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HIVLinks                                     Summer

                                HIV, STD, and TB news and information for health professionals
                                                                                                   2019

                                                                     Feature Ar ticle
                                                                   • The Aging of the Epidemic:
                                                                     Caring for Older People Living
                                                                     with HIV ........................................... 2

                                                                    Practice Tips
                                                                  • The Impact of Menopause on
                                                                    the Sexual Health of Older
                                                                    Women Living with HIV ............ 10
                                                                  • New Jersey TB Update .............. 16
                                                                  • HIV Care in Rural
                                                                    Communities ................................ 17

                                                                     Spotlight
                                                                  • The People, Problems and
                                                                    Policies of Aging with HIV ........ 18
                                                                  • Deloris: A Life Well Lived,
                                                                    A Life of Peace .............................22
Published by the FXB Center, School of Nursing,                   • Aaron: You Can't Complain If
    Rutgers, The State University of New Jersey
     and the New Jersey Department of Health,                       You're Not At The Table.............26
           Division of HIV, STD, and TB Services
HIVLinks - François-Xavier Bagnoud Center
Feature Article

  The Aging of the Epidemic: Caring
  for Older People Living with HIV
  Darcel Reyes, Ph.D., ANP-BC; Jeffrey Kwong, DNP, MPH, AGPCNP-BC, FAANP; Thomas Loveless, CRNP, Ph.D., AAHIVS;
  Nancy Murphy, NP, Ph.D.; and David M. Kietrys, PT, Ph.D, OCS, FCPP

  Introduction

  E
       ffective antiretroviral therapy (ART) has enabled people        Electronic Resources to Check for Drug Interactions
       living with HIV (PLWH) to survive into their senior years
                                                                      Epocrates                   www.epocrates.com
       and experience HIV as a chronic disease. The Centers
  for Disease Control and Prevention (CDC) surveillance report        Lexi-Comp                   www.lexi.com
  indicates 35% of older PLWH have both HIV infection and             Tarascon                    www.tarascon.com
  AIDS.¹ Nearly half (47%) of all PLWH in the United States           AETC National               https://aidsetc.org/resource/helpful-
  are over 50 years of age and 17% of those newly diagnosed           Coordinating Resource       hiv-medication-tables-pharmacists
  with HIV are in this age group.¹ Similarly, in New Jersey (NJ),     Centers’ Helpful
  41% of all PLWH are 55 years of age or older and 7% of              HIV Medications for
  all new cases of HIV occurred in that age group in 2017.²           Pharmacists
  Consequently, 70% of all PLWH will be over the age of 50            University of Liverpool’s   https://www.hiv-druginteractions.org
  by 2030.¹ The epidemiological data highlights the need the          HIV Drug Interaction
  complex interplay of HIV disease, the aging process, and            Website
  multi-morbidity in order to provide clinical care for a large       HIVInSite Database          http://arv.ucsf.edu
  cohort of older people living with HIV.                             of Antiretroviral Drug
                                                                      Interactions (UCSF)
  Antiretroviral Therapy in Older PLWH                                DHHS Guidelines on          https://aidsinfo.nih.gov/drugs
  The U.S. Department of Health and Human Services (DHHS)             the Use of Antiretroviral
  guidelines for ART are the same for all adults.3,4 However, as      Medications
  PLWH age, they experience decreased immune and meta-
  bolic functioning that may result in lower CD4 cell counts,        Age associated changes such as reduced renal and hepatic
  increased risk for opportunistic infections, and more difficulty   function as well as physiological changes in the proportion of
  achieving viral suppression.3-5 Older PLWH who need medi-          fat to lean muscle mass, body water content, and weight may
  cations to treat co-occurring chronic conditions in addition       require dose adjustments.6-8 For older PLWH who have renal
  to ART have an increased risk of polypharmacy, drug-drug           insufficiency, the Cockcroft-Gault derived creatinine clear-
  interactions, drug toxicities, and non-adherence.6,7               ance calculation should be used to calculate the appropri-
  Clinicians should review the patient’s medication list at          ate medication dose or frequency adjustments.6-8 Common
  each visit to ensure it is complete, up to date, and most          medications prescribed for PLWH that require renal dose
  importantly, to screen for potential drug-drug interac-            adjustment include acyclovir, fluconazole, gabapentin, H2-
  tions. Validated instruments such as the Beers Criteria, the       antagonists and most Nucleoside Reverse Transcriptase
  Medication Appropriateness Index, or the Screening Tool of         Inhibitors (NRITs). Medications metabolized by the liver can
  Older Person’s Prescriptions /Screening Tool to Alert doctors      accumulate in toxic levels in older PLWH who have hepatic
  to Right Treatment (STOPP/START) can be used to iden-              dysfunction, therefore, the Child-Pugh score should be cal-
  tify medications that present a risk for adverse effects in        culated to determine the appropriate medication dose.8
  the older adult.6,7 The Beers Criteria focuses on potentially      Medications that require dose adjustment based on hepatic
  inappropriate medications for older adults; the Medication         function include abacavir, non-nucleoside reverse transcrip-
  Appropriateness Index determines the appropriateness of a          tase inhibitors (NNRTIs) and protease infibitors (PIs).3
  particular medication, and the STOPP/START criteria focuses
                                                                     Multi-Morbid Conditions in PLWH
  on inappropriate medication-disease combinations.6-8 The
  table below lists electronic resources clinicians can use to       Multi-morbidity refers to the experience of living with several
  check drug-drug interactions.                                      co-occurring chronic conditions.9 Among PLWH, multi-
                                                                     morbidity occurs earlier in the aging process and is more
                                                                     common compared to persons without HIV.10 This may be
                                                                     a result of chronic immune activation caused by HIV and

Page 2 / New Jersey HIVLinks, Summer 2019
HIVLinks - François-Xavier Bagnoud Center
The Aging of the Epidemic: Caring for Older
People Living with HIV                                                                             HIVLinks                                Summer      2019

