HIV, Aging, and Palliative Care: Peter Selwyn and Meredith Greene

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And Alex, we got a lot to talk about today. Who are our guests?

Alex 00:07

We are delighted to welcome Peter Selwyn, who is a family medicine and palliative medicine doctor and chairman of the Department of Family and Social Medicine and director of the Palliative Care Program at Montefiore Einstein and author of Surviving the the Personal Journey of an AIDS Doctor. Peter, welcome to the GeriPal Podcast.

Peter 00:25

Thank you. Happy to be here.

Alex 00:27

And we’re delighted to welcome Meredith Greene, a friend, a geriatrician, researcher, associate professor at Indiana University, who was previously with us at UCSF in our division of geriatrics. And when she was here, she co founded the Golden Compass Clinic at San Francisco General Hospital for older adults living with HIV. Meredith, welcome to the GeriPal Podcast.

Meredith 00:48

Thank you, Alex and Eric.

Eric 00:50

So we’re going to be talking about HIV and geriatrics and palliative care. Before we do, Meredith, I think you have a song request for Alex.

Meredith 00:59

Yes, I am requesting One by U2.

Eric 01:03

Why did you pick One by U2?

Meredith 01:06

I picked this because there’s not one song that can encapsulate aging with HIV affects so many different people. But this song was actually a fundraiser for AIDS when it was released. And so I picked this and for the ongoing work that you two and Bono have done globally.

Eric 01:28

Wonderful.

Alex 01:28

I love this song. Thank you. Meredith.

Alex 01:42

(singing)

Eric 03:33

Great song. Peter, I heard you had maybe a different song for Alex.

Peter 03:43

Oh, well, I was hoping he might be able to sing the message from Grandmaster Flash and the Furious 5, which next time.

Alex 03:52

Yeah, that would be a good challenge. I’m always up for a challenge.

Eric 03:57

Next time, okay, we got a lot to talk about, HIV, geriatrics and palliative care. But to kind of ease us into it. Peter, I’m going to start off with you. How did you get involved and interested in this topic?

Peter 04:12

Well, I mean, my whole career really has sort of grown along with and moved through the AIDS epidemic. Have been now a care provider for people with HIV for over 40 years. And I graduated from medical school in the early 80s. In fact, the same month and the same year that the first AIDS cases were reported by cdc, which were the clusters of cases of pneumocystis and also kaposi sarcoma in New York and California. And through my residency became just immersed more, which was in the Bronx, at Montefiore, immersed more and more in the care of people with HIV, and then became involved as both the clinician and director of programs involving HIV and substance use in the Bronx and beyond. And so really from the very beginning, I was surrounded by, by people who at that time were all dying of aids.

And that was before we even thought about palliative care as, as a specific field necessarily. It certainly hospice was something that was known about, but in terms of training or preparation, that really didn’t exist. And so I became in some ways a palliative care specialist for people with HIV almost just by being there. And over that first 15 years, which was a very difficult time when there was no treatment at all available, everybody died and usually within months or a year or two of when they were diagnosed. So it felt like it was being part of this huge kind of change in the whole environment and the whole experience of that community. And I became more and more involved in it, including becoming involved in research and developing some of the programs initially to provide care for people with both drug use and HIV related problems, women with HIV vulnerable populations.

And over time, by the mid-90s, when it became sort of evident, thankfully at last that treatment would be available and was effective, it was miraculous that people started living. And I was working at the time at Yale in New Haven, and I became medical director of a facility which was initially created in New Haven as a hospice like facility for people with HIV, which is in late 1995 and in 1996 when the Protease inhibitors came along. And then in the years soon after, everything changed completely. And so the patients who had been admitted there to die, essentially most, if not all, got better and HIV became much more of a chronic condition. So in a very short time, and I know we can talk about this if you want, in More detail later.

But the population with HIV changed from people who were young and most likely to die within months to a year or two older and going through sort of the life cycle. And so I essentially, both in terms of my own life cycle and doing the work, I sort of followed that trajectory. And then at one point, probably in the late 90s, I realized that I was interested in not only the HIV medicine, which I continued to be interested in or involved with, but also the palliative and end of life care aspects itself. And so I went through some additional training in palliative care and then decided I wanted to start a palliative care program, which is what we did then at Montefiore, when to the Bronx to do that. So really for almost, well, 40 years, I suppose I’ve been in this path that’s involved both HIV and that path.

