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The Graying of the AIDS Epidemic

By Liza Berger, Staff Writer

 

People are aging with HIV. The introduction of highly active antiretroviral therapy (HAART) more than a decade ago has allowed people to live with the illness that was once almost certainly fatal. But the problems associated with growing older have introduced a new set of challenges.
 
While the virus is “not a death sentence,” it’s “not a cake walk” either, said Dr. Kelly Gebo, a doctor and researcher at Johns Hopkins Bloomberg School of Public Health. She treats many infected patients over age 50. “The medications have toxicities and are not easy to take,” she explained.
 
Among the issues older people face are weaker immune systems that have a harder time fighting off infections, toxic side effects from medications, and co-morbid diseases that may stem, at least in part, from the aging process. “They appear to be prematurely aging,” said Gebo, noting that people over 50 have higher rates of malignancies, as well as cardiovascular disease and strokes.
 
 
New Face of AIDS
 
This older group represents a new face of the HIV/AIDS epidemic. About 29 percent of all people with AIDS (acquired immunodeficiency syndrome) in the United States are age 50 and older. (AIDS is the serious disease that can develop from the human immunodeficiency virus, better known as HIV.)  In some cities, as many as 37 percent of people with AIDS are in this age group.
 
Meanwhile, the rates of HIV/AIDS among older people are 12 times higher for blacks and five times higher for Hispanics compared to whites. Also, in the last decade, AIDS cases in women over 50 were reported to have tripled; heterosexual transmission rates in this age group may have increased by as much as 106 percent.
               
These adults represent the first generation of older adults living with HIV. Most are in their 50s, but some are in the 60s, 70s, 80s and even 90s. Also, while some of these cases are newly acquired, most are people who have been living with the disease long-term, perhaps 10, 15 or 20 years or more.
 
“We are working with the first-ever generation of older people growing old with HIV,” noted Karen Taylor, director of advocacy and training for the organization SAGE (Services & Advocacy for GLBT Elders).
 
 
Lack of Education, Awareness
 
One reason why this older cohort is succumbing to the illness is because of lack of understanding, education and testing of older adults, several resources say.
 
Many older people, because of divorce or the loss of spouses, are dating again. They may not realize the risk of contracting HIV because they were not raised in the “safe sex” era. Older women, in particular, may believe they are immune to the virus because they are beyond childbearing age. (Older women actually may be more susceptible because of a decrease in vaginal lubrication and thinning vaginal walls that can put them at higher risk during unprotected sexual intercourse.)
 
But health officials and doctors have not effectively communicated the message. Little HIV prevention education is targeted at older people. Most older people do not receive training in safer sexual activities. Because older people don’t see themselves on posters or billboards advertising AIDS prevention, they may think they are immune to the illness, Taylor of SAGE said. Society itself has a blind spot when it comes to thinking about older people contracting HIV. “We don’t tend to think of older adults as sexual people and don’t tend to think of them as using recreational drugs,” she said.
 
The reality is that because people are living longer, they are engaging in sex until a later age. Viagra and other sexual enhancement drugs may contribute to increased rates of sexual activity. Also, physicians may not diagnose HIV infection in older people, or inquire about their sexual habits or drug use, or talk to them about risky behaviors. Moreover, doctors may overlook early symptoms of HIV as normal signs of aging.
 
 
Aging with HIV
 
The aging process tends to complicate the effects of HIV. While older adults tend to adhere to drug regimens better than younger people, the side effects can be more severe, researcher Gebo said. Renal failure is more likely to happen in the elderly. Metabolism of the drugs is affected by worsening kidney and liver function with aging, she added.
Complications from a variety of drugs also appear to be a major problem. Medicines for age-related conditions, such as heart disease, depression, osteoporosis and diabetes, may interfere with strong ARVs, which are used to treat HIV.
 
Dementia is another problem that older people with HIV or AIDS are facing. While older people tend to develop cognitive problems, ARVs may worsen them. Moreover, many other health problems older people face, such as osteoporosis, may progress faster in people with HIV.
 
Other “hidden” illnesses, such as depression and loneliness, are common in older adults with HIV. Because of the stigma attached to HIV and AIDS, they may feel they can’t tell their families and friends about their illness. (“What will the people in church think?”) Some may stop seeing their grandchildren. While there are advocacy groups for older adults, this cohort may shy away from joining support groups. Depression, while a problem in younger people, can lead to other health problems and have more detrimental effects in older adults.
 
 
Financial Stress
 
Financial problems among this population also cannot be overlooked, according to Gebo. Under Medicare Part D, the government program that pays for Medicare prescription drugs, there is a coverage limit at which the government will stop paying for drugs annually. That threshold is $2,250. When Medicare recipients reach this level in drug costs, they are responsible for the total cost of their formulary expenses—until they reach $5,100 in total spending. Many older adults with HIV must seek other sources of funding, such as the Ryan White CARE Act, that provide assistance to cover this gap.
 
Also, many older adults with the virus are in lower socio-economic groups. Staying “in shape” is not as easy for them because they may not have the means to join a gym, Gebo said. Exercising is important in helping reduce the risk of diabetes and cardiovascular disease, both of which are more common in older people.
 
Caregiving could present another financial burden as many older adults may need to rely on paid caregivers, such as home health aides.
 
 
Problems to Solve
 
Many answers still elude scientists regarding this population with HIV. Still a mystery is the precise cause of certain diseases, such as Alzheimer’s, in older adults with HIV. Is it the medication? The aging process? Or the disease itself, which can cause dementia in younger adults? Neurological problems can be caused by vitamin deficiencies, opportunistic infections or ARVs. Also, how much HIV is worsening co-morbidities, such as heart disease and diabetes, remains unclear.
 
Gebo is working on fine-tuning drug regimens for elderly people living with AIDS to reduce the pill burden and offer the best combination of therapies.
 
Another quandary doctors face with this population is what to treat first. For example, is it more important to treat the HIV or the tuberculosis? Those are just some of the new questions that scientists are grappling with as the population with the disease continues to age.
 
There no doubt is still a lot to figure out regarding this population. Exacerbating the problem for researchers is that drug companies have not included older people in clinical trials of new drugs. Clearly, that has to change. The population of people with HIV is not getting any younger.

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