1. Ferreira CE et al (2007) J Gynaecol Endocrinol
    2. Santoro N et al. Maturitas 200964160-164 3.
    Boonyanurak et al. (2012) Menopause 4. Yin MT
    et al. J Clin Endocrinol Metab 201297(2)554-62

16
17
Potential contributors to early onset of
menopause in women with HIV
  1. de Pommerol M et al (2011) Int J STD AIDS 2.
    Cooper GS et al (1999) Epidemiology 3. Luoto R
    et al (1994) Am J Epidemiol 4. Gold EB et al
    (2001) Am J Epidemiol

18
Menopausal symptoms may mimic HIV-related symptoms
Hot flushes at night
Mood changes
Vaginal dryness
Irregular menstrual cycles
  • It is important for women to monitor their
    menstrual cycle so that symptoms are not confused
    with effects from HIV or ART

Margolese S. http//www.thewellproject.org/en_US/W
omens_Center/Menopause.jsp
19
Hormone replacement therapy in women living with
HIV
  • HRT may be useful for some women with HIV but
    should be used at the lowest effective doses for
    the shortest time possible
  • Risks may outweigh the benefits if they
  • Smoke
  • Are overweight
  • Have had blood clots, breast cancer, diabetes,
    high cholesterol levels, liver problems, or a
    family history of heart disease
  • Oestrogen and/or progesterone have been shown to
    interact with many HIV drugs and this must be
    considered when prescribing HRT

New York State Department of Health AIDS
Institute (2010) Margolese S.
http//www.thewellproject.org/en_US/Womens_Center/
Hormones_and_HIV.jsp
20
Managing the menopause in women with HIV
  • Strategies to offset effects associated with
    menopause include1
  • Healthy lifestyle choices e.g. exercise and diet
  • Smoking cessation
  • Adherence to effective ART
  • Symptom management
  • Alternative therapies
  • If these strategies dont help then Hormone
    Replacement Therapy (HRT) can be considered1
  • Many ART medications may be affected by HRT and
    so this should be discussed with a healthcare
    professional2
  • 1. Monroe A. BETA 200739-441 2. New York State
    Department of Health AIDS Institute. Medical Care
    for Menopausal and Older Women With HIV
    Infection.

21
Managing the menopause in women with HIV
  • As part of the HCP consultation, points to
    discuss include
  • Recognising menopausal symptoms
  • Any medical tests required in relation to the
    menopause
  • Things they can take or do to help them through
    the menopause
  • Potential interactions between ART and HRT
  • Menopause support groups
  • Sources of further information

22
Osteoporosis
23
Risk factors for decreased bone mineral density
in women
Secondary
Chronic diseases (e.g. hyperthyroidism,
hyperparathyroidism, liver disease,
rheumatological conditions, eating disorders,
etc.) Hypogonadism Renal dysfunction Malnutriti
on/low BMI Medications (e.g. corticosteroids,
anticonvulsants, anticoagulants)
Adapted from Glesby MJ (2003) Clin Infect Dis
24
Increased risk of osteoporosis in women living
with HIV
  • A decrease in bone mineral density (BMD) may be
    due to HIV itself or to ART13
  • Vitamin D deficiency is relatively common among
    individuals with HIV
  • In one study, hip and spine BMD was significantly
    reduced in women with HIV compared with
    HIV-negative controls4
  • Older age was also associated with lower BMD

1. Rodriguez M et al. (2009) AIDS Res Hum
Retroviruses 2. Moore AL et al. (2001) AIDS
3. Yin MT et al. (2010) J Clin Endocrinol Metab
4. Arnsten JH et al. (2006) Clin Infect Dis
25
Clinical studies report an increased risk of
osteoporosis in HIV
  • Being HIV-positive conferred an increased risk
    for osteoporosis compared with HIV-negative
    individuals (n654, mean age 38.1)
  • 6.4 fold increased risk for reduced BMD

Brown TT et al (2006) AIDS
26
Consequences of osteoporosis
  • Osteoporosis is a major risk factor for hip
    fractures
  • Women living with HIV may be more likely to
    experience falls, increasing the likelihood of a
    fracture in patients with osteoporosis