Eric 07:45

Has now looked really different. Right before people were dying of HIV. And even in my training I remember those days, I gotta say, in the last couple years I see more people dying with HIV. Is that what you’re seeing as a palliative care provider now or.

Peter 08:06

Yeah, generally that’s true. I mean, most of the people that are dying in the hospital now and even in the community with HIV tend to have non AIDS defining malignancies and or untreatable end organ failure or just combined, you know, comorbidities, some sepsis still, but. But the HIV we do see, and it feels tragic because the people who are dying of and affected by the more kind of traditional, if you call it that, kinds of complications, some of which can be fatal of HIV AIDS are the people who are not on treatment. And usually there’s a reason for that that is hard to sometimes overcome.

So most of the time, if you were to go to parts of the developing world where antiretroviral therapy is not available, where thankfully there are fewer and fewer such places, although we’ll have to see what happens now with all of these recent attacks on global health that have started coming out of the new regime. But you would see probably the same kind of pattern of what we used to see. But primarily it’s a condition now that affects people. The median age has gone from mid-30s probably to mid-60s in most industrialized settings, including ours. So really significant changes over time.

Eric 09:24

And Meredith, so you actually got interested in HIV and aging early on in your academic career, if I remember correctly?

Meredith 09:33

Yes. And actually I think in medical school I had a slight idea, not that I was going to combine the two areas, but I really liked my ID rotation, which was, unfortunately, a lot of people with HIV and opportunistic infections. This was in the early 2000s in Detroit. And then when I came to residency at the University of California, San Francisco, I was definitely interested in HIV, also in geriatrics and general medicine.

And that was partially why I came to UCSF for residency. But it wasn’t until the end of residency that I started hearing about, oh, well, actually now people with HIV are. Are older, and we’re trying to figure out, you know, some of the challenges they have. And that was kind of a moment of, oh, I can maybe combine these interests. And it was good timing that I was finishing residency, and so I did a one year kind of pseudo HIV fellowship, and then I did my geriatrics fellowship.

Alex 10:51

Was Eric your fellowship director?

Meredith 10:53

He was. And actually, Eric was one of my first attendings as an intern.

Eric 10:58

Oh, boy.

Alex 10:58

Oh, you. I. I think I was your attending when you were a resident.

Meredith 11:03

Yes, you were one of my first resident attending at the va, But Eric was. Yeah, my first month of internship was.

Alex 11:11

At the San Francisco va. Yeah, we go back.

Eric 11:14

Yeah, we go way back. And I also remember. So you. You did a research fellowship after fellowship, and in that fellowship, I think you published a Java paper on HIV and aging. A review article, which I still like to go to.

Meredith 11:29

Yeah. It is kind of weird that my first publication was in jama, part of the Care of the Aging Patient series. Yeah. Systematic review, just outlining some of the challenges. And that was. That’s been 10 years now, I think.

Eric 11:45

Yeah.

Meredith 11:46

Since we did that initial work.

Eric 11:49

So refresh my memory, because I’m getting the story from Peter, is that people are living longer and longer with HIV. That population is aging. What do we know about the epidemiology of HIV in older adults?

Meredith 12:04

Yeah. So I can start off. So right now, in the US we know that more than half of all people living with HIV are age 50 or older. I can share in San Francisco. It had been that way for many years. And in fact, I believe the last report I saw, it’s more than 70% of people living with HIV are over age 50 in San Francisco, and close to 30% are over age 65, or at least 25%. So the overwhelming majority of people in places like San Francisco are older.

Eric 12:48

Okay, I gotta ask a question. Today is March 24th. March 25th is a big day. I turned 50. I guess by this definition, I am now an older adult. I do think I get an AARP card. So why 50? Why are you calling 50 an older adult?