                                                                                                   HIV, STD, and TB news and information for health professionals

the consequences of long term ART.10
As a result, there is an increasing in-
cidence of non-HIV defining chronic
conditions such as cardiovascular
disease, metabolic disorders, renal
complications, and malignancies in
older PLWH.9
Cardiovascular disease. Cardiovascular
Disease (CVD) occurs more frequently
in PLWH.11 The risk of myocardial in-
farction (MI) is almost twice as high
in PLWH compared to those without
HIV, even accounting for arterioscle-
rotic factors.12 Some HIV medications,
chronic inflammation related to HIV in-
fection, and tobacco use may account
for the increased risk of MI in PLWH.13
The Framingham Risk Score and
the American College of Cardiology/
American Heart Association CVD risk
tools do not include chronic immune
inflammation as a variable and thus
underestimate cardiac risk in PLWH.14      who have diabetes, HbA1C should             fumarate) and the increased prevalence
Patients should be counseled about         be checked at least twice a year.15         of diabetes and hypertension.20 PLWH
tobacco cessation, diet, and maintaining   Treatment guidelines established by         who are female, African American, or
a healthy weight to reduce CVD risks.      the American Diabetes Association           have an AIDS defining disease are at
Clinical management of CVD is the          include a HbA1C goal of 6.5%.15 In          increased risk of HIV-related nephropa-
same for PLWH as that for persons          contrast, the American Academy of           thy compared to other HIV-infected
without HIV, however, clinicians           HIV Medicine recommends increasing          groups.21 Proteinuria may be over-
should be mindful of potential drug-       the HbA1C goal to 8% for older PLWH         looked as an indication of HIV infection
drug interactions with these medica-       who have diabetes and are frail, have       in older adults because it also occurs in
tions and ART.                             a life expectancy of less than 5 years,     heart failure and diabetes mellitus.21
Diabetes. Similar to CVD, HIV medi-        and are at high risk for hypoglycemia,      ART preserves kidney function in PLWH
cations, chronic inflammation, and         polypharmacy, or drug interactions.15       who have HIV related nephropathy, al-
coinfection with hepatitis C (HCV)         However, screening for diabetes with        though there is evidence that some PIs
are associated with higher rates           fasting blood glucose (FBG) may be          (indinavir and atazanavir) are associated
of diabetes in PLWH.15-17 Clinicians       more appropriate in PLWH on NRTI            with crystal-induced obstruction. TDF
should screen PLWH for diabetes            or PI therapy because these medica-         should be avoided due to renal toxicity in
using hemoglobin A1C (HbA1C) at            tions lower HbA1C.18                        individuals with chronic kidney disease
least yearly, as well as before and        Lipodystrophy. PLWH may experi-             (CKD) and GFR
HIVLinks - François-Xavier Bagnoud Center
Feature Article

  interactions, and adverse drug effects.   and are at increased risk of Vitamin           Several screening tools exist for cogni-
  At minimum, clinicians should screen      D deficiency as well as other debilitat-       tive deficits but may miss more subtle
  PLWH for changes in renal function with   ing bone diseases such as avascular            presentations of HAND and may
  a urinalysis and an eGFR at least twice   necrosis of weight-bearing joints.25, 26       not be applicable across all cultures.
  a year.21                                 Women living with HIV experience               The Montreal Cognitive Assessment
  Cancer. Lung cancer prevalence is         menopause at an earlier age and                (MoCA) is recommended for initial
  increasing among PLWH while AIDS-         men living with HIV experience an-             screening.31 The HIV Dementia Scale
  defining cancers such as Kaposi’s         drogen deficiencies; both conditions           and the International HIV Dementia
  sarcoma, non-Hodgkin’s lymphoma,          contribute to increased risk for os-           Scale are validated screening tools;
  and cervical cancer have decreased.23     teoporosis. ART, specifically TDF and          however, some studies indicate that
  PLWH are at increased risk of develop-    some PIs, may also increase risk for           they do not reliably identify more
  ing non-AIDS defining cancers (NADC)      osteoporosis.27 Smoking, a sedentary           subtle forms of cognitive impair-
  related to anal, cervical, vaginal,       lifestyle, and poor nutritional status         ment.29 The Mini-Mental State Exam
  penile, nasopharyngeal, laryngeal,        are also risk factors for osteoporosis.        does not assess cognitive functioning
  and oral infections; liver cancer from                                                   impaired by HAND and therefore is
                                            Older PLWH who have osteopo-
  hepatitis and nasopharyngeal cancer                                                      not recommended.29
                                            rosis are at increased risk of fragil-
  and Hodgkin's lymphoma related to         ity fractures. Clinicians should use           Treatment options for HAND include
  Epstein-Barr Virus.24 PLWH are also       the Fracture Risk Assessment Tool              ART (for those not already on ART)
  at risk for tobacco-related NADC such     (FRAX) for all PLWH who are 40-49              and addressing reversible underlying
  as non-melanoma skin cancer and           years of age, and dual energy x-ray            causes, such as thyroid disease or
  other head or neck cancers; screening     absorptiometry (DXA) in men over 50,           vitamin B12 deficiency.29 Encouraging
  for tobacco use and assisting current     postmenopausal women living with               older PLWH to remain socially engaged,
  users with cessation can modify risks     HIV, and PLWH who have a history of            get regular exercise, and monitoring
  associated with these conditions.24       fragility fracture, are on chronic glu-        for depression and cerebrovascular
  Rates of breast and prostate cancer       cocorticoid treatment, and those at            risk factors are additional strategies to
  in PLWH are comparable to persons         high risk for falls.27, 28 Treatment for os-   prevent or delay HAND.29
  without HIV.                              teoporosis includes avoiding the use           Frailty and Physical Functioning.
  Cancer screening is the same for          of TDF and PIs, adding bisphospho-             Decreased mobility and physical func-
  PLWH and those who do not have            nate therapy, optimizing calcium and           tion in older PLWH is associated with
  HIV, with two notable exceptions:         vitamin D intake, limiting or reducing         depression, multi-morbidity, neuro-
  cervical and anal cancer screening.       alcohol and tobacco, and incorpora-            cognitive impairment, and low CD4+
  Cervical cancer screening for women       tion of weight bearing exercise.28             cell count.32 Presence of functional
  with HIV should continue after age        HIV-Associated Neurocognitive Dis-             decline and frailty is almost twice
  65 and the screening interval with        order. HIV-associated neurocognitive           as common in PLWH compared to
  cytology and human papilloma virus        disorder (HAND) ranges from mild neu-          non-HIV populations.33 Clinicians can
  (HPV) co-testing is 3 years due to in-    rocognitive deficits to HIV-associated         assess functioning using a combina-
  creased risk of HPV-related cancer.24     dementia.29 More than half of older            tion of patient self-report and in-of-
  Anal cancer associated with HPV is        PLWH experience some level of neuro-           fice performance tests. The review
  significantly more prevalent in PLWH,     cognitive impairment.29 Older PLWH at          of history for the older PLWH should
  therefore an annual rectal exam is        risk for HAND are those with a history of      include questions about performing
  recommended for both men and              central nervous system (CNS) disease,          daily tasks, driving, managing money,
  women living with HIV.24 Cytology         a low nadir CD4 cell count, detect-            taking medications, and any falls or
  screening with an anal Pap smear has      able HIV viral load, and a low CD4 cell        injuries.32,33
  also been recommended by some             count.29 Diabetes, hypertension, HCV,          The Short Physical Performance Battery
  experts.24 It is recommended that cli-    medication toxicities, and substance           (SPPB) developed by the National
  nicians consider the functional status    use disorders contribute to poor neuro-        Institute on Aging provides a com-
  and life expectancy of the older PLWH     psychological performance.29 Clinicians        posite assessment of balance, walking
  when using the current cancer screen-     need to consider Alzheimer’s disease           speed, and ability to stand from a
  ing guidelines.²⁴                         and the impact of cerebrovascular              sitting position.34 Low SPPB scores
  Osteoporosis. Experts recommend           disease when evaluating the cognitive          predict risk for falls, impaired mobility,
  screening for and treatment of osteo-     functioning of PLWH.29 HAND can result         declines in physical performance, and
  porosis because many older PLWH           in poor ART adherence, worsening de-           mortality. If mobility or physical func-
  experience accelerated bone loss          pression, and earlier mortality.30             tional deficits are identified, evaluate
Page 4 / New Jersey HIVLinks, Summer 2019
HIVLinks - François-Xavier Bagnoud Center
The Aging of the Epidemic: Caring for Older
People Living with HIV                                                                           HIVLinks                                Summer      2019