Triant VA et al (2008) J Clin Endocrinol Metab
27
Managing osteoporosis in women living with HIV
  • European AIDS Clinical Society (EACS) guidelines
    recommend screening for osteoporosis using a bone
    density scan in1
  • Postmenopausal women living with HIV
  • Women living with HIV who have a history of low
    impact fracture or high fall risk
  • Clinical hypogonadism
  • Oral glucocorticoid users
  • Strategies to help reduce the risk of developing
    osteoporosis in women can include24
  • Weight-bearing exercise
  • Adequate dietary calcium intake / vitamin D
    supplements
  • Avoidance of smoking and excess alcohol
  • Avoidance of ARTs related to increased BMD loss
  • Standard medications approved for the treatment
    and prevention of osteoporosis may be appropriate
    for women with HIV2

1. EACS Guidelines, Version 6, 2011 2. Lee S.
BETA 200618(2)33-35 3. National Osteoporosis
Society 4. Lima AL et al. HIV AIDS (Auckl)
20113117-24
28
Questions women should ask during medical
consultations
  • Am I at risk of osteoporosis now? Will I be at
    risk as I get older?
  • What symptoms should I look for?
  • How can I reduce my risk of osteoporosis?
  • Am I taking any medicines that could put me at
    higher risk for osteoporosis?
  • Are there any tests or screening programs for
    osteoporosis that I should have?

29
Women with HIV should ask questions during
medical consultations
  • What medications are available for osteoporosis?
  • What are their benefits and side effects?
  • Will these drugs interact with any other
    medications that I am taking, like my HIV
    medications?
  • Are there any other things I can do, besides
    taking medication, to reduce my risk of
    osteoporosis and bone fracture? Lifestyle,
    activities, diet?
  • How much calcium and vitamin D should I get from
    my diet?
  • Should I take supplements? What should I do to
    make sure I'm getting enough vitamin D and dairy
    products?
  • Where can I get further information?

30
Cardiovascular disease
31
Cardiovascular disease among women living with HIV
  • Women living with HIV may be at increased risk of
    CVD
  • Several other major factors increase risk of CVD

32
Increased risk of myocardial infarction in women
with HIV
Large data registry 3,851 HIV-infected
patients 1,044,589 non HIV-infected patients
HIV
HIV-
Triant VA et al (2007) J Clin Endocrinol Metab
33
Cardiovascular disease risk and exposure to ART
  • Incidence of myocardial infarction (MI) has been
    shown to increase with longer exposure to
    combination ART

DAD Study incidence of MI in HIV compared to
patients not exposed to ART
Plt0.001 for trend
The DAD Study Group (2003) N Engl J Med
34
SMART Higher CVD incidence with interruption vs.
continuous HAART
  • CD4-guided drug conservation strategy was
    associated with significantly greater disease
    progression or death, compared with continuous
    viral suppression RR 2.5 (95 CI 1.8-3.6
    Plt0.001)

No. of Patients With Events
Parameter
RR (95 CI)
1.5
Severe complications
114
1.4
CVD, liver, or renal deaths
31
1.5
Risk of Complications
Nonfatal CVD events
63
1.4
Nonfatal hepatic events
14
2.5
Nonfatal renal events
7
1.0
10.0
0.1
El-Sadr W, et al. CROI 2006. Abstract 106 LB.
35
Managing CVD risk in women living with HIV
  • Strategies to help reduce the risk of CVD in
    women can include
  • Smoking cessation
  • Control of hypertension
  • Diet and cholesterol management
  • Diabetes control
  • Physical activity / exercise
  • Management of depression
  • Standard medications approved for the treatment
    and prevention of CVD may be appropriate for
    women living with HIV

36
Managing CVD risk in women living with HIV
  • As part of the HCP consultation, points to
    discuss include
  • Personal risk factors for developing CVD and
    treatments/interventions to help address these
    factors
  • Adherence and avoidance of unstructured treatment
    interruptions
  • Signs and symptoms of CVD
  • Lifestyle activities and supplements/medication
    that may help offset the risk for, or
    consequences of CVD
  • Motivation to feel responsible for oneself
  • Sources of further information

37
Cancer
38
Cancer in HIV
  • Many cancers are now treatable, especially when
    diagnosed early
  • Late diagnosis and older age at diagnosis can
    lead to poorer outcomes and greater disease and
    treatment burden
  • Cancers can be classified as AIDS-defining and
    non-AIDS defining
  • AIDS-defining cancers among women include
  • Kaposi's sarcoma
  • Lymphomas
  • Cervical cancer