Meredith 13:15

I can start and Peter can chime in. Some of this is historical, how cases were lumped together in the early days of the HIV AIDS epidemic in the U.S. but there is data now showing that people with HIV have higher rates of multimorbidity polypharmacy than people without HIV. Some age related chronic conditions seem to develop earlier in people with HIV and also geriatric syndromes can be common even amongst people in their 50s. So I think there’s still a lot of argument about the debate and we know that aging isn’t a magical cutoff number anyways, whether it’s 65 or 50 or whatever. But I would say there’s enough evidence that we should be thinking about age related conditions in people with HIV earlier.

Eric 14:13

And I guess from a historical perspective, Peter, like how much of this was 30 years ago at a population of HIV positive patients? You were older if you were over the age of 50 versus now. Right. The gap between those with and without HIV, their mortality is now shrunken a lot.

Peter 14:31

No, no, absolutely. I mean, you know, the probably 75% of patients with HIV at that time and certainly deaths among people with HIV 45 and younger and now 75% over 55, probably 50 or 55. So it’s completely 75% of deaths.

Eric 14:48

Oh yeah.

Peter 14:48

So it’s completely shifted. And again, if you were to go to, you know, AIDS in terms of transmission is primarily a sexually transmitted disease of young adults, which is why it presented the way it did in the pre treatment era, really all over the world. But it just has a completely different dynamic now. And one of the things that’s sort of been an irony in a way, some ways a success, but also a new challenge of the HIV epidemic is that people used to die before they had a chance to develop some of the chronic conditions and comorbidities that we’re seeing now that are so rampant because they would die of pneumocystis or die of cancer or die of disseminated cryptococcosis or whatever it was Mai long before they had a chance to develop liver failure from hepatitis C or renal failure.

Well, there was a certain syndrome of potentially accelerated renal failure, but some of the end organ disease, certainly the neurodegenerative disease, aside from HIV dementia, which was early described in the absence of antiretroviral therapy, but pretty much became much more quiescent or less pronounced in the era of antiretroviral therapy. But that that sense of people living longer to then experience some of the complications or morbidities that they would have died before they had experienced, which is sort of a, you know, in some ways an ironic sort of evolution that’s been, I think, true throughout.

Eric 16:08

Yeah. And I also read that 1 out of 10 newly diagnosed HIV cases are in older adults. Does that sound about right?

Peter 16:18

Yeah, no. So some of it is. I mean, there’s what’s been called the senescence of the immune system over time and other age related changes in biomarkers or resilience or a number of different factors. But part of why the prevalence is so high is that it’s a longer surviving cohort. But also there are people becoming newly infected, and they also may progress more rapidly in the natural history of infection, even in the setting of treatment, if you become infected at an older age to start with. So in some ways there’s an increasing concentration for different reasons among people who are older.

Alex 16:55

My guess is probably not something that most geriatricians or internists or family medicine docs caring for older people have on their differential diagnosis. Is a new diagnosis of HIV.

Meredith 17:07

Yes. That is the number one thing I tell people that they have to think about it. And I think patients too, don’t always people. Older adults may not have received AIDS education. You know, they were when they had sex ed in school. If they did, it was before AIDS was a diagnosis. And so I think there’s still some thought that people aren’t at risk both by providers and sometimes older adults themselves, but that’s just not true.

Eric 17:39

Well, I’m also just thinking about like the prep ads. I think they’re all younger people smiling. I can’t. I mean, I’m gonna have to watch next time. I don’t think I’ve seen older adults in any of those ads.

Meredith 17:51

Yeah, there’s very few targeted campaigns that I’ve seen looking at older people. There was actually one in New York City several years ago, and that’s the only one I can think of that highlighted older adults in a prevention campaign. And this is actually a big concern. And the CDC had actually recently submitted guidance. They were considering eliminating the upper age cutoff of universal opt out testing, which has been a big point of advocacy for many, because right now it’s opt out testing. Everyone should have an HIV test at least once in their life up to age 65.

Eric 18:33

Why did they do that?

Meredith 18:35

There was some just. I don’t know exactly. There was some at the time, which was 2006 so also, it’s been a while since the guidance has been updated and other guidance for other viral infections like hepatitis B and C. You know, those age limits have been removed. It’s more universal, except for HIV.

Eric 18:59

What is the recommendation currently for HIV screening in older adults or in non older adults? I don’t even know the answer to that.

