Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Good morning again to our listeners tuning into the podcast to hear more about the contemporary context of the HIV disease state. I'm Bruce Packett, host of the Academy Exchange, and I'm really happy to be on the podcast today talking about an issue that manages to sort of run beneath contemporary public consciousness around HIV. And that's the issue of older Americans with and at risk for HIV.

It really feels like the popular perception is that HIV is essentially, first and foremost, a young gay man's disease. And as we've seen from previous episodes, how inaccurate this assumption is today with women and HIV, transgender and gender diverse and poor minority communities being key prevention, demographic categories. And part of that perception comes from the fact that, statistically speaking, that term towards the earlier days of the epidemic, this was basically true.

By 1992, HIV AIDS was the leading cause of death among men between the ages 25 and 44. But the picture's really changed. And just to offer one powerful statistic to demonstrate this, going back to 2018, the CDC estimated that nearly half of Americans living with HIV were over the age of 55, which as a proportion is certainly increasing over time.

Part of that, I think most people will probably surmise, is the great successes of all the HIV medications that have been developed since the mid 1990s. But that certainly isn't the whole story. And my guest today is Dr. Milena Murray, an HIV clinical pharmacist who has published quite a bit of research in this space of HIV in Americans over the age of 55.

So just by way of introduction, Mliena Murray is an associate professor of pharmacy practice at the Midwestern University College of Pharmacy, Downers Grove Campus and a system level HIV ID clinical pharmacist at Northwestern Medicine. She completed her doctor of pharmacy degree at the Philadelphia College of Pharmacy at her Master's of Science in Clinical Investigation at Northwestern University. Her postgraduate training consisted of a PGY1 pharmacy residency at Maimonides Medical Center in Brooklyn, New York, and an infectious Disease Pharmacotherapy Fellowship at Northwestern Memorial Hospital through Midwestern University. Dr. Murray is a board certified infectious disease pharmacist and an AAHIVM HIV Pharmacist.

Dr. Murray, welcome to the Academy Exchange. Really happy to have you here to discuss the unique landscape of HIV in the older generation.

Dr. Murray

Thank you so much for having me. I'm really looking forward to this discussion today.

Bruce  

Yeah, absolutely. It's a very important one. Just to start us off and I kind of touched on this in my intro. What is your professional understanding of this phenomenon of older Americans bearing an increasing burden of HIV in their cohorts?

We obviously know that the treatments work to return someone with HIV life to its expected length, and many of those survivors are now, of course, advancing or maybe well into their graying years. What else is going on here is my question. For example, what can you say about the increasing phenomenon of new HIV diagnoses in this older cohort? And what’s sort of your thinking on the causes of these demographic shifts in the epidemic?

Dr. Murray 

Absolutely. So this is something that I'm definitely seeing every day with this, you know, aging population. And of course, as you noted, a lot of this is because we're 40 years into this epidemic and we are seeing a lot of these people now surviving with our new antiretroviral medications. But when we think about the opposite side of new diagnoses, I think one of the more important things is that there is a lot more information around testing. And people are aware to get tested.

So I think some of these people who are old or older over the age of 55, they're being tested because of recommendations, whereas they might not be tested before. I also think that there's a lot of sexual movement, sexual health, talking about, as you said, transgender individuals. A lot of the things that we're talking about that we didn't talk about ten, 15, even five years ago. So I think that's really on the horizon as well.

And then I also think there's this phenomenon of people who are no longer of childbearing age, who have gone through menopause when they're not concerned about pregnancy intentions. Sometimes there's different risk factors involved. And so we see that as well, where, you know, people are just enjoying their sexual health in their graying years, as you said, and it just happens to lead to an HIV transmission.

So I'm glad that we're going to be addressing some of these things today and really talking about those who do have HIV and how we can go beyond undetectable.

Bruce

Yeah, I think it's a surprising thing for some in the public to hear that the risk factors are what they are in this group. So I'd love to talk briefly about some general prevention awareness for older Americans who also may not think that HIV is an issue for them. Right? So what should what should an HIV negative person over 60, say, be aware of when it comes to HIV prevention?

What are the prevention tools that this group in particular might or maybe should avail themselves of? And I guess and what context or when should those be considered?

Dr. Murray

So we do have updated guidelines from the Centers for Disease Control. So the CDC, about pre-exposure prophylaxis or PrEP for HIV prevention. And what I love about this guideline update is that it really takes the guesswork out and it basically says if you are sexually active, there should be a discussion about PrEP. So regardless of age, I think that it's a good conversation to have and that people should know there are several options that we have now for PrEP.