                                                                                                 HIV, STD, and TB news and information for health professionals

the patient’s socioenvironmental con-         Distal sensory polyneuropathy (DSP)     TENS, manual therapy, stretching ex-
dition and mental status. Social isola-       is the most common form of PN in        ercises, yoga, and use of night splints
tion, decreased physical activity, poor       PLWH.46 DSP symptoms include im-        can also help manage PN pain.53,54
diet, multi-morbidity, depression, and        paired sensation and/or paresthesia     Self-care strategies include avoid-
ART non-adherence contribute to physi-        in a stocking/glove distribution and    ing extended periods of standing or
cal decline.34 Provide older PLWH with        sluggish or absent Achilles tendon      walking, soaking feet in warm or cold
education about aerobic and weight            reflex.47 DSP in PLWH has been as-      water, or use of contrast baths.
bearing exercises to increase muscle          sociated with reduced quality of
mass, strength, flexibility, and balance.34   life, impaired lower extremity func-    Chronic Pain. The prevalence of
                                              tion, sleep disturbances, and limited   chronic pain in PLWH ranges from
Peripheral Neuropathy. The preva-                                                     54-83%.55 Chronic pain in PLWH can
lence of peripheral neuropathy (PN)           ambulation.48,49
                                                                                      lead to impaired physical functioning,
in PLWH is 30% to 62%.35 HIV medi-            Treatment of PN addresses causes
                                                                                      disability, depression, and adversely
cations, specifically older NRTIs and         as well as symptoms. To treat causes
                                                                                      affect adherence to ART.56-59 The eti-
PIs have been linked to PN.37,38 Some         of PN, clinicians can avoid prescrib-
                                                                                      ology is often multifactorial and can
evidence implicates gp120 mediated            ing neurotoxic medications, correct
                                                                                      include direct effects of HIV infec-
neuronal apoptosis mitochondrial tox-         vitamin B6 (with caution, overdos-
icity as a contributing factor.39 Diabetes,   ing can cause PN), B12, and folate      tion, chronic systemic inflammation
HCV co-infection, low CD4 nadir, ad-          deficiencies, and consider thiamine     and immune responses, side-effects
vanced HIV disease, and substance             replacement if the patient is mal-      of medications, co-morbidities such
abuse increase the likelihood of devel-       nourished.50 OTC pain medications or    as musculoskeletal disorders and PN,
oping PN.40-43 Diagnosis of PN is based       NSAIDs can help relieve mild symp-      opportunistic infections, and psycho-
on subjective symptoms and clinical           toms. For more severe neuropathic       social influences.60-62 A small number
examination findings. Two available           pain, gabapentin or pregablin are       of randomized controlled trials suggest
screening tools are the Brief Peripheral      often prescribed.51 Additional agents   that patient education, cognitive be-
Neuropathy Screen and the Subjective          include capsaicin cream or lidocaine    havioral therapy, and exercise can help
Peripheral Neuropathy Screen.44, 45           patches, and anti-depressant drugs.52   reduce pain ratings in PLWH.63-66

                                                                                        New Jersey HIVLinks, Summer 2019 / Page 5
HIVLinks - François-Xavier Bagnoud Center
Feature Article

                                      Mental Health                      should be referred for treatment with a mental health or substance
                                      in Older PLWH.                     abuse specialist.71 Information about substance abuse treatment
                                      Depression, loneliness, anxie-     in NJ is available in NJ HIVLinks Winter 2018 edition. http://www.
                                      ty, and chronic stress is higher   fxbcenter.org/downloads/AIDSLINE/HIVLinks-Winter2018.pdf
                                      in older PLWH compared to
                                      older adults without HIV,          Prevention and Health Maintenance
                                      regardless of race, ethnic-        in Older PLWH
                                      ity, gender, or sexual orienta-    Sexual Health. Sexual health is integral to quality of life for
                                      tion.67 Lack of mental health
                                                                         older adults, yet many clinicians do not address sexual health
                                      treatment in older PLWH
                                      contributes to cognitive defi-     during medical visits. Mobility, mood disorders, medica-
                                      cits. Untreated mental illness     tion side effects, history of sexual abuse, HIV-related stigma,
                                      is a risk factor for HIV and       complications from other chronic illnesses, and physiological
                                      non-adherence to ART.              changes affect sexual health.72 A further hindrance to sexual
                                     Depression. The risk for de-        health assessment is reluctance on the part of older PLWH to
                                     pression increases in older         discuss sexual issues with clinicians. This reluctance puts older
                                     PLWH as HIV symptom burden          PLWH at risk for acquiring and transmitting HIV as well as other
                                     increases.67 Newly infected         sexually transmitted diseases.
                                     older adults may develop de-
                                                                         Incorporating sexual health screening and counseling, includ-
                                     pression because of isolation
  from supportive networks related to the dual stigma of HIV and         ing tailored prevention messages, as part of the overall assess-
  ageism. Early onset of HAND in older PLWH may present as               ment of older PLWH normalizes discussions about sex.72, 73
  depression.67 Untreated depression is a predictor of non-adher-        Sexual health screening is an opportunity to address barriers
  ence to ART. In addition, older PWLH who experience depression         to sexuality in older adults; treating erectile dysfunction or
  may self-medicate with illegal substances, tobacco, or alcohol to      vaginal dryness can be linked to specific education about safer
  relieve their symptoms, increasing the potential for non-adher-        sexual practices to prevent transmission.
  ence to ART and contributing to poorer health outcomes.67
                                                                         Undetectable equals Untransmittable or U=U is a preven-
  Older PLWH should be screened for depressive disorder with
                                                                         tion intervention based on research that indicates there is no
  the Geriatric Depression Scale and may be treated with the
  same medications that would be indicated for younger PLWH.             risk of sexual transmission from PLWH who are undetectable
  Drug-drug interactions should be considered when prescrib-             (HIV viral load of
HIVLinks - François-Xavier Bagnoud Center
The Aging of the Epidemic: Caring for Older
People Living with HIV                                                                                                      HIVLinks                                 Summer      2019