Meredith 19:07

I’ll let Peter chime in, but there isn’t for specific. It’s opt out after age 65 up to age 65, and then like risk basis. But we know that providers are not great at talking about sexual health or drug use with anyone, let alone older adults.

Eric 19:27

Peter, anything else, but.

Peter 19:29

Well, I think the 65 was somewhat arbitrary. In fact, I remember being at a HIV conference years ago and John Bartlett, who was really one of the giants of infectious disease and HIV treatment and research, really just legendary, who was almost an emeritus, I think at that time. He was giving a talk and he complained like, well, why won’t they give an HIV test to me? What’s up with this sort of 65 limit? So I think it’s arbitrary.

Alex 19:56

Can I ask a naive question? And I don’t want this to come off the wrong way, but this is really an invitation for you to mount a spirited argument. Both of you. Treatments have improved dramatically. I remember when I was in med school at ucsf, you know, the treatments were associated with so many different side effects and there was a lot of morbidity, not from the disease itself, but from the treatments. And that has changed so much. They’re simplified, they have very few side effects. Do we need specialists who care for people living with HIV, whether they’re geriatrics specialists or palliative care specialists? Or is the aging process and development of serious illness so similar to people who are not living with HIV that we can sort of move on and consider it, you know, sort of like diabetes, for example. Who wants to go first?

Peter 20:55

No, I think it’s an important question, and I think it’s the most important thing is to make sort of awareness of and consideration of HIV infection, certainly in terms of diagnosis, but also as far as treatment. I mean, treatment is really best done in a chronic or continuity setting, whether it’s in a primary care setting or some other. But I think primary care clinicians, geriatricians, should be able to do at least the basic management and HIV care. Certainly there’s a gap still in diagnosis and initiation of treatment, which I think is best sort of pursued in a primary care sort of, you know, sort of low threshold setting. But I think that, you know, the basics of antiretroviral therapy are pretty simple. But I think there are still situations like with some other conditions.

I mean, you know, you mentioned diabetes. I mean, there are times when it’s helpful to have input from a diabetologist or nephrologist, and I think so. I think, you know, the HIV specialist as a designation makes sense to some degree, but it’s probably less necessary in terms of having the kind of expertise that it takes to provide ongoing, uncomplicated care to people with HIV than it used to be. And the treatments have gotten certainly so much simpler. Not only are the medications less toxic, but there are fewer of them. The administration frequency is less, as you know, now they’re injectable, long acting regimens that can be given every few months and probably even less going forward. So I think that that’s, I think that’s where it will evolve.

But, but, you know, by the same token, and again, I think you could say this is true for other specialties. Cardiology, certainly. You know, I remember when, when, when statins first came out, only cardiologists could prescribe them. And that’s now, you know, I mean, there were these like precious drugs that like, you didn’t, you had to make sure that patients, you know, qualified or that they were properly, properly handled. And that’s obviously not. Wow. But, but, but, but they’re still cardiologists. So I, somewhere in there, you know, where. I don’t know where the right cut point is, but yeah, that’s what I would say.

Eric 23:04

What do you think, Meredith?

Meredith 23:06

Yeah, I mean, I think about this a lot. In San Francisco, HIV care was more specialized in that. The HIV clinics also served as primary care. So somebody could go in and they would get all their care in one place. So it was more integrated. Now, where I work in Indianapolis, the HIV clinics are specialty clinics. They’re not in primary care, but their patients are already coming into the clinic every six months, usually to get blood work to make sure their medications are working and that they’re not developing side effects. And many of them do not feel comfortable going to yet another clinic. Plus, it’s a bit of an inconvenience having to go somewhere else to get your blood pressure checked and managed, for example.

And the reality is that a lot of, in the specialty clinic, a lot of primary care is being done because there’s no one else doing it. There are some patients who have gone and gotten separate primary care and just come in every six months. A lot of it is also tied to the services and how patients can get their medications paid for, you know, if they need to enroll in ADAP and other HIV specific programs. And, you know, I’ve seen that some primary care providers, there’s still so much stigma that they don’t feel comfortable or they feel like that managing HIV is somehow too complicated. So I do think we need to make it feel more accessible and make sure people know that there are resources to help them start medications.

