Focus Turns to Aging with AIDS

As the global AIDS epidemic continues to age, greater focus is being paid to older adults living with HIV.

AIDS advocates are calling on service providers and health departments to tailor HIV prevention services, including HIV testing, to meet the needs of people aged 50 and above. And new guidelines for doctors with patients who have HIV are being released that highlight the need to focus on preventive care.

The issue of an aging HIV and AIDS population has been a growing focus for local health officials for several years now, with new programs being developed to address the specific needs older adults are confronting due to the AIDS epidemic.

A 2011 Bay Area Reporter story noted that for the first time people 50 years of age or older accounted for the majority of people living with an AIDS diagnosis in San Francisco.

The 2012 HIV/AIDS Epidemiology Report released by the Department of Public Health demonstrated the aging of persons living with HIV, with decreasing proportions in the 30-39 and 40-49 years age groups accompanied by persons aged 50 years or above rising from 42 to 51 percent between 2009 and 2012.

The number of people living with HIV in the city age 50 or older last year was 8,063. The second highest age bracket was among 40-49 year olds, who accounted for 5,150 people living with HIV.

In the United States, the Centers for Disease Control and Prevention estimates that 31 percent of people living with HIV nationwide are over the age of 50. As of 2010, the most recent year for federal data due to delays in reporting, an estimated 872,990 persons in the U.S. were living with a diagnosed HIV infection, according to the CDC.

By 2015, the federal agency predicts that more than 50 percent of people living with HIV will be over the age of 50.

"That is a pretty daunting statistic in terms of the rise in folks with an increased prevalence for HIV disease because of longevity," said University of Washington at Tacoma professor of social work Charles A. Emlet. "But guess what? Older people have sex and are at risk for HIV regardless of sexual orientation."

During the Gerontological Society of America's annual scientific meeting held last week in New Orleans Emlet presented a paper titled "The Impact of HIV on the Lives of LGBT Older Adults."

The paper is based on data from the Caring and Aging with Pride project, a national study of more than 2,500 LGBT older adults that issued a groundbreaking report in 2011.

The paper's co-authors were Karen I. Fredriksen-Goldsen, Ph.D., a professor at the University of Washington and director of the Institute for Multigenerational Health, and Hyun-Jun Kim, a research scientist and director of Caring and Aging with Pride at the University of Washington School of Social Work. Fredriksen-Goldsen oversaw the national LGBT study and was hired to conduct a similar study this year for the San Francisco LGBT Aging Policy Task Force.

The researchers reviewed the survey responses and estimated that 9 percent of the 2,560 LGBT older adults were living with HIV or AIDS. They found that the average age was 66 with 58 percent gay men. About half were living at or below 200 percent of the federal poverty level.

"People didn't expect to live. Then antiretroviral therapy came along and they are living longer and healthy lives," said Emlet, who began working on AIDS issues for the Solano County health department in the late 1980s through 1999. "There are a number of issues, ways this population is affected adversely."

Those living with HIV or AIDS were less likely to have children, more likely to live alone and have experienced the death of a partner, according to the paper's findings.

Due to the loss of their same-sex partner there is a corresponding loss of social support as people grow older with HIV, found the researchers.

There is "the possibility of double jeopardy," said Emlet, from living longer with HIV and having elevated stress levels. The respondents in the national study reported having more anxiety, thoughts of suicide, and were more likely to be lonely.

"There was no difference in their physical health compared to HIV-negative people. But HIV-positive people had significantly lower mental health," reported Emlet. "Clearly, there is an issue around social support and social connectedness with this population."

The data from the study was unclear on whether the health issues older adults with HIV or AIDS are facing stem from HIV, age, or the medications they are taking. The Caring and Aging with Pride project has received federal funding to conduct a longitudinal study of older LGBT adults that could provide more insight.

The current survey data "begins to paint a picture of pretty serious risk for these individuals," said Emlet. "HIV appears to have additional impacts on LGBT older adults."

Aging HIV Epidemic Has Global Impacts

The rise in older adults living with HIV is also being seen across the globe.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), which issued a report on the state of the worldwide HIV epidemic ahead of this year's World AIDS Day, an "increasingly significant trend" globally is the growing number of people aged 50 years and older living with HIV.

The agency estimates that, worldwide, there are 3.6 million people aged 50 years and older living with HIV. At the same time, UNAIDS reported that AIDS-related deaths have dropped by 30 percent since the peak in 2005 due to expanding access to antiretroviral treatment.

The majority of older people living with HIV - 2.9 million - are in low-and middle-income countries, reported UNAIDS in early November, where the percentage of adults living with HIV who are 50 years or older is now above 10 percent. In high-income countries almost one-third of people living with HIV are 50 years or older, according to the agency.

"People 50 years and above are frequently being missed by HIV services," stated UNAIDS Executive Director Michel Sidibe. "This is costing lives. Much more attention needs to be given to their specific needs and to integrating HIV services into other health services which people 50 years and over may already have access to."

The HIV Medicine Association of the Infectious Diseases Society of America has updated its HIV care guidelines, last revised in 2009, to reflect the fact that people with HIV are now living normal life spans, and their physicians need to focus on preventive care, including screening for high cholesterol, diabetes, and osteoporosis.

"In many HIV practices now, 80 percent of patients with HIV infection have the virus under control and live long, full lives. This means that HIV specialists need to provide the full spectrum of primary care to these patients, and primary care physicians need a better grasp of the impact HIV care has on routine healthcare," stated Dr. Judith A. Aberg, lead author of the guidelines and director of the Division of Infectious Diseases and Immunology at the New York University School of Medicine. "Doctors need to tell their HIV-infected patients, 'Your HIV disease is controlled and we need to think about the rest of you.' As with primary care in general, it's about prevention."

The updated guidelines, under the heading "Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus," will appear in the January issue of Clinical Infectious Diseases.

One of the more significant changes is that patients whose HIV is under control should have their blood monitored for levels of the virus every six to 12 months, rather than every three to four months as previously recommended. It also urges doctors to be vigilant about screening for high cholesterol and triglycerides, as people living with HIV are at greater risk due to the infection itself, ART or such thing as smoking and eating unhealthy foods.

The guidelines include new recommendations for screening for diabetes, osteoporosis and colon cancer, and suggest patients with HIV infection should be vaccinated against pneumococcal infection, influenza, varicella and hepatitis A and B.

It also suggests that doctors consistently discuss and counsel patients on their sexual history (current and past) and any risky behaviors, such as the use of illicit drugs, in a nonjudgmental manner and determine how patients are coping with living with HIV infection and if they have a sufficient support network.

HIV specialists need to be familiar with primary care issues, and primary care physicians need to be familiar with HIV care recommendations, stated Aberg, and the new guidelines are designed to bridge both gaps.

"Patients whose HIV is under control might feel they don't need to see a doctor regularly, but adherence is about more than just taking ART regularly; it's also about receiving regular primary care," stated Aberg. "These guidelines are designed to help ensure patients with HIV infection live long and healthy lives."

Matthew S. Bajko wrote this article through the MetLife Foundation Journalists in Aging Fellowships, a program of New America Media and the Gerontological Society of America.