                                                                                                                             HIV, STD, and TB news and information for health professionals

Table of Recommended Vaccines for Older Adults                                   Advanced Directives. Older PLWH may not want their
                                                                                 closest blood relative or other default surrogate decision
 Vaccine         Dosing Considerations                                           maker, based on state law, to make important medical de-
 Influenza       Administer inactivated, adjuvant inactivated, or high-dose      cisions for them. Clinicians should discuss advanced direc-
                 inactivated influenza annually. Live attenuated influenza is
                                                                                 tives with older PLWH, particularly those with heavy disease
                 not recommended.
                                                                                 burden, who exhibit functional debilitation, frailty, have a
 Tdap/Td         One dose of Tdap if not previously vaccinated, then Td
                                                                                 limited lifespan, or are beginning to show signs of cognitive
                 every 10 years
                                                                                 impairment.78
 Hepatitis A     Havrix®: initial dose, then the 2nd dose at 6 to 12 months
                 Vaqta®: initial dose, then 6 to 18 months fot the 2nd dose      Conclusion
                 Twinrix® (hepatitis A-hepatits B): 1st dose in 1 month, 3rd
                 dose in 6 months.                                               As the number of older PLWH increases, clinicians will need
 Hepatitis B     Single-antigen hepatitis B vaccine or combined hepatitis A      to address the intertwined complexity of aging, HIV infec-
                 and B vaccine (Twinrix®): initial dose, 2nd dose 1 month        tion, and multi-morbidity. Considering the need for medica-
                 later, 3rd dose 6 months later.                                 tions to manage multi-morbid conditions in PLWH, vigilance
 Meningitis      2 doses of serogroup A, C, W, and Y meningococcal               is needed when prescribing medications, including ART, to
                 vaccine (MenACWY®) 2 months apart; revaccinate every            prevent polypharmacy, adverse effects, and drug-drug inter-
                 5 years. Serogroup B meningococcal vaccine (MenB®) is           actions. Primary care assessments for older PLWH should
                 not recommended.
                                                                                 address cognitive status, physical functioning, sexual health,
 MMR             Two doses if born after 1957 and/or CD4+ count >t200            mental health and immunizations in addition to treatment for
                 cells/ml (if not previously vaccinated)
                                                                                 chronic conditions and HIV infection. Encouraging self-man-
                 DO NOT administer if CD4+ count 200 cells/mL.
                                                                                 diet, and smoking cessation can improve the quality of life for
                 DO NOT administer if CD4+ count is
HIVLinks - François-Xavier Bagnoud Center
Feature Article

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      HIVinfected men: effects of CD4 cell count,                                                                      Continued high prevalence and adverse
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      antiretroviral therapies and haematologi-                                                                        clinical impact of human immunodeficiency
      cal parameters. Journal of Antimicrobial             29. Drootin M, Kevin High MD, Amy Justice                   virus-associated sensory neuropathy in the
      Chemotherapy. 2014; 69(12):3360-3367.                    MD, South K, David Spach MD, Victor                     era of combination antiretroviral therapy:
                                                               Valcour MD. Older Age and HIV-associated                the CHARTER Study. Archives of neurology.
  19. Kooij KW, Vogt L, Wit F, et al. Higher prev-
                                                               neurocognitive disorder. The HIV and                    2010; 67(5):552-558.
      alence and faster progression of chronic
                                                               Aging Consensus Project: Recommended
      kidney disease in human immunodeficien-                                                                    42. Ghosh S, Chandran A, Jansen JP.
                                                               Treatment Strategies for Clinicians Managing
      cy virus-infected middle-aged individuals                                                                      Epidemiology of HIV-related neuropathy: A
                                                               Older Patients with HIV. https://aahivm.
      compared with human immunodeficiency                                                                           systematic literature review. AIDS Research
                                                               org/wp-content/uploads/2017/02/Aging-
      virus-uninfected controls. The Journal of                                                                      and Human Retroviruses. 2012; 28(1):
                                                               report-working-document-FINAL-12.1.pdf.
      infectious diseases. 2017; 216(6): 622-631                                                                     36-48.
                                                               Accessed April 16, 2019.
  20. Wyatt CM. Kidney disease and HIV infec-                                                                    43. Cherry CL, Wesselingh SL, Lal L, McArthur
                                                           30. Heaton RK, Franklin DR, Deutsch R, et al.
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                                                                                                                     Neurology. 2005; 65(11):1778-81.
  21.   Drootin M, Kevin High MD, Amy Justice                  gitudinal CHARTER study. Clinical Infectious
        MD, South K, David Spach MD, Victor                    Diseases. 2015; 60(3)473-80.                      44. McArthur JH. The reliability and validity
        Valcour MD. The kidney in HIV and aging.                                                                     of the subjective peripheral neuropathy
                                                           31.   Frazeli PL, Casaletto KB, Paolillo E, Moore
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                                                                 RC, Moore DJ. The Hnrp Group: Screening
        Recommended Treatment Strategies for                                                                         in AIDS Care. 1998; 9(4):84-94.
                                                                 for neurocognitive impairment in HIV-
        Clinicians Managing Older Patients with
                                                                 positive adults aged 50 years and older:        45. Verma S, Micsa E, Estanislao L, Simpson
        HIV. ht tps://aahivm.org /wp-content/
                                                                 Montreal cognitive assessment relates to            D. Neuromuscular complications in HIV.
        uploads/2017/02/Aging-report-working-
                                                                 self-reported and clinician everyday func-          Current neurology and neuroscience
        document-FINAL-12.1.pdf. Accessed April
                                                                 tioning. Journal of clinical and experimental       reports. 2004; 4(1): 62-67.
        16, 2019.
                                                                 neuropsychology. 2017: 39(9): 842-853.
                                                                                                                 46. Keswani SC, Pardo CA, Cherry CL, Hoke A,
                                                                                                                     McArthur JC. HIV-associated sensory neu-
                                                                                                                     ropathies. AIDS. 2002; 16(16):2105-17.

Page 8 / New Jersey HIVLinks, Summer 2019
HIVLinks - François-Xavier Bagnoud Center
The Aging of the Epidemic: Caring for Older
People Living with HIV                                                                                                 HIVLinks                                 Summer      2019