But because I’m thinking of a recent example where someone could not really engage in care and they were already connected to a primary care kind of behavioral health program, but the providers there would not start them on HIV medications. So this person was engaging in care, but they weren’t going to go to a separate HIV clinic to, you know. So I think it depends where somebody trusts and I think there does need to be basic knowledge of everyone.

Eric 25:32

Well, let me ask you this, Meredith. Yeah. Like for older patients with HIV, like, how important is it to actually have somebody who understands, like, there are other things that we should be thinking about besides antiretrovirals, like to think about. Like thinking about cognitive issues, vascular issues, bone health issues that we see potentially more common in older adults with HIV.

Meredith 25:58

I mean, I think for older adults, I think especially the people that have survived for 30 some years with HIV and may feel comfortable going to their HIV clinic, I think the geriatric and other services need to come to them.

Eric 26:17

Yeah.

Meredith 26:18

And I think I hear older adults with HIV say they also want people who understand that history, that understand what they may have gone through because of the trauma and every, say, the complicated grief that they’ve experienced in some cases that they need providers who understand that.

Eric 26:39

But I’m also hearing that 1 out of 10 newly diagnosed cases are not those individuals. I mean, I think the stereotype for exceptional, I will say for me, is that these older adults have lived through that. But what is shocking is that 1 out of 10 number, for me, these are people who haven’t lived through that. They haven’t built up that provider trust base with their HIV specialist.

Peter 27:06

No, I think that’s right. I was going to say, though, that I agree with what Meredith said and what you were suggesting. But I think it’s interesting how even within HIV care, whether it’s within a primary care setting or specialized HIV ID setting, it’s been interesting to see how the scope of care and attention has just broadened to go way beyond the antiretrovirals and the, you know, the virality.

Eric 27:31

What are you seeing?

Peter 27:32

Well, no, so if you. If you go to, you know, to the national or international AIDS conferences, probably half of the clinical presentations are about chronic disease management or metabolic, you know, complications of ARVs, or some of the inflammatory consequences of chronic viral infection. Both really, at the basic science level, where there’s been a lot of interesting research as well as clinically. So I think I remember the early years, once this became more of a chronic disease, I would go to these ID meetings and people would be wringing their hands saying, well, I don’t know how to treat diabetes. What am I doing? But I think some of that, not all, some of that, you know, has sort of expanded, but I think. I think you need both. So whether. Whether it’s in the context of a, you know, geriatric care setting where you can have at least the necessary amount or level of HIV expertise or, you know, vice versa, I think it’s important. But I don’t know that there’s a single, for me, at least, solution as to, you know, who’s. Who would be the best person to provide care.

And I think, you know, not speaking as a geriatrician, I’m not one in terms of training, but I think that that kind of attitude almost is, well, you know, we sort of. We don’t want to deal with this too complicated. You know, we’ll leave it to the specialist. That, to me, is kind of a cop out, which I see in or have seen in primary care over years. And I don’t think that’s really defensible, at least in terms of the medicine that you need to learn. I don’t think that should be so forbidding or a reason not to take it on.

Alex 29:01

When I see patients who are nearing the end of life, living with HIV, who are hospitalized, older adults, some of the major things that they’ve been grappling with are more in the social domain. And I wonder if you could speak to that. People whose communities have died and they’ve been living with HIV for so long and so many people died early on, but then again, now that they’re older, their loved ones have died, they may be isolated from family, they’re living alone. Loss of meaning and purpose in their lives. Does this ring true for you clinically in your experiences, Meredith, maybe starting with you?

Meredith 29:42

Yes, absolutely. And it’s why I did a study about loneliness, I think, when I was a fellow, because it’s what I saw in San Francisco and see in Indianapolis as well. And I think, especially for people who survived, there was a lot of loss. But I Think, the one thing I think, and I’m curious what Peter thinks, I think one thing that maybe general geriatricians and palliative care providers don’t always think about is just how stigmatizing, how much stigma there still is around HIV, and that that can also make people isolate. And I think that comes back to the to the care and where people feel comfortable getting care as well, that there’s a lot of fear of how they may be treated in healthcare settings for various reasons, but especially around HIV.

