Special Report: The Aging AIDS Epidemic

New face of HIV/AIDS presents challenges and new comorbidities

Experts discuss the future of the epidemic

(Editor’s note: Often overlooked, older HIV patients provide a glimpse into the future of the AIDS epidemic in nations where antiretroviral therapy is readily available. AIDS Alert has asked HIV clinicians, researchers, and patients to discuss how these older patients might help us predict the future of the epidemic as the population of HIV-infected people older than 50 increases.)

The face of AIDS is changing. It has some gray hair around the temples, perhaps some balding on top, and more wrinkles around the eyes.

The rising number of people older than 50 infected with HIV/AIDS is a triumph of the widespread use of antiretroviral therapy in affluent nations. It’s also a trend that creates an opportunity for researchers, clinicians, and public health officials to learn how the epidemic will evolve in coming decades as people begin to live 30, 40, and 50 years or more while infected with the virus.

The proportion of newly diagnosed AIDS cases among adults 45 and older increased from 1994 to 2000, although the rates of HIV diagnoses among older adults declined or were stable, according to the Centers for Disease Control and Prevention (CDC).1

The CDC reported these data at the 15th International AIDS Conference, which was held July 11-16 in Bangkok, Thailand.

In New York City, the proportion of people older than 50 who are living with HIV/AIDS has increased steadily. Currently, at least one in four people living with HIV/AIDS is 50 or older, says Judy Sackoff, PhD, director of surveillance at the New York Department of Health and the deputy director of the HIV Epidemiology Program.

"This has a lot to do with long-term survivors," she says. "People are living longer, and we know that; and they have less morbidity and less illnesses that we associate with HIV, such as pneumonia, tuberculosis."

Also, the Veterans Affairs (VA) cohort of people in care with HIV/AIDS is aging about 1 year per year because of plummeting mortality rates, says Amy Justice, MD, PhD, section chief of general medicine at the West Haven (CT) VA Healthcare System. Justice also is an associate professor of medicine at the Yale University School of Medicine in New Haven, CT.

"The median age in the VA is 49 years for people in care with HIV infection," she says. "The CDC data are a mixture of some states that report HIV infection and some that report only AIDS, so it’s more of a mixed bag for how they calculate that."

Nonetheless, it appears that the HIV-infected population is aging fairly rapidly because people are living past acute conditions that previously killed people, Justice notes.

"This means there is a lot of competing risk for mortality from other conditions like diabetes, heart disease, hepatitis C, hypertension," she explains. "And there are going to be interesting issues regarding whether or not these conditions progress more rapidly in people who have immune dysfunction."

Challenge for clinicians

For clinicians, this change from a deadly epidemic to a chronic disease has been a career-long odyssey.

"The first thing to say is that in thinking about the early days of the AIDS epidemic, we wouldn’t have imagined that patients would have survived this long," says Gerald Friedland, MD, director of the AIDS program at Yale New Haven Hospital and professor of medicine and epidemiology and public health at Yale School of Medicine.

"It really is quite an extraordinary accomplishment both for patients and, in general, for medicine," he explains.

"I have cared for patients through the period of no treatment to the current period of time, and so I’ve been a witness to that," Friedland notes.

Theoretically, HIV-positive patients who are stable on their antiretroviral treatment could live a life span that’s comparable to people who are not infected, says Michael Hickson, MD, senior vice president and chief medical officer of Housing Works in New York City.

"I know patients who are 15 years out on therapy and who are still fine," he explains. "They’re on a different therapy than they were when they started."

Michael Shernoff, MSW, a psychotherapist in New York City, is one such long-term survivor of HIV infection. He had a confirmed exposure to the virus in 1977 and was among the first generation of AZT and, later, combination therapy patients.

Shernoff, who has worked with HIV-infected patients in therapy since the 1980s, says he has been a firsthand witness to a completely new epidemic in the past eight years.

"I had 150 deaths in the first 15 years of the epidemic, but have not had anyone be seriously ill from HIV or from AIDS and no deaths in the last 10 years," he notes. "The most serious illnesses have been a couple of long-term survivors who got other metastatic illnesses related to their long-term status, but they are recovering from those cancers."

No one disputes that the new age of chronic HIV infection is a miraculous improvement, but it’s not a panacea.

"I think people who have been living with this virus and disease for a significant length of time are really in a period of great uncertainty right now," says Terje Anderson, executive director of the National Association of People Living With AIDS in Washington, DC.

"For people who are treatment experienced and who have been through a variety of antiretrovirals, the question of what comes next is really crucial," he says.

Due to the potential of antiretroviral resistance to whole classes of drugs, the long-term prognosis for HIV patients is unclear, Anderson adds. "When drugs like fusion inhibitors become available, it’s one more lifeline, but it’s not clear how many lifelines like that are out there," he notes.