                                                                                                                        HIV, STD, and TB news and information for health professionals

47.   Galantino ML, Kietrys DM, Parrott JS,         58. Uebelacker LA, Weisberg RB, Herman DS,          69. Ompad DC, Giobazolia TT, Barton SC, et al.
      Stevens ME, Stevens AM, Condoluci DV.             Bailey GL, Pinkston-Camp MM, Stein MD.              Drug use among HIV+ adults aged 50 and
      Quality of life and self-reported lower ex-       Chronic pain in HIV-infected patients: rela-        older: findings from the GOLD II study. AIDS
      tremity function in adults with HIV-related       tionship to depression, substance use, and          Care. 2016; 28(11):1373-1377.
      distal sensory polyneuropathy. Physical           mental health and pain treatment. Pain
                                                                                                        70. Drootin M, Kevin High MD, Amy Justice MD,
      therapy. 2014; 94(10):1455-66                     Medicine. 2015;16(10):1870-81.
                                                                                                            South K, David Spach MD, Victor Valcour
48. Sandoval R, Roddey T, Giordano TP, Mitchell     59. Lucey BP, Clifford DB, Creighton J, Edwards         MD. Substance use disorders. The HIV and
    K, Kelley C. Pain, sleep disturbances, and          RR, McArthur JC, Haythornthwaite J.                 Aging Consensus Project: Recommended
    functional limitations in people living with        Relationship of depression and catastro-            Treatment Strategies for Clinicians Managing
    HIV/AIDS-associated distal sensory periph-          phizing to pain, disability, and medication         Older Patients with HIV. https://aahivm.
    eral neuropathy. Journal of the International       adherence in patients with HIV-associated           org/wp-content/uploads/2017/02/Aging-
    Association of Providers of AIDS Care. 2014;        sensory neuropathy. AIDS care. 2011;23(8):          report-working-document-FINAL-12.1.pdf.
    13(4): 328-334.                                     921-8.                                              Accessed April 16, 2019.
49. Drootin M, Kevin High MD, Amy Justice           60. Frich LM, Borgbjerg FM. Pain and pain treat-    71. Han BH, Moore AA. Prevention and screen-
    MD, South K, David Spach MD, Victor                 ment in AIDS patients: a longitudinal study.        ing of unhealthy substance use by older
    Valcour MD. HIV-1-Associated Peripheral             Journal of Pain & Symptom Management.               adults. Clinics in geriatric medicine. 2018;
    Neuropathologies in HIV and Aging. The HIV          2000; 19(5): 339-347.                               34(1):117-129.
    and Aging Consensus Project: Recommended
                                                    61. Merlin JS. Chronic Pain in Patients With HIV    72. Flyn KE, Lin L, Bruner DW, et al. Sexual satis-
    Treatment Strategies for Clinicians Managing
                                                        Infection: What Clinicians Need To Know.            faction and the importance of sexual health
    Older Patients with HIV. https://aahivm.
                                                        Topics in Antiviral Medicine. 2015; 23(3):          to quality of life throughout the life course
    org/wp-content/uploads/2017/02/Aging-
                                                        120-124.                                            of U.S. Adults. The journal of sexual medi-
    report-working-document-FINAL-12.1.pdf.
                                                                                                            cine. 2016; 13(11):1642-1650.
    Accessed April 16, 2019.                        62. Tehranzadeh J, Ter-Oganesyan RR, Steinbach
                                                        LS. Musculoskeletal disorders associated        73. National Institutes of Health. Sexuality in
50. Hahn K, Arendt G, Braun JS, von Giesen
                                                        with HIV infection and AIDS. Part II: non-          later life. https://www.nia.nih.gov/ health/
    HJ, Husstedt IW, Maschke M, Straube ME,
                                                        infectious musculoskeletal conditions.              sexuality-later-life. Updated November
    Schielke E, German Neuro-AIDS Working
                                                        Skeletal Radiology. 2004; 33(6): 311-320.           30,2017. Accessed April 16, 2019.
    Group. A placebo-controlled trial of gaba-
    pentin for painful HIV-associated sensory       63. Maharaj SS, Yakasai AM. Does a rehabili-        74. Science Validates Undetectable = Untrans-
    neuropathies. Journal of neurology.                 tation program of aerobic and progressive           mittable HIV Prevention Message. NIAID.
    2004;251(10):1260-6.                                resisted exercises influence HIV-induced            https://www.niaid.nih.gov/news-events/
                                                        distal neuropathic pain?. American Journal          undetec table-equals-untransmit table.
51.   Phillips TJ, Cherry CL, Cox S, Marshall SJ,
                                                        of Physical Medicine & Rehabilitation. 2018;        Published July 22,2018. Accessed April 16,
      Rice AS. Pharmacological treatment of
                                                        97(5):364-369.                                      2019.
      painful HIV-associated sensory neuropa-
      thy: a systematic review and meta-analysis    64. Parker R, Jelsma J, Stein DJ. Managing pain     75. Preexposure prophylaxis for the prevention
      of randomised controlled trials. PLoS One.        in women living with HIV/AIDS: A random-            of HIV infection in the united states – 2017
      2010; 5(12):e1443.                                ized controlled trial testing the effect of a       update. U.S. Public Health Service. https://
                                                        six-week peer-led exercise and education            www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-
52. Gale J. Physiotherapy intervention in two
                                                        intervention. Journal of Nervous & Mental           prep-guidelines-2017.pdf. Published March
    people with HIV or AIDS-related periph-
                                                        Disease. 2016; 204(9):665-672.                      2018. Accessed April 16, 2019.
    eral neuropathy. Physiotherapy Research
    International. 2003; 8(4): 200-209.             65. Nkhoma K, Seymour J, Arthur A. An edu-          76. Drootin M, Kevin High MD, Amy Justice MD,
                                                        cational intervention to reduce pain and            South K, David Spach MD, Victor Valcour MD.
53. Sandoval R, Roddey T, Giordano TP,
                                                        improve pain management for Malawian                Immunizations in HIV and Aging. The HIV and
    Mitchell K, Kelley C. Randomized Trial
                                                        people living with HIV/AIDS and their family        Aging Consensus Project: Recommended
    of Lower Extremity Splinting to Manage
                                                        careers: A randomized controlled trial.             Treatment Strategies for Clinicians Managing
    Neuropathic Pain and Sleep Disturbances
                                                        Journal of Pain & Symptom Management.               Older Patients with HIV. https://aahivm.
    in People Living with HIV/AIDS. Journal of
                                                        2015; 50(1):80-90.e84.                              org/wp-content/uploads/2017/02/Aging-
    the International Association of Providers of
                                                                                                            report-working-document-FINAL-12.1.pdf.
    AIDS Care (JIAPAC). 2016; 15(3), 240-247.       66. Doerfler RE, Goodfellow L. Brief Exposure to
                                                                                                            Accessed April 16, 2019.
                                                        Cognitive Behavioral Therapy Reduces Side-
54. Kietrys DM, Galantino ML, Cohen ET,
                                                        Effect Symptoms in Patients on Antiretroviral   77. Helleberg M, May MT, Ingel SM, Dabis F,
    Parrott JS, Gould-Fogerite S, O’brien KK.
                                                        Therapy. Journal of the Association of              Reiss P, et al. Smoking and life expectan-
    Yoga for Persons With HIV-Related Distal
                                                        Nurses in AIDS Care. 2016; 27(4): 455-467.          cy among HIV-infected individuals on an-
    Sensory Polyneuropathy: A Case Series.
                                                                                                            tiretroviral therapy in Europe and North
    Rehabilitation Oncology. 2018;36(2):123-31.     67. Drootin M, Kevin High MD, Amy Justice MD,
                                                                                                            America. AIDS. 2015; 29(2): 221-229.
                                                        South K, David Spach MD, Victor Valcour
55. Parker R, Stein DJ, Jelsma J. Pain in people
                                                        MD. Depression in the Aging HIV Infected        78. Drootin M, Kevin High MD, Amy Justice
    living with HIV/AIDS: a systematic review.
                                                        Population. The HIV and Aging Consensus             MD, South K, David Spach MD, Victor
    Journal of the International AIDS Society.
                                                        Project: Recommended Treatment Strategies           Valcour MD. Advanced Care Planning in HIV
    2014; 17(1): 18719.
                                                        for Clinicians Managing Older Patients              and Aging. The HIV and Aging Consensus
56. Merlin JS, Westfall AO, Chamot E, Overton           with HIV. https://aahivm.org/wp-content/            Project: Recommended Treatment Strategies
    ET, Willig JH, Ritchie C, Mugavero MJ. Pain         uploads/2017/02/Aging-report-working-               for Clinicians Managing Older Patients
    is independently associated with impaired           document-FINAL-12.1.pdf. Accessed April             with HIV. https://aahivm.org/wp-content/
    physical function in HIV-infected patients.         16, 2019.                                           uploads/2017/02/Aging-report-working-
    Pain Medicine. 2013;14(12): 1985-1993.                                                                  document-FINAL-12.1.pdf. Accessed April 16,
                                                    68. Drootin M, Kevin High MD, Amy Justice MD,
                                                                                                            2019.
57. Hanass-Hancock J, Myezwa H, Carpenter               South K, David Spach MD, Victor Valcour MD.
    B. Disability and living with HIV: Baseline         Anxiety Disorders in HIV and Aging. The HIV
    from a cohort of people on long term ART            and Aging Consensus Project: Recommended
    in South Africa. PLOS ONE. 2015; 10(12).            Treatment Strategies for Clinicians Managing
                                                        Older Patients with HIV. https://aahivm.
                                                        org/wp-content/uploads/2017/02/Aging-
                                                        report-working-document-FINAL-12.1.pdf.
                                                        Accessed April 16, 2019.

