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Graying plague: By 2015 over half of HIV in U.S. will be in those over 50
Late diagnoses contribute to problem
Contrary to stereotypes, HIV in America is showing more than a touch of gray. Researchers are studying the impact of HIV on the aging process as HIV demographics show the disease's impact on people ages 50 years and older is on a sharp rise. This demographic uptick is coupled with increasing evidence that HIV infection ravages the body, adding years and decades to one's actual age health-wise — even with treatment.
Together, the two trends make it increasingly important that HIV clinicians focus on both comorbidity prevention and early detection and treatment with their older patients.
Nearly one-quarter of Americans with HIV infection are 50 years or older, according to the most recent Center for Disease Control and Prevention surveillance data from 33 states with HIV reporting.1,2
Also, older Americans account for 15% of new HIV/AIDS diagnoses, 29% of persons living with AIDS, and 35% of all deaths of people with AIDS.
Projections show this trend could increase until people over age 50 account for half of HIV infections in the United States by 2015.
From 14 to 19 years ago, the CDC reported that 11% of all AIDS cases were among people ages 50 and up. While successful antiretroviral therapy (ART) has contributed to people living into middle-and-older age with HIV, there also is an increasing trend of older people becoming infected through the same high-risk behaviors that impact younger Americans.
Studies also show that older Americans often are sicker when they are first diagnosed with HIV infection, and their immune system's ability to bounce back is limited once they are treated with ART.
"At least once a month I have a patient who is 50 or above and being diagnosed with HIV infection," says Beau Ances, MD, PhD, assistant professor of neurology at Washington University in St. Louis.
"It's becoming more of a norm," he says. "Usually these people have had the infection for a longer period of time and have not gone into care, so they have two knocks against them."
Their virus is not well controlled, their CD4 cell counts are low, and their ability to fight infection is not as good, Ances adds.
Societal, individual misperceptions
Both societal and individual misperceptions contribute to a later diagnosis among older people, clinicians say.
"There's still a stereotype of youth developing HIV infections," says Nur Onen, MBChB, an instructor in internal medicine in the infectious diseases division of Washington University School of Medicine in St. Louis, MO.
"People think of drug users or men who have sex with men (MSM)," she adds. "Also, younger people are more inclined to do HIV testing, so we are increasingly seeing older people who are diagnosed after considerable delay."
Delayed diagnosis is particularly troubling for older HIV patients, she says.
"We see symptoms occurring in the older population because they are tested much later in illness, and some have very severe immunosuppression, and they either have an AIDS-defining moment or a very low CD4 cell count," Onen explains. "This poses another problem because we have to get their CD4 count up as high as we can, and it's harder for the older population to get the CD4 count up to a normal range."
Also, older HIV patients have a higher prevalence of frailty, even if they're under age 65, Onen says.
"Once they enter the frailty state, it's very hard to reverse and has a lot of negative implications on morbidity and mortality outcomes, including deaths, falls, etc.," Onen says.
The key is to identify older HIV-infected individuals earlier in their disease, and this means educating the public about the risk older, sexually-active adults face.
As older Americans divorce or lose their partners, they become engaged in sexual relationships, sometimes for the first time in decades, and they often are unaware that some things have changed, notes Diane Zablotsky, PhD, an associate professor of sociology at the University of North Carolina at Charlotte.
An expert and researcher on aging and HIV, Zablotsky has found that older women, in particular, might not know how to negotiate condom use. Perhaps they became sexually active in the years after oral contraceptives first were introduced, and then were married when HIV was identified. So they have never used condoms and need help in improving their comfort level with discussing condom use with partners, she explains.
Also, HIV prevention campaigns need to include older faces in posters, brochures, and advertisements.
"Don't let information campaigns reinforce the stereotype that sexual risk and sexual behavior end at mid-life," Zablotsky says. "We should broaden [older] people's knowledge and open them to the idea of risk prevention."
The CDC's four-year-old guidelines for providers to offer opt-out HIV testing for everyone between ages 13 and 64 might have a positive impact, but some pressures fueled by stigma and lack of knowledge continue to hinder the older set from receiving optimal screening and treatment, experts say.
"The main gist of the CDC's recommendations is to stop people from being driven by stereotype beliefs and to test no matter how old you are," Onen says.
There are other issues HIV clinicians need to consider when dealing with older patients, and one has to do with the disease's impact on cardiovascular, neurological, and other diseases.
For instance, a new study on HIV and its impact on the brain has found that HIV-positive patients have functional brain demands that are equivalent to those of HIV-negative people who are 15 to 20 years older.3
"If you're HIV positive, and you're older, you are really taxing your system," Ances says.
A 50-year-old who is HIV positive has similar cerebral blood flow as a 75-year-old who is not infected with HIV, Ances says.
"So they're aging, and the virus also is aging them, and the question is 'Why?'" he adds. "We really don't know the answer."
Ances and co-investigators used functional imaging measures as possible biomarkers of disease. The technique measured blood flow in the brain, and the study compared an HIV cohort with a non-infected cohort, finding that HIV infected persons consistently had lower blood flow than their same-age, non-infected peers.3
Older people diagnosed with HIV also are at greater risk for cardiovascular disease and mortality, another new study shows.4
The study found that people of all ages who were infected with HIV had a mortality risk that was three-fold higher during a five-year period than the mortality risk of non-HIV infected people of similar demographics and cardiovascular factors. This included people who were taking antiretroviral medications.
"We mainly looked at demographic risk factors, including age, race, and cardiovascular risk factors, including cholesterol, smoking, and blood pressure," says Leslie Cockerham, MD, an internal medicine resident physician at the University of California - San Francisco (UCSF).
"The main thing that came out was how older age impacted mortality," Cockerham says. "We looked at all of these factors among HIV-infected participants, who were a wide range of ages from 19 to 76 years, and when we looked at risk of death, the risk increased 60% with each decade of aging."
Mortality rates increased among HIV-infected people with lower CD4 cell counts, as anticipated, Cockerham says.
But there also was an increased risk of death due to non-HIV causes, including malignancy and cardiovascular disease, she notes.
"HIV is not only a disease of immunosuppression, but also of inflammation," Cockerham says. "It could be that some of the risk is due to chronic inflammatory diseases."
Cockerham's co-investigators have worked on another study that looks at how inflammation might be impacting mortality among HIV patients.
"It's still under investigation, but their speculation is that perhaps viremia has led to inflammatory changes, and these are contributing to mortality," Cockerham says. "There are increased rates of arteriosclerosis and cardiovascular disease."
HIV-infected people also have a higher rate of lung cancer, she notes.
"Whether it's due to inflammation or other factors, it's hard to know," Cockerham says. "Our study group has done a follow-up paper that looks at the roles of mortality risk in the same cohort — this definitely needs to be studied more."
Increased risk of comorbidities
Other new research has found these increased health risks in older HIV-infected populations:
When HIV clinicians work with older patients they often find it is difficult to determine which symptoms and comorbidities are due to the disease or natural aging, Onen notes.
"You're dealing with a person who has lived a lifetime, and we're seeing an impact on their lifestyle choices, including tobacco use, drug use, and dietary behaviors," Onen says. "We often have to deal with their HIV infection and a lot of other comorbidities as well, and you can't always tease out which is the result of HIV-uncontrolled viremia for years and low CD4 cell counts and immune dysfunction with aging."