And I think that just in general, again, sometimes when pregnancy is not a concern in this particular age group, people aren't looking at barrier methods or other things like that. So I think that PrEP should just be always considered when anyone is sexually active. I think beyond that, it's the conversation about how are you sexually active, what partners do you have, things of that nature.

And also just being aware that STI testing for sexually transmitted infections that doesn't end at a certain age. So there always needs to be a conversation as well. So I really want people to feel empowered.  Hey, I'm sexually active. What are my options for PrEP? What STI testing do I need to make sure that I'm keeping myself completely healthy?

Bruce

Yeah. So that's some really great background there on prevention and epidemiology for older patients with or at risk for HIV. I want to move into some of the special considerations around this older population that is either, as you talked about, to some extent, contracting HIV, a new or maybe it has been on treatment for some time and they've aged into their golden years living with HIV.

Can you start by commenting just briefly on whether those two groups paint a unique clinical picture from each other and if they do, how is that?

Dr. Murray

So, I will say that those with HIV, I think are honestly a little bit more aware of their health and of different screenings that they need to get, especially for cancers, age 40, 50, etc.. So I honestly think that someone with HIV has a better handle on their health. They're getting their cholesterol tested, they're monitoring their blood pressure, or at least going to that HIV specialist who sometimes then acts as their primary care provider.

So I think that that's a really good way, someone with HIV, they have a really good handle on their health, and that's to be separate from making sure their HIV is well controlled, that they are undetectable, and then looking at any other co-morbidities that they might have. And I know what kind of get into some of those issues a little later in the podcast.

But the people who are not living with HIV, I think maybe they're not going to their primary care doctor every year, every six months. Anything. There's a lot of medical mistrust. We're talking about a generation that grew up when doctors would just bill to the insurance for, you know, every 2 minutes of care and they'd order all these tests to make money.

And we know that that's not the case anymore. We know that there's a lot of stewardship when it comes to ordering tests and lab values and things like that. So there's just this fear of going to the doctor. This this fear of, you know, what? If there is an error on the part of the doctor?

So I think medical mistrust comes into that. And because of that, they're not going to the doctor. They're not having those conversations about their sexual health. They're not getting the tests that they need. And I think that that can also contribute to potential HIV transmissions.

Bruce

Yeah, you're so right about that. And you know, now I'd like to pivot to talk about those specific clinical pictures. And I want to talk about particularly polypharmacy, which is a medical term for multiple ongoing drug regimens for varying comorbidities and conditions, and an area you've done some research and publishing also. And then before we dive into polypharmacy, specifically, I want to ask you about comorbidities and HIV and older patients. 

We already know that people as they age tend to experience a number of increasing health issues and complications, which could be a lot of things. But commonly we're talking about, and you can help me with this, but hypertension, diabetes, cardiovascular disease, neurocognitive issues and on and on. What does that aging picture look like specifically for someone with HIV versus someone who doesn't have HIV? Does the HIV specifically make those things more difficult to deal with as a clinician, or does it make them accelerated somehow?

Dr. Murray

HIV is an inflammatory disease. So I like to think about this, that if somebody has a mosquito bite and you look at it, it's red, it's raised, it's inflamed. That's basically the same process that's going on within the body. So when we think about cardiovascular health, when we think about heart disease, we have to think that everything is really accelerate.

So I have to start thinking about someone's cholesterol levels probably like ten years before I would if someone doesn't have HIV. So HIV accelerates disease. We know it accelerates liver disease. We know people are more likely to have issues with other metabolic conditions, diabetes and so on. And so it definitely speeds up those processes. Now, in terms of saying are they more difficult to deal with, I think that we have really great medications for things like hypertension, diabetes, etc..

And so what we have to do is just be careful about any drug-drug interactions. We have to make sure that we're monitoring both diseases. So HIV, and any other comorbid diseases to make sure that one isn't affecting the other or that a drug isn't affecting the other one. But I think overall the important thing is being aware of this and that everyone is going in, getting those appropriate screenings, getting those appropriate lab tests so that we can make sure we get ahead of any potential issues.

Bruce

Right. And we'll talk about those drug-drug interactions a little more in detail later in the in the conversation. But going back to polypharmacy. So, again, these mixed drug regimens for different conditions. Because from what you're describing, it seems as if HIV has a negative impact being an inflammatory condition, right? On common conditions of poor people. But it sounds to you like treating these more common conditions may also have an impact on the HIV disease itself.

So I want to get your opinion on that last component as a clinical pharmacist. And I'm also hoping you can elaborate on some of your research around the common phenomenon of polypharmacy in older people living with HIV. What typically happens with a person's HIV when they're on a large number of prescription medications in addition to their HIV medications?