Peter 30:39

PETER yeah, I would agree, and I think that’s important in many different settings. And that sort of social isolation, which can be, as you all know better than I, in terms of the geographic aspect. I mean, that’s an important element of people with chronic illness coming to the end of life anyway. And then when you add the HIV stigma on top of that, that sort of amplifies it, as well as people who may have had, for whatever reasons, alienation from their families of origin or some social relationships, and then are increasingly isolated. I think that’s really an important dimension. And then the other aspect, which certainly is a part of geriatrics and aging, is the kind of, you know, the development of frailty and the inability to sort of take care of, you know, people’s sort of daily functions.

Among people who are both socially isolated and feeling cut off and even fearful, perhaps, of contact. I think that that’s a real concern. You know, I’ve been aware of some they’re not enough, but some programs that have been developed to provide, you know, both social support, community support, some of the, you know, the supervised or sort of assisted living settings where people with HIV have lived in a congregate setting, at least in the Northeast, that I’m aware of, there are some settings like that which can be very, I think, helpful in addressing that level of isolation.

The other thing which we haven’t mentioned, but just to say it, when you’re thinking about sort of the care of people approaching the end of life, is that not only have they lived with us for such a long time, but so have their caregivers, and their caregivers themselves are aging and may even be close to the end of life. It used to be common, not so much anymore, thankfully, that if you had patients with AIDS who were dying, it was often one of their contacts, a partner who also had the disease and was also on their own trajectory. So you had two people who were kind of approaching the end of life at the same time. It’s not so much like that anymore. But you have a frail and aging and in some ways isolated caregiver sort of cohort at the same time as you have the patient. So I think all of those things are important to really consider.

Eric 32:56

And let me ask you this. I’ll turn to you, Meredith. So I’m hearing this. Older adults with HIV, this issue of the geriatric syndromes, whether it be frailty, HIV associated neurocognitive impairment, earlier atherosclerotic disease, like we’re seeing these, what do you call them, comorbidities or how much of it is. I guess that’s my question. How much of this is a side effect of living with a virus and the inflammation from the virus, how much of it is a side effect from antiretroviral therapy? How much is it just aging and this population’s getting older, so they’re having normal geriatric syndromes.

Meredith 33:37

I don’t know that we can definitively quantify how much of each, but I think those are the things that are being looked at. And it’s, I think from a geriatrician perspective, it’s probably all of the above. We know that there is chronic inflammation. That’s why people, even when someone has an undetectable viral load. And that is why, you know, part of the reason beyond for cardiovascular disease, beyond like smoking and other traditional risk factors, that people with HIV have an increased risk. We know that antiretroviral drugs have side effects like tenofovir, the earlier formulation, which almost everyone was on at one point, can accelerate osteopenia, osteoporosis. So that is why there are different screening guideline recommendations around osteoporosis. Even saying for men at age 50 in postmenopausal women, because of this increased risk.

Eric 34:41

Is that the recommendation for osteoporosis?

Meredith 34:43

Yeah, people with HIV to have screening for osteopenia, osteoporosis at age 50 or postmenopausal women.

Eric 34:51

And you also mentioned atherosclerosis. Do we do anything differently with that for HIV positive older adults?

Meredith 34:57

Yeah. So now there was actually a large study last year, the Reprieve trial, which looked at people who would not traditionally meet the criteria for statin, so were lower risk. And basically the study supported that people with at least a 5% cutoff of 10 year cardiovascular risk would benefit in terms of decreased atherosclerotic disease to be on a statin. So there are now different guidelines around statin management in people with HIV, and that was people 40 and older. I think the Other thing that we haven’t talked about yet is that there’s a group of people who are younger, they might only be in their 30s or 40s, but have also been living with HIV for 30 to 40 years. People who acquired HIV perinatally and they are kind of also missing and they don’t really fall in any of these buckets. And in the US sometimes they refer to themselves as dandelions or life term survivors.