39
Increased risk for cancer among women living with
HIV
Ratio of observed to expected cancer casesa
AIDS-defining cancers
Kaposi's sarcoma 178.49
Non-Hodgkins Lymphoma 48.97
Invasive cervical cancer 9.20
Non-AIDS-defining cancers
Cancer of the lung 7.95
Oesophagus 7.69
Multiple myeloma 7.37
Oral cavity and pharynx 6.55
Hodgkins disease 5.65
Leukaemias 4.52
Rectal/anal cancers 3.23
aStandardised incidence ratio (SIR)
Fordyce EJ et al (2000) AIDS Public Policy
40
Human Papillomavirus and cervical cancer
41
Relationship between HIV suppression and HPV
  • At time of first HPV screen, high-risk-HPV
    prevalence was 43 in 20111
  • Presence of high-risk HPV infection was
    significantly less frequent in women
  • gt30 years
  • with higher CD4 count
  • who had prior CD4 nadir gt500/µL
  • who had received cART for gt24 months
  • with sustained VLlt 50 cp/ml for gt24 months
  • Sustained HIV suppression for more than 40 months
    and CD4 count above 500 cells/µL for more than 18
    months are independently associated with a lower
    risk of cervical high-risk-HPV infection

1. Konopnicki D et al (2011) EACS Congress 2011
42
Cervical Cancer
  • One of the most common types of cancer among
    women worldwide
  • Women living with HIV are at a significantly
    higher risk for cervical cancer than are
    HIV-negative women
  • Women living with HIV may be particularly
    vulnerable to high risk HPV type infections that
    can lead to cancer1,2
  • HAART is associated with regression of cervical
    intraepithelial neoplasia (CIN)
  • the HAART has not shown a clear benefit of HAART
    in decreasing the incidence of invasive cervical
    cancer3

1. Frisch M et al (2000) J Natl Cancer Inst 2.
Palefsky J (2009) Curr Opin HIV AIDS 3. Adler DH
et al (2010) Curr HIV Res
43
Breast cancer
  • The most common cancer among women worldwide its
    incidence appears not to be increased among women
    living with HIV
  • Women living with HIV are less likely to undergo
    routine screening mammography
  • May lead to later diagnosis and more advanced
    disease at presentation
  • HCP should ensure women with HIV are referred to
    screening mammography services

43
44
Managing cancer in women with HIV
  • Highly effective ART regimens significantly
    reduce the risk of AIDS-defining cancers
  • Healthcare vigilance and screening is important
    to ensure early diagnosis and intervention
  • Drug?drug interactions between cancer drugs and
    ART are common but can be predicted and managed
  • The HIV physician should work closely with the
    oncologist to ensure optimal care
  • As part of the HCP consultation, points to
    discuss include
  • Screening programs for cancer, particularly
    cervical cancer
  • HPV vaccination if available
  • Sources of further information

45
Renal disease
46
Renal disease and age
  • Age is one of the major risk factors for renal
    disease
  • Special monitoring of glomerular filtration rates
    should be considered in women aged 45 years,
    especially if using an ART that may increase risk
    for CKD and/or concomitant risk factors are
    present
  • Dyslipidaemia
  • High blood pressure
  • Diabetes Mellitus
  • Obesity
  • Use of other nephrotoxic drugs

47
Renal disease in women living with HIV
  • Women living with HIV may be at an increased risk
    for acute renal failure or CKD1, affecting 1 in 6
    people living with HIV2
  • risk of HIV-associated nephropathy and/or ART
    induced renal dysfunction1
  • The mortality risk for women with CKD is twice
    that of those who do not have CKD 5

Plt0.0001
Gardner LI et al (2003) J Acquir Immune Defic
Syndr
48
Frequency of renal impairment in women living
with HIV
  • The ANRS C03 Aquitaine cohort study reported a
    significantly higher frequency of renal
    impairment in women living with HIV compared to
    men (Odds ratio 2.5 (2.13.9)
  • Renal impairment was also associated with being
    older, having a low BMI, and having a high blood
    pressure

Deti et al (2010) HIV Med
49
Kidney care in women living with HIV
  • Regular monitoring of renal function
  • Treat concomitant risk factors for kidney disease
  • diabetes
  • hypertension
  • dyslipidaemia
  • In patients with renal damage
  • adjust ARTs and other drugs as necessary
  • avoid nephrotoxic treatments unless no
    alternative
  • take special care with drug?drug interactions

50
Frailty
51
Definition of frailty
  • In attempting to define frailty as an independent
    syndrome (or phenotype), three of the following
    criteria need to be present