Dr. Murray

Sure. So polypharmacy is you defined is someone who's on many medications. It hasn't been so well defined in the literature, but we have a consensus that it's anything more than five medications. And so you might think, wow, five medications. That's a lot. You know, But honestly, someone could have, you know, one pill a day for their HIV. They could have then a one or two blood pressure meds, something for cholesterol. They're on a multivitamin. They're taking, you know, something else for, just an herbal supplement. And so they add up very quickly. And so the research that I looked at, we looked at people who were over the age of 55 with HIV and basically saw that there was this split.

So we grouped patients into ten or more medications and then less than ten medications. And we basically saw that the number of medications that someone is taking does have an effect on whether or not their viral load is undetectable. And so I think what can happen is when someone has, you know, ten, 15, 20 medications even to deal with, that's a lot of bottles to get at the pharmacy. They're probably not all on the same refill schedule. So they might have to be going to the pharmacy multiple times, are getting multiple packages in the mail if they use a mail order pharmacy. And then they're trying to open all those bottles every day, maybe they're trying to fill a pill box. So there's just a lot going on that can affect whether or not all of those medications actually get taken.

We have to think about things like pill fatigue. People just don't want to take that many medications. It can really wear on a person to have to take that many medications. And we also know that in addition to having a potential effect on their HIV, it also, they are more likely to have mental health issues, to have other co-morbidities, which does make sense, right?

If someone's on more medications, they're on them for a reason. Hopefully. They have a co-morbid disease, they have high cholesterol, etc.. So I think that there are just a lot of factors that go on. And really when we're thinking about, you know, everyone is squeezed for time, when we when they go to these appointments, all of our providers.

So what my research really points to is that if we're going to try to focus on anything, try to focus on people who are on more than ten medications, and we'll talk about this a little later, too. But do they need all those medications? And so I think that's the impact that the HIV has on the other comorbid conditions that also have a lot of medications associated with them.

Bruce

Yeah, sure. So just talking to your peers who provide medical care and expensive prescriptions. So you talk about reducing the number of overall prescriptions. Besides that, are there any other interventions that provider could pursue to mitigate that negative impact of polypharmacy?

Dr. Murray

So I think one of the most important things is that, a) there has to be an updated medication list and hopefully with electronic medical health records, this will cross over. But we cannot assume that the medication list is updated. We have to go through that at each appointments and patients should feel empowered like, No, I want to go through my medications.

 Some people have them memorized. They could tell you the day they started it. Some people have no idea. Some people have a list with them. But it's really important to make sure that we're checking and that we know everything that they're on. The other piece of this is trying to minimize the number of pharmacies that the person is using.

Sometimes insurance will dictate they have to get certain medications through mail order. But if they have mail order and then one local community pharmacy and making sure that both are aware of the other medications to check for potential drug-drug interactions, I know in these days you go into a grocery store and it's like, oh, if you transfer five prescriptions, we'll give you a $20 gift card. Oh, if you fill certain a number of prescriptions, you know, you get 20% off your grocery bill. And so these are people who are maybe on a fixed income. And of course, this all looks very enticing, but we have to really try to get them to stay in one spot to make sure that if a medication has been discontinued, that they're aware they're not refilling or transferring inappropriate prescriptions pharmacy to pharmacy.

Bruce

Yeah, sure. And I kind of want to stay with that progression of HIV disease itself in older patients, especially on those on these multiple different drug regimens that we're talking about. What does it tell us about how to approach treating the HIV itself in that context? I think there's a common misconception maybe even among some inexperienced providers, that simply prescribing a patient, you know, a potent HIV regimen and getting that patient to an undetectable viral load on their labs is sort of the be all end all of managing HIV, right? And that you can simply, you know, stick forever with whatever regimen got you there. 

And your research indicates that probably more subtlety is likely needed in treatment approaches to older HIV patients. And that there's important benefits to looking beyond just undetectable HIV viral load as an indicator of health and wellness. Can you elaborate on that for starters?

And then maybe give some clinical examples or an example where switching, an undetectable patients regimen would likely yield benefits in their overall health?

Dr. Murray

So I think the very important keyword here is going to be options. I think that we can't just set it and forget it. Oh, the viral load is undetectable. We have to think about what else is going on with that patient and really assess that each visit at each clinical encounter, is this medication still working for that patient on a holistic level?