                                                                                                           New Jersey HIVLinks, Summer 2019 / Page 9
Practice Tips

  The Impact of Menopause on the Sexual
  Health of Older Women Living with HIV
  Gertie E. Heider, PhD, MSN, GNP-BC, ANP, Associate Professor, Graduate School of Nursing, Rutgers, The State University of NJ

  Introduction

  O
          ften, healthcare professionals
          do not talk to older adults
          about their sexual health and         Approximately 68% of doctors rarely or never
  this is a missed opportunity for HIV
  testing and prevention. Research in-
                                                  discuss risk factors related to HIV/AIDS in
  dicates that only 68% of healthcare                   patients over 59 years of age.
  professionals discuss risk factors
  related to HIV with patients who are
  59 years of age or older.1 In one com-
  munity sample of 101 older adults
  (70% women), 90% of participants
  reported that their health care pro-
  viders never discussed HIV or other
  sexually transmitted diseases (STD)
  with them.2 Rates of HIV testing in the
  population indicate that only 10–15%
  of people aged 45–64 years are
  tested and some studies report that
  as few as 3% of older adults receive
  a recommendation for HIV testing.2,3         among gay and bi-sexual males com-           and only young people have sexual
  Often, older adults are tested later in      pared to heterosexuals.7-10 In addition,     intercourse.6 Although the frequency
  the course of HIV and as a result, they      older women living with HIV (WLWH)           of intercourse decreases with age,
  are more likely to have opportunis-          are at a higher risk of STDs because         sexuality remains important for older
  tic infections, progress more rapidly        of vaginal atrophy associated with           women; many older women actually
  to AIDS, or die within a year of HIV         aging.7-10 Health care professionals do      have a higher sex drive compared to
  diagnosis.4 According to the Centers         not believe that older adults, especial-     when they were younger.6 Research
  for Disease Control and Prevention           ly older adults with HIV, are sexually       studies confirm that sexual inter-
  (CDC), nearly half of the people in          active.6 As a result of this mispercep-      course is enjoyed by older women
  the United States living with HIV are        tion, they fail to engage older adults       into their 80’s, 90’s and beyond.6 This
  aged 50 and older.5 Although new             in a conversation about sexual health        article discusses the impact of meno-
  HIV diagnoses are declining among            and the need for safe sex practices,         pause on the sexual health of older
  people aged 50 and older, in 2016,           which has consequences including             WLWH.
  approximately 1 in 6 new HIV diag-           the risk of HIV transmission.11
  noses occurred in people 50 years of
                                               Sexuality is an important factor in the      Age-Related Changes in
  age or older.5
                                               quality of life for older women, includ-     Female Sexuality
  There are several reasons for the            ing WLWH. Sexuality and sexual activ-        Multiple factors may affect sexual re-
  prevalence of HIV and rate of new in-        ity make women feel desirable and            sponse in older women. Hormonal
  fections among older adults. An esti-        attractive and increases a woman’s           changes associated with menopause
  mated 80% of 50-90 year old adults           sense of self-worth in a society that        can lead to dyspareunia because of
  are sexually active.6 Results of studies     equates beauty with youth. We are            decreased elasticity and lubrication of
  about sexuality in people living with        all familiar with many of the myths          the vaginal walls and increased fragility
  HIV (PLWH) 50 years of age and               that exist about sexuality and older         of the vaginal mucosa.12 One-third of
  older showed that about 41% of               women. Some of the common myths              sexually active women over 65 years
  sexually active PLWH reported engag-         are that sexual desire decreases with        old complain of painful intercourse.13
  ing in unprotected anal or vaginal sex       age, older women lose interest in            Testosterone influences female sexual
  and condom use rates were lowest             sex, all older adults are heterosexual,      behavior; low levels lead to impaired
Page 10 / New Jersey HIVLinks, Summer 2019
The Impact of Menopause on the Sexual Health
of Aging Older Women Living with HIV                                                            HIVLinks                                Summer      2019