Unintentional weight loss
Self-reported exhaustion
Low physical activity
Slowness measured by time taken to walk 3m
Weakness grip strength
Fugate Woods N et al (2005) J Am Geri Soc
52
HIV and premature frailty in women
  • A 55-year old individual living with HIV for 4
    years has the same frailty as a seronegative
    individual of 65 years1
  • 80 of women living with HIV for 15 years felt
    they were prematurely ageing, compared with 18
    of men (p lt0.001)2
  • Women recorded a significantly higher average
    intensity of mobility difficulty, joint pain,
    postural balance difficulty, dry skin, hair
    thinning, sadness, anxiety, and loss of sexual
    interest than men2
  1. Desquilbet L et al (2007) J Gerontol A Biol Sci
    Med
  2. Fumaz CR et al (2010) 1st International Workshop
    on HIV and Aging

52
53
Frailty in women living with HIV
  • Severe CD4 cell depletion is an independent
    predictor of slowness, weakness, and frailty1
  • Women with CD4 counts lt100 cells/mm3 have 2.7
    times higher prevalence of frailty1
  • Independent predictors of frailty include2
  • unemployment
  • greater number of co-morbid conditions and past
    opportunistic illnesses
  • higher depression severity score
  • receipt of antidepressants
  • lower serum albumin
  • Hospitalisation rates are greater for frail
    persons with a five-fold longer duration of
    inpatient stay2

53
1. Terzian AS et al (2009) J Womens Health 2.
Onen NF et al. (2009) J Infect
54
Emotional, psychological and psychiatric
challenges of ageing in women with HIV
55
Neurocognitive disorders
56
HIV-associated neurocognitive disorders
Women with HIV and neurocognitive difficulties
may have problems performing everyday tasks,
learning new things, movement and balance
  • Neurocognitive changes associated with HIV
    consist of cognitive and motor dysfunctions1
  • Neurocognitive deficits and effects on motor
    functioning increase with age in the HIV
    population2,3
  • Main psychiatric and neurocognitive changes
    include major depressive disorder and
    HIV-associated neurocognitive disorder (HAND)4
  • HAND is characterised by neurocognitive changes
    of different degrees and is associated with, or
    is one manifestation of, a depressive mood4

1. Ances BM et al. (2007) Semin Neurol 2. Kim
DH et al. (2001) Can J Neurol Sci 3. Valcour V
et al. (2008) J Neurovirol 4. Valcour V et al.
(2012) CROI
57
Neurological function in women with HIV
  • Some degree of neurological impairment occurs in
    gt50 of HIV-infected individuals
  • Neurological dysfunction, including memory
    impairment and psychomotor function, has been
    shown to be increased in women with HIV
  • Risk increases with age, especially with respect
    to neurocognitive deficits

CDC Centers for Disease Control and Prevention
A asymptomatic B Symptomatic C AIDS
indicator conditions
Clifford DB (2008) Top HIV Med
58
Factors influencing neurological function in
women with HIV
  • Risk of neurocognitive impairment is no higher
    for HIV positive women taking ART than for
    seronegative women1
  • Risk of neurocognitive impairment is
    significantly increased for seropositive women
    not taking ART
  • HCV co-infection is an independent risk factor
    for neurocognitive damage in women2
  • Memory impairment is associated with alterations
    in the hippocampus3
  • AIDS diagnosis and HIV seropositivity predict
    psychomotor slowing4

1. Richardson JL et al (2002) J Int Neuropsychol
Soc 2. Richardson JL et al (2005) AIDS 3. Maki
PM (2009) Neurology 4. Durvusala RS et al
(2001) J Clin Exp Neuropsychol
59
Neurological function and adherence with ART
Negative adherence cycle
Neurocognitive impairment among older patients
provokes poor adherence with medication
Suboptimal ART adherence can make patients
vulnerable to neurocognitive dysfunction
Adherence to effective ART that penetrates into
the CNS may be important to maintain
neurocognitive health
Ettenhofer ML et al (2009) Am J Geriatr
Psychiatry
60
Managing neurocognitive changes in women with HIV
  • A healthy lifestyle may help to preserve
    cognitive function
  • Diet fruits, vegetables, beans, soy, fish, whole
    grains, no added fat, no added salt, little or no
    coffee and alcohol
  • Vitamin D3 supplementation
  • Exercise
  • Stress management meditation, yoga
  • Smoking cessation
  • Sufficient sleep

