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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
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
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
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
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
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
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
Feature Article
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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.
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Quality of life and self-reported lower ex- Chronic pain in HIV-infected patients: rela- older: findings from the GOLD II study. AIDS
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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
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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
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of Lower Extremity Splinting to Manage
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Neuropathic Pain and Sleep Disturbances
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54. Kietrys DM, Galantino ML, Cohen ET,
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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
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Sensory Polyneuropathy: A Case Series.
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ET, Willig JH, Ritchie C, Mugavero MJ. Pain uploads/2017/02/Aging-report-working- for Clinicians Managing Older Patients
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New Jersey HIVLinks, Summer 2019 / Page 9Practice 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 2019The 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 11Practice 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 13Practice 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.
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Interventions. Healthcare providers with HIV 3 McDavid K, Li J, Lee LM. Racial and ethnic
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¡ 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
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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
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¡ 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-
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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
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