                                                                                                HIV, STD, and TB news and information for health professionals

sexual desire, arousal, responsive-
ness, decreased genital sensation, and
reduced ability to achieve orgasm.14 The
following changes occur in the stages of
sexual response in older women:
Excitement: Older women need more
time to become sexually aroused. The
clitoris may require longer direct
stimulation. There is decreased genital
engorgement and reduced vaginal
lubrication.
Plateau: There is decreased expansion
of the vagina. During sexual arousal,
there is increased blood flow to the
genitalia, resulting in vasocongestion.
Orgasm: Although women can still
achieve multiple orgasms, they may
experience fewer and weaker con-
tractions and occasional spastic and
painful uterine contractions.
                                           Menopause                                such as cardiovascular disease, osteo-
Resolution: After sexual intercourse                                                porosis, and fragility fractures, which
                                           The World Health Organization (WHO)
is completed, women return to the                                                   are associated with earlier mortality.7
                                           defines menopause as the self-
pre-aroused stage faster than they                                                  Therefore, it is important for the pro-
                                           reported cessation of menstruation
would at an earlier age due to rapid                                                vider to evaluate the older WLWH for
                                           for 12 months. The average age for
loss of vasocongestion.14                                                           these conditions, assess if she needs
                                           natural menopause in the US is 51
                                           years.16 Menopause does not require      hormonal therapy, and offer counsel-
Pathophysiologic Changes
                                           an evaluation of reproductive hor-       ing about the symptoms and effects
that Affect Female Sexuality
                                           monal levels by a healthcare provider,   of possible co-morbidities.7, 8
in all Women:
                                           which may be problematic for WLWH,
¡ HIV                                                                               The Effect of
                                           who may have difficulty distinguishing
                                                                                    Menopause on HIV
¡ Diabetes                                 between symptoms of menopause
                                           and symptoms of HIV.15 Menopausal        WLWH experience particular chal-
¡ Stroke                                   symptoms, such as irregular menstru-     lenges during menopause. They
                                           al cycles, anovulation, amenorrhea,      have difficulty distinguishing meno-
¡ Arthritis
                                           decreased sexual interest, respon-       pausal symptoms from HIV-related
¡ Surgeries that affect body image         siveness, and increased urogenital       symptoms, accessing appropriate
  and diminish self-esteem (e.g.           symptoms are experienced by 85%          menopause care, and managing the
  mastectomy, ostomies)                    of all menopausal women; these           impact of menopausal symptoms on
                                           are also common symptoms experi-         HIV self-care, including adherence to
¡ Neurological disorders (e.g., Spinal                                              antiretroviral therapy (ART). Barriers
  cord injuries, or diseases of the        enced by WLWH.13
                                                                                    to intimacy that WLWH experience
  central or peripheral nervous            WLWH may have a lower average            include the negative impact of HIV
  system)                                  age of menopause and are at higher       stigma on intimate partner relation-
                                           risk of developing early and prema-      ships, body image concerns, and the
¡ Effects of alcohol or recreational       ture menopause.16,17,18 The term early
  drugs                                                                             dilemma of HIV disclosure.19 Research
                                           menopause refers to the occurrence       has provided some insight into how
¡ Female urinary incontinence              of menopause between 40 and 45           HIV infections affect menopause in
                                           years, and premature menopause           older WLWH:
¡ Cardiovascular disease14                 as occurring before the age of 40.
                                           Early or premature menopause has         Estrogen Deficiency. Studies have
                                           important clinical implications. They    not provided evidence of estrogen de-
                                           are linked to alterations in mood and    ficiency (i.e., menopausal state), affect-
                                           sexual function, decline in quality of   ing CD4 count or response to ART.20
                                           life, development of comorbidities       In addition, there is no evidence of

                                                                                    New Jersey HIVLinks, Summer 2019 / Page 11
Practice Tips

  differences in the percentage of pre-                                                   ART Drug distribution. There is
  and postmenopausal WLWH achiev-                                                         limited research about the effects of
  ing plasma HIV RNA viral loads
The Impact of Menopause on the Sexual Health of
Aging Older Women Living with HIV                                                                        HIVLinks                                Summer      2019

                                                                                                         HIV, STD, and TB news and information for health professionals

                                             Sexually Transmitted Diseases.             There were 33,879 reported cases
                                             Those responsible for HIV education        of gonorrhea in 2016 among people
                                             and prevention messages have ne-           45 years of age and older, up from
                                             glected older women, thus they know        26,005 in 2015 and 16,257 in 2012.
                                             less about the risk of transmission
                                             and infection compared with younger                Primary and Secondary
                                                                                                Syphilis among people
                                             women.13 Regardless of HIV status,
                                                                                                45 years of age and older
                                             older women are less likely to talk        6,000
                                             about their sex lives with their health-
                                             care providers compared to younger         5,000

                                             women and providers frequently do          4,000
                                             not ask older patients about sex.1 In
African-American or Hispanic ethnicity,      addition, older women often mistake        3,000
decreased body mass index, vitamin D         the symptoms of HIV for the aches          2,000
deficiency, chronic steroid use, amen-       and pains of normal aging and are
orrhea, and hypogonadism are more            less likely to get tested.5 According      1,000
common in WLWH and contribute to             to the CDC, STD surveillance rates,           0
low BMD.37 Many aspects of the rela-         there was a 20% increase in STDs
tionship between HIV and Low BMD are                                                              2012           2015            2016
                                             among older adults between 2015
unclear; for example, researchers have       and 2016.42
not been able to determine the extent                                                   There were 5,650 cases of primary
to which low BMD in HIV is explained                                                    and secondary syphilis were report-
by low body weight and smoking.38                         Chlamydia among people        ed in the 45 years of age and older
                                                          45 years of age and older     cohort; up from 4,848 in 2015 and
Mental health and menopause.                   50,000                                   3,176 in 2012.42
Anxiety, low mood, and clinical depres-
                                               45,000
sion may occur at any stage during                                                      Sexual Health Assessment
                                               40,000
menopause. Depressive symptoms are                                                      The need to include sexual health
increased two to four-fold during peri-        35,000
                                                                                        content in healthcare provider train-
menopause.39 A study conducted by              30,000                                   ing is clear. Healthcare providers are
Maki et. al., found no significant differ-     25,000                                   inconsistent in their ability or willing-
ence in the occurrence of depression                                                    ness to conduct a sexual history as-
                                               20,000
between HIV-negative women and                                                          sessment and this may be related to
WLWH during menopause.40 Among                 15,000
                                                                                        inadequate training. In one study, ge-
the HIV-positive cohort, lower CD4             10,000                                   riatric fellows reported that barriers to
count was associated with depres-               5,000                                   developing sexual health taking skills
sion, whereas ART adherence was                                                         included the need to develop other
                                                      0
associated with a lower rate of de-                                                     competing competencies, lack of
pression.41 The lack of information                          2012     2015    2016
                                                                                        educational materials, and discomfort
concerning past mental health history        There were 43,409 reported cases           with this topic.43
was a limitation of the study accord-        of chlamydia among people 45 years
ing to the authors. This is important                                                   Sexuality Assessment: The PLISSIT
                                             of age and older in 2016, up from          tool provides an effective evidence-
because the prevalence of depres-            38,185 reported cases in 2015 and
sion among PLWH is higher than the                                                      based sexual assessment guide.
                                             26,405 in 2012.                            PLISSIT is not a diagnostic tool but
rates of depression in the general
population.41                                                                           does serve as an effective method to
                                                                                        initiate a discussion about sexuality.
                                                      Gonorrhea among people            The components of PLISSIT are:
                                                      45 years of age and older
                                                                                        P= Obtain Permission to discuss
                                             40,000
                                             35,000
                                                                                        sexual behaviors/practices
                                             30,000
                                             25,000
                                                                                        LI= Provide the Limited Information
                                             20,000                                     needed to function sexually
                                             15,000
                                             10,000                                     SS= Give Specific Suggestions for
                                              5,000
                                                  0                                     the individual to proceed with sexual
                                                                                        relations
                                                          2012      2015     2016                     continued on next page
                                                                                         New Jersey HIVLinks, Summer 2019 / Page 13
Practice Tips

