Aging and HIV

As we enter the fourth decade of AIDS, the crisis continues largely unabated.

About 1.1 million Americans live with HIV/AIDS, as do 33 million around the world. Every year about 56,000 more Americans are newly infected; roughly half are gay men and half are African American. While HIV incidence in the U.S. remains static, infections among gay and bisexual men are increasing, the only risk group for which this is occurring. Infections are particularly increasing among young black gay men.

Globally 2.7 million people were newly infected in 2008, down from a peak of 3.5 million newly infected in 1997. Despite this relative progress, for every two HIV positive people who get into treatment globally, another five are newly infected.

Most of the 33 million people living with HIV around the world don't have access to anti-retrovirals (ARVs), the HIV medications that revolutionized treatment in the mid-1990s, and are not likely to anytime soon. In sub-Saharan Africa, where most of these people live, access to something as basic as palliative care (pain medication) is often beyond reach.

That is the bad news.

But 30 years after the Center for Disease Control reported the first cases of Pneumocystis carinii pneumonia among five homosexual men who appeared to have a "cellular-immune dysfunction" and a "disease acquired through sexual contact," scientific advances have transformed HIV from a likely death sentence to a condition people can live many decades with. In fact, a 20 year old who today initiates ARV treatment with a CD4 cell count of at least 200 has a life expectancy of 70.

Science and advances in biomedical research have transformed the HIV/AIDS epidemic, and promise dramatic shifts in both prevention and care in the near future. Thanks to widespread availability of ARVs in the developed world, people are now living into old age with HIV. This is something most would not have imagined in the 1980s or early '90s.

Aging and HIV

About one-third of all people living with HIV/AIDS in the United States today are 50 years of age or older, a figure that will grow to one-half by 2017. The development of Highly Active Anti-Retroviral Therapy (HAART) in the 1990s changed what it meant to be diagnosed as HIV-positive, making it possible not only for people to live with HIV, but to thrive well into their 50s, 60s, 70s and beyond.

With this welcome development come new challenges.
Increased life expectancies bring a suite of new health problems that involve complex interactions between the virus, antiretroviral therapies, the natural aging process, and in some cases, other behavioral risk factors. Some evidence suggests that HIV accelerates the aging process, and both aging and HIV infection dramatically influence the immune system. It is well-known that older people in general have more chronic diseases.

We have limited knowledge about the effects of long-term exposure to antiretroviral therapy and the effects of drug toxicity. We also have limited understanding of the effect of HIV medications on aging bodies, how HIV and other health conditions interact, and how medications to treat HIV and other health conditions, such as diabetes or high cholesterol, interact together.

Recently Gay Men's Health Crisis and the AIDS Community Research Initiative of America surveyed 180 of GMHC's HIV-positive clients age 50 and older. The average client had had an AIDS diagnosis at some point and had 3.5 comorbidities, such as depression, arthritis, neuropathy, and Hepatitis C. Thankfully, the National Institutes of Health, under the leadership of Dr. Anthony Fauci, is funding significant research in the area of HIV and aging.

Many older adults living with HIV are long-time survivors, but about one in six new infections in the U.S. occurs among an older adult (50+). In general, doctors tend not to proactively assess older patients for sexual health risks or their sexual activity.

A national study found that adults over 50 at risk for HIV were 80% less likely to be tested for HIV as at-risk adults 20 to 30 years of age. Most newly diagnosed older adults learn that they have HIV while hospitalized for other medical issues. As a result, older adults are disproportionately diagnosed long after their HIV infection.

Unprotected homosexual sex appears to be the most widely reported transmission route among older men newly diagnosed, with unprotected heterosexual sex the most common route of transmission for women in the U.S. There is a dearth of sex education and prevention messages aimed at people over 50.

HIV-positive people on antiretroviral therapies can live well into their 60s, even if they started therapy with severely depleted immune systems. Those who begin therapy with CD4 counts over 200 can live into their 70s. At the same time, however, life expectancies for people on therapy (and who adhere to their medication regimens) are still only two-thirds that of the general population.

The need for culturally competent senior services for older adults living with HIV is growing as baby boomers hit retirement age starting this year. Significant anti-gay bias has been found in senior centers and services, among both providers and clientele. HIV-positive seniors report unauthorized disclosure of their HIV status by peers in senior settings.

Older adults are also more likely to believe that HIV can be casually transmitted, for example by a handshake or by touching a door knob. Lambda Legal is suing an Arkansas nursing home for kicking out an HIV-positive gay man after telling his daughter that they could not serve him and protect the safety of their staff working in the dining room and laundry.

Clearly, HIV stigma remains widespread. Policy makers must ensure-through the Older Americans Act, state aging plans, Medicare regulations, and other mechanisms-culturally competent treatment of older adults living with HIV in senior services and congregate living facilities.