Atkinson M. (2010) Positive Side Levy L (2007)
The Positive Side
60
61
Managing neurocognitive changes in women with HIV
  • As part of the HCP consultation, points to
    discuss include
  • Screening programs/assessments for neurological
    disorders
  • Lifestyle activities and supplements/medication
    that may help
  • Management of symptoms of depression
  • Sources of further information

61
62
Depression and anxiety
63
Depression and anxiety in women with HIV
  • Depression and anxiety are common among women
    with HIV1
  • Rates of depression in people living with HIV
    and AIDS are 5?10 times greater than in the
    general population1

1. Pence BW (2009) J Antimicrob Chemother 2.
Mavandadi S et al (2009) J Acquir Immune Defic
Syndr
64
Depression can lead to poor ART adherence and
increased mortality
Time on ART therapy by depressive symptoms1
HIV-related mortality by depressive symptoms2
1. Bangsberg DR et al (2001) ICAAC, Chicago,
USA 2. Ickovics JR et al (2001) JAMA
65
Managing depression and anxiety in women with HIV
  • Women with HIV should be screened for depression
    and anxiety to ensure appropriate intervention is
    offered
  • Strategies for managing depression and anxiety
    that have been shown to have a positive effect in
    people with HIV include
  • Interpersonal therapy
  • Exercise
  • Massage
  • Drug therapy
  • Cognitive behavioural therapy

66
CRANIum study Prevalence of anxiety and
depression in Western Europe and Canada
  • 35.5 and 17.9 of females screened positive for
    anxiety and depressive symptoms, respectively
  • Depressive symptoms were significantly more
    common when compared with men living with HIV
    however this difference was reported only in ART
    naïve population (20.8 vs 10.6)
  • Prevalence of depressive symptoms in women in the
    study is twice as high as the general population
    in Europe

1. Bayon et al (2012) 2nd International Workshop
on HIV and Women, Abst 0_1
67
Managing depression and anxiety in women with HIV
  • As part of the HCP consultation, points to
    discuss include
  • Signs and symptoms of depression/anxiety
  • Screening programs/assessments for
    depression/anxiety
  • Support groups for depression/anxiety
  • Lifestyle activities and supplements/medication
    that may help offset the risk for, or
    consequences of depression/anxiety
  • Sources of further information

67
68
Insomnia
69
The causes and consequences of poor sleep quality
  • Insomnia and sleep disturbances are medical
    conditions that can require treatment
  • If untreated, sleep disturbances can make other
    conditions, such as depression, worse
  • Insomnia is more prevalent in women than men and
    increases with age

Mood, depression, anxiety
Sleep quality, insomnia
70
Managing sleep disturbances in women with HIV
  • Strategies to help alleviate sleep disturbances
    in women living with HIV can include
  • Identification of potential causative factors
    including ART regimen
  • Drug therapy
  • Improved sleep hygiene, including less napping
    and more daytime activity
  • Management of depression and anxiety
  • Relaxation techniques
  • Smoking cessation
  • Possible change of schedule of food intake
  • Exercise

71
Managing sleep disturbances in women with HIV
  • As part of the HCP consultation, points to
    discuss include
  • Signs and symptoms of insomnia
  • Lifestyle activities and supplements/medication
  • Sources of further information

72
Family and parenting issues
73
Parenting and caregiver challenges in older women
living with HIV
  • Older women often have a dual role of caring for
    their own health whilst caring for children,
    grandchildren or elderly parents
  • Older women are more likely to have issues around
    disclosure to their children
  • Delaying starting a family due to HIV may be
    compounded by premature menopause, having
    implications for parenthood

74
Support
75
Support for women living with HIV as they age
  • Older women living with HIV may require more
    healthcare and emotional support than those
    without HIV

Alleviate concerns/fears around their health
Older women living with HIV may be reassured by
more regular healthcare screenings
Financial circumstances and support from a
partner may be decreased with older women with HIV
Additional community or healthcare support
Information and support on caring and bereavement
Double role of caring for ailing parents or
coping with parental loss
76
Supporting women with HIV as they age
Feelings of stigma and isolation still common
among ageing women with HIV
Information available to women with HIV about
ageing is limited with regard to what is due to
the disease and what is due to the normal ageing
process
Enriquez M et al (2008) J Assoc Nurses AIDS Care
77
Peer support and peer education
  • Allows sharing of feelings, experiences and
    information
  • Provides mutual support
  • Helps women to realise they are not alone
  • Acceptance of HIV
  • Disclosure to family or loved ones
  • Many opportunities for women with HIV to provide
    support and encouragement to others
  • Active participant in a support group
  • Giving presentations
  • Communicating personal experiences
  • Becoming a peer worker
  • Offers support women with HIV to understand
    instances when people may be uninformed about HIV
    e.g. a healthcare professional without HIV
    specialist knowledge