And there have been a few studies now showing that they have, you know, people now in their 30s, 40s have a higher rate of chronic kidney disease, hyperlipidemia. But again, those results of the study didn’t apply to them because most of them are under 40. So I do think, I think as they continue to age, we may know more about how much is from the virus, living with the virus for 30 plus years versus other factors. But I think there’s a lot of different things to consider. And as a geriatrician, I try to think about them all because that’s what we do, right? We think of multiple things causing a condition.

Eric 36:48

And all the polypharmacy now that were not just the antiretroviral therapies, but now we’re putting them on a statin, we’re putting potentially on something on their bone health. Like we’re adding these things up. How do you think about polypharmacy for these individuals?

Meredith 37:04

Yeah, so, I mean, there’s been several studies now showing that polypharmacy is more common in people with HIV, especially older adults with HIV. And I think you, yeah, you hit. That’s why. And I, you know, I remember again a study I did as a fellow just looking at describing polypharmacy and potentially inappropriate medications. And we had a very small group of HIV negative people. And one of the things we had thought of because the group with HIV had higher prescribing concerns is maybe that in this case where people were getting their primary care from ID or HIV providers, maybe they’re not as aware or thinking about polypharmacy yet Again, this was 10 years ago. And I think that has shifted where people are. You know, the HIV guidelines actually talk about polypharmacy and frailty and cognition now, which is a big improvement in my mind.

Eric 38:06

And Peter, one of the challenges I often face, like in our hospice patients speaking of polypharmacy, is that they may have been on antiretroviral therapies for, for decades and they’re being admitted to our hospice unit. Time is getting shorter. And the question is, when do we stop?

Alex 38:24

Yeah, yeah.

Peter 38:26

So that’s something that I’ve thought about and written about some over years. It’s really striking to me that since effective therapy became available, which is sort of the, really mid-90s, but even before then, in the early period, there was a time when there was just really intense sort of assessment of when do you start treatment. And still, you know, now it’s pretty much easy because it’s like basically, you know, everybody all the time. But, but there is not one guideline within the ID or HIV world about when to stop antiretroviral therapy, even, even in the hospice literature. And I’ve written about it some, but, you know, we don’t, we don’t have a, like a, you know, an algorithm, but I think that’s telling. And you know, what makes it easier in a way now is that the, you know, the morbidity burden of the ARVs is so minimal that if people want to continue, there’s no particular reason not to.

You know, it’s been argued over time that viremia, uncontrolled viremia, may be associated with worsened, you know, sort of symptomatic or constitutional type, you know, manifestations of HIV. I’m not sure that that’s true, but, but the idea is that ARVs are providing some benefit, even though not necessarily life prolonging. But beyond that, if someone is tolerating a medication that they can take orally, still I don’t think there’s a big push to stop it unless the person wants to. And most of the time people are connected enough to their treatment that they don’t want to stop unless there’s some particular reason for it. So the big sort of deciding point often in the hospital at least comes down to when someone is able to take oral medications or anything by mouth. And when they are not, you might ask the question, well, should they put in a feeding tube or some other way of providing enteral feeding? And I think for ARVs there’s no really good reason to. There are a couple of conditions for which ARVs have been found to have specific benefit, but I think at the end of life it’s probably not a significant thing.

And similarly for prophylactic regimens, which are usually also now pretty well tolerated, really the issue is what the consequence of not continuing them is so that for someone to not have to develop pneumocystis pneumonia if they’re dying, it may be reasonable to find a way to continue to provide prophylaxis even if they’re not able to take oral medication just so that they don’t have the symptom burden.

Eric 40:57

But at some point there’s a lag time where it’s just like it’s not going to develop in the time period that they have.

Peter 41:03

Yeah, yeah. And similarly for HIV, I mean the ARVs have benefit aside from whether you believe that there may be some short term effect just on viral burden, which may have clinical consequences. Although again, I sort of hesitate about that, but that, you know, the benefits of ARVs are not for weeks to even a month or two, but more from months to years.

Eric 41:22

So, so if somebody has months to.

Peter 41:23

Years, a typical situation, if somebody who say has well controlled HIV develops a untreatable rapidly progressive cancer like pancreatic cancer or something like that, and then at a certain point is not able to take meds anymore, there’s really no benefit in trying to find a way to continue the ARVs.