So, for example, someone might be undetectable, but maybe they're having weight gain. Maybe their fasting blood glucose is starting to creep up and there's some type of insulin resistance going on. Maybe they're just not feeling as great as they could. You know, they have mental health diagnosis. Maybe that medication isn't working the best for them now. And so we get into this, kind of battle of, well, it's undetectable. I don't want to change it, you know. 

But in this day and age, we have such great medications that are so potent, we don't have to worry about, oh, I need to save this drug class. I don't want to use it right now because five years from now, my patient might develop resistance. I'm going to need it. I think we need to look at the person right now and say, How are they doing?

Oh, they're having weight gain. That's unexplained. Let me try switching this medication, monitoring them appropriately and seeing how they do. You know, they've reported feeling more depressed lately. Could it be this regimen, do I need to change them? And so we have to have this personal algorithm as providers to say, when do I need to switch? What do I need to switch to? What questions do I need to ask my patient to really elicit that response? Because there's so much going on now that we really have to look at everything and we can't just check a box and say, yes, they're undetectable.

Bruce

Yeah, for sure. And there's one more pressure point that we hit on earlier that you started to talk about that I wanted to dig a little deeper on and it's around HIV in older patients with those multiple comorbidities. And it's something that I think a lot of people are familiar with and maybe sensitive to. And that's those drug-drug interactions.

It may have unintended health effects or side effects by combining drugs that treat or do separate things. So my question is, what can patients and providers do to mitigate this risk in cases when there are so many agents a patient may be taking on a regular basis to avoid unintended interactions that may be harmful?

Dr. Murray

This is really going to be a multi-pronged approach. The first thing that we want to think about is never assuming that there aren't going to be drug interactions. I know with our integrase strand transfer inhibitor, INSTI class, everybody says, Oh gosh, there's no interactions. There are less interactions with this class than there have been in the past with, say, like protease inhibitors, which is notorious for having a lot of drug interactions.

So I think it's important to really check drug interactions regardless of what we have a feeling of if there's going to be any or not. And this should be done at each visit, making sure again that updated medication list is so important so that everything can be checked, especially over-the-counter medications, herbal supplements, anything like that. The second thing that we can do and patients too, should feel empowered, is to de-prescribe.

So do I need this medication? Why was I started on this medication? I can't tell you the number of times I've asked a patient, Why are you taking this medication? They don't know. They've been on it for ten years. I can't find a diagnosis for it. So we really want to make sure that we're looking at everything appropriately, that we are not prescribing medications to people who are over the age of 55 or 65 that might have a negative effect on their health and so making sure that we are on the least amount of medications possible to get the therapeutic outcomes that we want, to get that effectiveness and efficacy that we're looking for whatever the comorbidity or HIV cure.

Bruce

And, you know, the context of all of these these sort of great answers you're providing sort of indicate a picture where the, you know, HIV is complicating some of those common health problems of aging. So my question is, what are the main considerations when looking at the overall health of an older patient with HIV? So you know what I mean is what are the principal indicators for overall health in this population?

Dr. Murray

So that is honestly going to really depend on the patient. I think that we don't ask patients enough what are their goals, what do they want to be able to do? And I think that this can have an effect on the number of medications they take, etc.. 

I could sit here and say, well, their blood pressure should be controlled, their cholesterol levels should be good. They should be reducing their risk for, you know, cancer by wearing sunscreen, by doing a lot of different things. But I think what's important is to say what is important to that person? What do they want to do? Do they have grandchildren that they want to see get married? Do they just they don't want to take a lot of pills. They don't care what happens. They just want to kind of enjoy the years as they have them. 

So I think it's a very important conversation to talk to someone, especially in this population over 65. I mean, we're seeing diagnoses into the nineties right now, you know, 90 years old with a new diagnosis. And of course, that, you know, there's a lot of maybe failures that have come with education and things because of that. But in that person there are overall health indicators are going to be very different than someone who's diagnosed in their thirties. 

So I think that we really have to involve the person in that discussion and to talk about it in an appropriate way. And I think just obviously with that my medical hat on we can talk about numbers and things of that nature. But I really think we need to pull in making sure that they feel empowered, that they say there's a lot of stigma with this.

So making sure they understand what their resources are, you know, getting them different types of maybe support groups if needed, and really trying to make sure that they are living their best life as according to what they think their best life should be.

Bruce

What a great message to end on. I really appreciate that. Careful, individualized approach to care in prescribing in patients with HIV. You know, it's such an important consideration for this demographic, as you spelled out throughout t his podcast. Dr. Murray, thank you for your insightful look into the issues of older patients living with and at risk for HIV. Thank you for being here today. I really appreciate it.

Dr. Murray

Thank you so much for having me.