Allison Webel, PhD, RN, on the Aging HIV Population

In this podcast, Allison Webel, PhD, RN, talks about the aging population with HIV, what the 6M framework is and how health care providers can implement it in practice, and the pharmacologic and nonpharmacologic therapies on the horizon. 

Additional Resources:

• Webel A. Aging well with HIV. Talk presented at: Association of Nurses in AIDS Care 2020; November 11-13, 2020; Virtual. https://www.nursesinaidscare.org/i4a/pages/index.cfm?pageid=4815 
• HIV Drug Interactions. University of Liverpool. Reviewed October 27, 2020. Accessed October 28, 2020. https://www.hiv-druginteractions.org/
• The Webel Research Lab. Frances Payne Bolton School of Nursing; Case Western Reserve University. https://case.edu/nursing/research/research-areas/faculty-research-studies-labs/webel-research-lab
• Erlandson KM, Karris MY. HIV and aging: reconsidering the approach to management of co-morbidities [the 6M Framework]. Infect Dis Clin North Am. 2019;33(3):769-786. https://dx.doi.org/10.1016%2Fj.idc.2019.04.005

Allison Webel, PhD, RN, is an associate professor of nursing in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

By 2020, it’s projected that 50% of people with HIV will be older than age 50 years, and by 2030, 70% of people with HIV will be older than age 50 years, and perhaps half of them will be aged 70 years or older. With the aging process comes comorbidities and more-complex disease management.

This was the topic of discussion during an expert speaker session at the Association of Nurses in AIDS Care 2020 annual meeting. I’m joined today by the speaker of that session, Dr Allison Webel, who is an associate professor in the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio.

Thank you for joining me today, Dr Webel. To start, can you give us a brief overview of your session?

Allison Webel: My session at ANAC 2020 really is focused on helping nurse practitioners and nurses around the globe to provide the best possible care for adults who are aging with HIV.

Globally, there are more than 7 million people over the age of 50 with HIV. In the US, more than half of all people with HIV are over the age of 50, so clearly this is a growing population and they do have some very specific health concerns and needs. That's really what our presentation is focused on.

Also, given that today much of the primary care that people with HIV receive occurs in HIV specialist clinic, there is a real need to help HIV and ID practitioners understand those needs so that they can provide great clinical care. My presentation really focuses on describing the key considerations for patients who are aging with HIV.

I also described the modified geriatric 6M framework that providers can use to provide holistic care to those who are aging with HIV.

Finally, I discussed some nonpharmacological strategies that nurses and nurse practitioners can counsel patients on to really help them maximize their ability to live well or maximize their health span. These are even strategies that providers can start to counsel patients on earlier in their lifespan.

Amanda Balbi: Treatments for HIV have come a long way since the start of the HIV epidemic in the 1980s and now the number of older adults, like you said, living with HIV is increasing. So which therapies are most effective in older adults, and are there any ART regimens on the horizon?

Allison Webel: Yeah, so we don't have age-specific antiretroviral therapy or ART regimens for older adults with HIV. But we do know that as people with HIV get older, they are much more likely to be diagnosed with multiple chronic health conditions than in previous decades. As you indicated, they are living longer lives now compared to the early 80s.

Also, a recent analysis showed that much of this multiple morbidity is associated with high cholesterol, high blood pressure, and chronic kidney disease. This is important because multi-morbidity is associated with polypharmacy, which can lead to some pretty bad drug-drug interactions with ART medications for people aging with HIV.

In my presentation, I talked about some of those potential drug-drug interactions between ART and statin medications and also potential interactions with antihypertensive medications.

The University of Liverpool has recently developed a great new HIV drug interactions tool that I recommend HIV providers or ID providers use when starting patients on new medications. These can be antiretroviral therapy medications or any other medication to really address some of their chronic health conditions or symptoms associated with those chronic health conditions.

The great thing about the HIV field is that we’re always developing, I think, really exciting therapeutics. And there are a number of exciting HIV regimens that are in the pipeline, including long-acting injections that would allow for less than daily dosing of ART, as well as simplified ART compounds targeting all phases of the HIV lifecycle, but none of those are really older adult specific, so I don't talk too much about those in my presentation.

Amanda Balbi: You spoke earlier about the 6M framework. Can you talk a little bit about that and what it is?

Allison Webel: Yeah. This is actually the bulk of my presentation, because I think it's a really important framework. The 6M framework is an adaptive geriatric framework that helps healthcare providers focus what’s often a very short appointment time with the aging patients on really what's most important to the patient and their caregivers.

This framework was adapted by Erlandson and Karris last year for people who are aging with HIV. The 6Ms are (1) mind, which tends to refer to cognition and mood; (2) mobility when we think about gait, balance, and falls; (3) medications as I just talked about with polypharmacy and those potential drug-drug interactions. It also includes what (4) matters the most to (5) me, which is a focus on the individual's own health goals and preferences.

And also, what's (6) modifiable, and these are the shared modifiable risk factors, including physical activity, nutrition, and tobacco use that really do underlie much of the morbidity we see in older adults.

In our own work in our lab, we see that patients aging with HIV really appreciate this simple and patient-focused framework, and they really do feel like it facilitates shared decision-making with their health care team.

Amanda Balbi: Absolutely. What are your tips for health care providers who manage older patients with HIV?

Allison Webel: I think that it's a big field, but the key takeaways that I would suggest are really that all HIV clinical care must be integrated with geriatric principles. And there are tools that really do help the geriatric population age well. Bringing those into HIV primary care can be really helpful to the patients and their families.

I suggest that the 6M framework actually really does provide a framework with which to organize and prioritize care with patients who are aging with HIV and that nonpharmacological approaches to addressing modifiable risk factors really are the most promising interventions we have to help increase the health span of this population and really help patients aging with HIV live the best possible life that they can.

Lastly, I'd say there are a lot of tools available to help provide care for this population. Encouragingly, the evidence base in the space is really kind of rapidly growing.

Amanda Balbi: Absolutely. And so, what other research are you working on in this area currently?

Allison Webel: We believe very strongly in those nonpharmacological approaches, so we have 2 large national studies. One is the PROSPER-HIV study, which is really trying to understand exactly how much physical activity and what dietary components reduce symptoms in people living with HIV. We're focused on the all symptoms, but we're particularly interested in fatigue and mental health symptoms and then other types of quality of life.

That's currently ongoing, and the other study we're just getting ready to start is a study focused on older adults. It's called the HEALTH-HIV study.

In this study, we're testing high-intensity interval training to see how it improves physical function in adults over the age of 50 who are also living with HIV. So, we are excited to start that in the coming months.

Amanda Balbi: Great! I'll definitely be looking out for that study when it's published, we can follow up on it.

Allison Webel: Yeah, it'll be a little while. COVID-19 has slowed everyone down, but the patients are excited, and our clinical partners are very excited about it as well.

Amanda Balbi: So, thank you so much for speaking with me today and answering all my questions.

Allison Webel: You're very welcome. It was my pleasure.