Eric 41:40

And do you think when people are on antiretroviral therapy, do you think about some of your palliative care, go to drugs differently like methadone, which has a lot of drug reactions, or GABA to some extent.

Peter 41:53

I mean that used to be much more the case with the protease inhibitors and the first generation non nucleoside reverse transcriptase inhibitors. There were major interactions both with antiretrovirals, with anti TB drugs, in some cases Rifampin particularly, but also anticonvulsants, a number of other meds. So I think always being aware of the potential drug interactions is important. We use those drugs much less now, but at least one, and if you include ritonavir, still two of the drugs that are used in standard HIV regimens and have pharmacologic effects with other medications. So you think about that, but it’s not a reason not to prescribe palliative medications as needed.

Eric 42:34

And real quick, Meredith, the other thing that I see, actually a fair amount now is people with HIV who’ve lived long with HIV. We’ve talked a little bit about this, but cognitive impairment dementia, whether or not this is vascular dementia or Alzheimer’s disease versus this, what is it called, hand HIV associated neurocognitive disorder. How do you think about separating all of that or is it important to.

Meredith 43:00

That is the ongoing research area that I think needs the most attention because hand has changed. I think Peter alluded at the beginning, you know, it’s not AIDS dementia anymore, but there are still maybe some more subtle symptoms related to HIV and cognition. And we know the CNS is an HIV reservoir. But now that people are living into older ages, yes, there’s increased risk of vascular disease, especially because there’s this increased risk of atherosclerosis. And people could have Alzheimer’s or other neurodegenerative conditions. And I think it’s harder to distinguish sometimes. And again, I think this gets back to your perspective on dementia. But I am someone who thinks it’s helpful to try to elucidate what the process is so you can advise on how it may progress. In particular, because HAND may not have the same progression as Alzheimer’s, it’s more of a fluctuating course and people may not progress to full dementia.

Eric 44:07

Huh.

Meredith 44:09

That could be a whole other hour.

Alex 44:11

I know we’re running out of time.

Meredith 44:12

Alex is pulling up his guitar.

Alex 44:14

I got the guitar out. But I want to say, Eric, are we an international podcast?

Eric 44:18

We are an international podcast.

Alex 44:19

We are an international podcast. And you know, Peter alluded to this earlier, the loss of funding for International Health and pepfar. Meredith, I know you. This has affected people who you work with clinically around the world. I wonder if we could just take a moment to speak to what’s going on in terms of loss of support for research studies, clinical efforts, treatment, screening, et cetera.

Meredith 44:45

Yeah. I will focus on the global piece as there have also been changes to the CDC and other federal organizations. But the reason I am now able to do research in rural Uganda or in Kenya is because of the success of PEPFAR and usaid. And now life expectancy has increased in some of these countries and people are now studying geriatric syndromes in Uganda and people with HIV. And that would not be possible without the life saving work of USAID and pepfar, which is under threat right now and will have serious consequences. Taking HIV back to a life threatening diagnosis instead of the chronic condition. That is why we’re having this whole conversation about HIV and aging today. Millions of people’s treatment is at risk.

Eric 45:50

What do we do about that? We’re not in control. Meredith, I see you got a T shirt on. What does that say?

Meredith 45:55

Yes. So I’m going to encourage everyone to act up and fight back against what is happening in the United States and to encourage people to contact their legislatures about support for PEPFAR and usaid. And I will be happy to give anyone talking points if millions of lives at risk is not enough.

Eric 46:22

Thank you.

Alex 46:22

And Meredith Cert says silence equals death.

Eric 46:25

Peter, anything from your perspective, anything we should be doing?

Peter 46:29

No, I think that says it all.

Peter 46:36

Not just roll over and accept this as some aberration. But I think, you know, we still haven’t found the best way to respond and fight back. But I think that’s. That’s what’s important.

Eric 46:52

Well, I want to thank Meredith and Peter for joining us on this podcast. We’re going to end a little bit more with some Bono.

Alex 47:10

(singing)

Eric 47:55

Meredith, Peter, thank you for joining us on this podcast.

Peter 47:57

Thank you.

Meredith 47:59

Thank you.

Eric 47:59

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.