Comorbidities pose another barrier to a long life for HIV patients.

An Australian study presented at the International AIDS conference found that people older than 50 living with HIV/AIDS had significantly higher rates of most comorbidities, including CVD, hypertension, diabetes, arthritis, back pain, and hepatitis A and hepatitis B infections, than HIV-positive people younger than 50.3

"There needs to be a recognition that as treatments sustain people living with HIV/AIDS longer, the combined consequences of growing older and living longer with HIV will present clinical challenges concerning treatment resistances and comorbidities, and service challenges to ensure the needs of this particular group are well served," says Marian Pitts, professor and director of the Australian Research Centre in Sex, Health and Society at La Trobe University in Melbourne, Victoria.

The Australian study also found that HIV-infected people older than 50 were significantly less likely to use the variety of social and health services available to them, and they were more likely to live on incomes below the poverty line. Also, while 38% of HIV-infected people younger than 50 reported being in a relationship, only 5% of those older than 50 reported the same.3

"There is a tendency to focus on young and recently infected people for prevention and treatment messages," Pitts explains. "This needs to change."

People older than 50 with HIV infection have significantly more comorbidities than younger people infected with HIV, according to another study presented at the international conference.

Investigators found that 62% of the people age 50 and older with HIV infection had been diagnosed with other medical conditions. This compared to 54% of the people age 49 and younger.4

Clinically, older HIV patients are coping with multiple chronic illnesses, and so an HIV physician can’t focus only on treating the infection as might be the case with younger HIV patients, says Kathleen N. Nokes, PhD, RN, FAAN, professor at Hunter-Bellevue School of Nursing in New York City.

"If someone is 35, then you can deal with just HIV; but with an older patient, you might be dealing with the HIV, diabetes, high blood pressure, liver problems, the number of medications and interactions — and that’s just a really big problem," Nokes explains. "From a provider point of view, they are great on HIV, but they may not be so great on things like the conditions of aging."

Another challenge for HIV clinicians will be to decide which symptoms are due to HIV infection or treatment and which are due to aging, says Rita Strombeck, PhD, president of HealthCare Education Associates in Palm Springs, CA.

"With newer drugs, people in their 30s and 40s are living longer, and so we’re going to have a huge population over age 50 of people who are HIV infected in coming years," she says. "And the problem is going to be different because they’re going to develop other conditions that are part of the normal aging process; and it’s going to be difficult to sort those out from HIV."

Strombeck helped to create a web-based training program for health care providers who work with older patients. The program walks clinicians through the process of screening, diagnosing, and treating HIV/AIDS in midlife or older adults.2

The interactive on-line program was introduced through an abstract presented at the International AIDS Conference.

Clinicians sometimes fail to screen older people for HIV infection because of a misconception that they are not at risk and due to the fact that some HIV symptoms are masked by similar aging symptoms, she adds. "Many of the symptoms are common to aging and HIV, including extreme fatigue, night sweats, and a whole range of symptoms that may not be suspected as being related to HIV," Strombeck says. "We’re trying to stress the importance of taking a risk assessment of all patients to enhance the early identification of people who might be at risk."

The bottom line is that more attention should be paid to older people with HIV, Pitts says.

"I am simply calling for more attention to be paid to this group — who are, in many ways, the success stories, but whose needs will foreshadow issues that we hope will become relevant to more and more countries," she adds.

(Editor’s note: The interactive HIV screening, diagnosis, and treatment program, developed by HealthCare Education Associates of Palm Springs, CA, will be available later this fall for continuing medical education credit at www.vlh.com. Also, information about a program developed by HealthCare Education Associates for the general public about HIV risk among older Americans —"The Forgotten Tenth"— is available at www.hceassoc.com.) 

References

1. Daniels D, Curtis AB, Klevens RM, et al. Status report on HIV diagnosis rates in older adults in the United States — rates decline or remain stable. MedGenMed 2004; 6(3). Presented at the 15th International AIDS Conference. Bangkok, Thailand; July 2004. Abstract: WePeD6513.

2. Strombeck R, Donohoe TJ. Screening, diagnosing and treating HIV/AIDS in midlife and older adults — a web-based training program for health care providers. Presented at the 15th International AIDS Conference. Bangkok, Thailand; July 2004. Abstract: WePeD6510.

3. Pitts MK, Grierson W, Thorpe R, et al. Growing older with HIV. Presented at the 15th International AIDS Conference. Bangkok, Thailand; July 2004. Abstract: MoOr D1092.

4. Hamilton MJ, Corless IB, Sefcik EF, et al. Identifying differences in older (50+) and younger persons living with HIV/AIDS. Presented at the 15th International AIDS Conference. Bangkok, Thailand; July 2004. Abstract: WePe D6492.