77
78
Existing peer support initiatives for women
living with HIV
79
Case studies
80
Case study 1 characteristics
  • 54-year-old woman
  • Owns a restaurant business
  • Works long hours
  • Diagnosed with HIV in 2005 and was devastated
  • She has suffered episodes of depression since
    diagnosis and is recently feeling more anxious,
    with mood swings and problems sleeping
  • She wants to know when she will be able to feel
    like herself again
  • Needs to concentrate to handle the duties of her
    job
  • Wants to be in better control of her moods and
    emotional wellbeing

81
Case study 1 actions
  • Assess for depression/anxiety and insomnia
  • Review ART for ARVs that may affect mood
  • Consider changes to ART to exclude potential drug
    causes for depression/anxiety?
  • Discuss pharmacologic and behavioural
    interventions to treat both depression/anxiety
    and insomnia
  • Cognitive behavioural therapy
  • Improved exercise routine
  • Relaxation therapies e.g. massage
  • Anti-depressant and/or mood stabiliser?
  • Sedative?

82
Case study 1 actions
  • Suggest peer support
  • Help to manage emotional stress
  • Develop effective coping skills
  • Individual/group counseling
  • Encouragement often required for patients to seek
    social or psychological support
  • Ongoing screening for co-morbidities of ageing
    and management of any physical symptoms
  • Osteopenia/osteoporosis
  • CVD
  • Renal disease
  • Cancer
  • Menopause

83
Case study 2 characteristics
  • 42-year-old woman
  • Diagnosed with HIV over 15 years ago
  • Started treatment 7 years ago
  • Family history of CVD
  • Medical history of moderately elevated
    cholesterol and blood pressure
  • Heavy smoker since early teenage
  • Significant alcohol intake and cannabis use
  • Has sleep problems and suffers from anxiety

84
Case study 2 actions
  • Discuss behavioral changes to decrease risk of
    CVD and early onset of menopause
  • Smoking and drug cessation
  • Alcohol moderation
  • Improved diet and exercise routines
  • Ongoing monitoring for CVD risk factors including
    raised cholesterol or blood pressure
  • Assess for depression/anxiety and insomnia
  • Review ART for ARVs that may affect mood
  • Consider changes to ART to exclude potential
    propagators of depression/anxiety?
  • Discuss pharmacologic and behavioural
    interventions to treat both depression/anxiety
    and insomnia
  • Suggest peer support and individual/group
    counseling
  • Encouragement often required for patients to seek
    social or psychological support

85
Case study 3 characteristics
  • 65-year-old woman
  • Lives alone
  • Is barely managing to get by on state benefits
  • Diagnosed with HIV in 1991
  • On long-term ART
  • She feels socially isolated and lonely, and
    suffers bouts of severe depression
  • She is becoming increasingly frail and suffers
    from short-term memory loss
  • It is probable that she will have to move into a
    care home in the next few months
  • She worries about how she will be accepted
    because of her HIV status

86
Case study 3 actions
  • Assess for depression/anxiety and insomnia
  • Review ART for ARVs that may affect mood
  • Consider changes to ART to exclude potential
    propagators of depression/anxiety?
  • Discuss pharmacologic and behavioural
    interventions to treat depression/anxiety
  • Relaxation techniques e.g. massage
  • Improved exercise routine
  • Anti-depressant and/or mood stabiliser?
  • Monitor for development of comorbidities that
    increase with age e.g. osteoporosis

87
Case study 3 actions
  • Suggest peer support
  • Opportunity to interact with women who may have
    had similar experiences and increase social
    interaction
  • Develop effective coping skills
  • Individual/group counseling
  • Encouragement often required for patients to seek
    social or psychological support
  • Discuss option of care homes with experience of
    managing HIV
  • Screening for co-morbidities and management of
    any physical symptoms
  • Osteopenia/osteoporosis
  • Cardiovascular disorders
  • Renal disease
  • Cancer
  • Menopause

88
Summary
89
Ageing in women living with HIV
  • Women living with HIV face many potential
    physical and emotional health issues as they age
  • With the appropriate interventions, lifestyle
    choices and integrated support from healthcare
    professionals and community groups, the impact of
    these challenges can be effectively managed
  • Women living with HIV may require additional
    medical and emotional support as they age

90
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