  IT= Provide Intensive Therapy about           changes, and changes in sexual func-        References:
  issues of sexuality for that patient          tioning. Explain that older adults need     1   Durvasula R. HIV/AIDS in Older Women:
                                                a longer arousal time due to natural            Unique Challenges, Unmet Needs.
  When taking a sexual history, it is im-                                                       Behavioral Medicine. 2014; 40(3):
  portant to take into account vision           changes. Describe the use of sexual             85–98. doi:10.1080/08964289.2014.89
  problems, cognitive impairment, hear-         enhancement strategies to compen-               3983.

  ing loss, communication barriers,             sate for normal changes of aging,           2   Harawa NT, Leng M, Kim J, Cunningham
                                                such as artificial water-based lubri-           WE. Racial/ethnic and gender differences
  movement and tactile loss, and psy-                                                           among older adults in nonmonogamous
  chological factors that may influence         cants and/or estrogen creams.                   partnerships, time spent single, and HIV
  assessments.44                                                                                testing. Sex Transm Dis. 2011; 38(12):
                                              ¡ Assess the patient’s ability to cope            1110.
  Interventions. Healthcare providers           with HIV                                    3   McDavid K, Li J, Lee LM. Racial and ethnic
  should feel confident and comfortable                                                         disparities in HIV diagnoses for women
                                              ¡ Discuss the impact of menopause                 in the united states. JAIDS J Acquired
  when talking about sex and dealing with
                                                on HIV                                          Immune Defic Syndromes. 2006;
  patients’ sexual expression. Patient edu-                                                     42(1):101–107.
  cation should include:
                                              Conclusion                                    4   Siegel K, Schrimshaw EW, Dean L.
  ¡ Explain federal regulations regard-                                                         Symptom interpretation: Implications
                                              The CDC recommends regular HIV/                   for delay in HIV testing and care among
    ing STDs and HIV transmission.            AIDS testing in persons up to the                 HIV-infected late middle-aged and older
                                              age of 64; yet, few older adults are              adults. AIDS Care. 1999; 11(5):525-535.
  ¡ Encourage patients to inform sexual
                                              tested.45 Older people are less likely        5   HIV Among People Aged 50 and
    partners of their HIV status and/or                                                         Older. Centers for Disease Control and
    any STD infection so the partner          to be tested for HIV for the following            Prevention. https://www.cdc.gov/hiv/
    can get treatment, if needed              reasons:                                          group/age/olderamericans/index.html.
                                                                                                Published September 18, 2018. Accessed
                                              Health care providers may not think               April 8, 2019.
  ¡ Teach safer sex practices and offer
                                              to ask older adults about their HIV risk      6   Taylor A, Gosney MA. Sexuality in
    methods patients can use to
                                              factors, including sexual activity, and           older age: essential considerations for
    protect themselves from STDs and                                                            healthcare professionals. Age and Ageing.
                                              may not recommend HIV testing.
    HIV, such as condoms, pre-expo-                                                             2011; 40(5): 538-543.
    sure prophylaxis (PrEP) for patients      Some older people may be embar-               7   Karpiak SE, Shippy RA, Cantor MH.
    who are HIV negative, and U=U for         rassed to discuss HIV testing or sexu-            Research on Older Adults with HIV. New
                                              ality with their health care providers.           York (NY): AIDS Community Research
    patients who are HIV positive                                                               Initiative of America. 2006. https://www.
  ¡ Discuss alternative methods that          In older adults, signs of HIV infec-              health.ny.gov/disease s/aids/providers /
                                              tion may be mistaken for symptoms                 conferences/docs/roah_final_report.pdf.
    people can use for sex and intimacy–                                                        Accessed April 8, 2019.
    positions, cuddling, touching             of aging or of age-related conditions.
                                                                                            8   Golub SA, Botsko M, Gamarel KE,
                                              Particular to women, the symptoms                 Parsons JT, Brennan M, Karpiak SE.
  ¡ Promote a healthy lifestyle, and offer    of HIV may mimic the symptoms of                  Dimensions of psychological well-being
    guidance about diet, exercise, stress     menopause. Consequently, older adults             predict consistent condom use among
                                                                                                older adults living with HIV. Ageing
    management, adequate sleep, and           are not offered HIV testing and HIV is            International. 2013; 38(3): 179-194.
    smoking cessation                         more likely to be diagnosed at an ad-
                                                                                            9   Lovejoy TI, Heckman TG, Sikkema KJ,
                                              vanced stage. When HIV is diagnosed               Hansen NB, Kochman A, Suhr JA et al.
  ¡ Show empathy and sensitivity when         late, it is more likely to advance more           Patterns and correlates of sexual activity
    talking to patients; use active listen-   rapidly to AIDS. 45                               and condom use behavior in persons
    ing and refrain from negative com-                                                          50-plus years of age living with HIV/
                                              Healthcare providers should initate               AIDS. AIDS and Behavior. 2008; 12(6):
    ments and facial expressions                                                                943-956.
                                              discussions about sexuality with older
  ¡ Reinforce the need to take pre-           adults; this may facilitate earlier diagno-   10 Lindau ST, Schumm LP, Laumann EO,
                                                                                               Levinson W, O'muircheartaigh CA, Waite
    scribed medications. Explain medi-        sis of HIV or prevent infection with HIV         LJ. A study of sexuality and health among
    cations, including side effects, drug     in older adults. Healthcare providers can        older adults in the United States. New
    and food interactions, and the reason     use the PLISST Model to address sexu-            England Journal of Medicine. 2007;
                                                                                               357(8): 762-774.
    for taking the medication. Talk to the    ality with older adults. For older women,
    patient about the effect of medica-                                                     11 Woodard TL, Diamond MP. Physiologic
                                              healthcare providers should include a            measures of sexual function in women: a
    tions on sexual performance.              discussion about menopause, provide              review. Fertility and sterility. 2009; 92(1):
                                              information about symptoms common                19-34.
  ¡ Encourage adherence to medical
                                              to both HIV and menopause, and con-           12 Andany N, Kennedy VL, Aden M, Loutfy
    appointments.                                                                              M. Perspectives on menopause and
                                              sider HRT for older WLWH experiencing
                                                                                               women with HIV. International Journal of
  ¡ Explain normal aging changes in body      symptoms of menopause. v                         Women's Health. 2016; 8: 1.
    appearance, age related physiological

Page 14 / New Jersey HIVLinks, Summer 2019
The Impact of Menopause on the Sexual Health of
Aging Older Women Living with HIV                                                                               HIVLinks                                Summer      2019

                                                                                                                HIV, STD, and TB news and information for health professionals

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