Potent drug therapies, and perhaps even the use of Viagra, are rapidly making HIV/AIDS a disease of older adults, bringing new challenges for prevention, diagnosis, and treatment.
Most of us are familiar with the major disorders associated with aging, such as heart disease, Alzheimer’s disease, and osteoporosis. Now, some experts say, we might need to add acquired immunodeficiency syndrome (AIDS) to the list.
The face of AIDS might once have been that of a young, gay male, but that is no longer the case. During the 1990s, the number of Americans over age 50 infected with HIV, the human immunodeficiency virus that causes AIDS, increased fivefold, from more than 16,000 at the start of the decade to close to 90,000 in 2001, according to the June 2003 Journal of Acquired Immune Deficiency Syndromes. By now, “an estimate of 150,000 wouldn’t be off-base,” says Stephen Karpiak, associate director for research at the New York City-based AIDS Community Research Initiative of America. According to the National Institute on Aging Web site, about 10% of all people diagnosed with AIDS in the United States are age 50 or older. In New York City, one of the epicenters of the disease, the Department of Health and Mental Hygiene reports that as of September 2003, almost 27% of all people living with HIV or AIDS were over 50.
Much of the explanation for the rise in the number of older people with HIV/AIDS stems from the effective drug treatments that came out in the mid-1990s. “We’re watching a phenomenon that’s really a function of highly active antiretroviral therapy [HAART],” says Karpiak. “With HAART, patients are living longer,” says John Mazzullo, an attending physician at Tufts-New England Medical Center in Boston, who treats patients with HIV infections. The therapy slows the progression of HIV infection to AIDS.
With HAART extending the lives of people with HIV, doctors are finding that the infection has special repercussions in the elderly. “Older people have other problems that are worsened by HIV,” such as heart disease and diabetes, says Mazzullo. And the virus can hasten the appearance of illnesses associated with growing old. Unfortunately, some of the potent antiviral regimens make matters worse–precipitating disorders such as diabetes, high blood pressure, and high cholesterol. “Some of the [HIV] drugs seem to push you into the diseases of aging 10 or 20 years early,” says Donna Gallagher, director of the New England AIDS Education and Training Center in Boston. “These changes come as a result of living with HIV and taking these medicines, so if you’re 50 with this disease, you could be pushed into your 70-year-old disease profile.”
Furthermore, many medications taken by older adults can interact negatively with the compounds prescribed to manage HIV. The class of antiviral agents known as protease inhibitors, for example, can interact adversely with drugs, such as statins and certain blood pressure and heart medications, says Bradley S. Bender, a physician at the North Florida/South Georgia Veterans Health System who teaches at the University of Florida, Gainesville.
Compounding the problem, doctors might also overlook a senior’s risk for HIV infection, thus delaying treatment. One woman in her late 70s returned to her doctor every few months and was subjected to all sorts of tests but could not get a proper diagnosis for her symptoms, relates Jim Campbell, president of the National Association on HIV Over Fifty in Boston. She didn’t think to get tested for HIV until she ran into her former husband and discovered he was being treated for HIV. She, too, tested positive. “If you don’t look like your average person at risk — a drug user or a sex-industry worker — it’s usually a diagnosis of last resort,” says Campbell. Mazzullo agrees: “There’s a delay in older patients referring themselves to be tested because they’re not thinking about HIV, and clinicians are thinking of the problems of aging rather than sexually transmitted diseases.”
Although more people are growing old with HIV/AIDS, experts debate whether more older adults are becoming newly infected. The infection rate in people over 50 is rising, says Campbell, especially in places such as Miami and New York City. But the newest Centers for Disease Control and Prevention data, presented at the Bangkok International AIDS Conference this July, show no increase in HIV diagnosis rates among older Americans. However, Karpiak points out that these figures might underrepresent the problem because they include only data gathered from the 25 states that had mandatory HIV reporting–a list that did not include states with the highest incidence of infection, such as Florida, Texas, and New York.
If seniors are becoming infected more frequently, some experts speculate that perhaps it’s because they’re having more sex. “Viagra has expanded the horizons for men. They’re engaging in high-risk behaviors and bringing HIV home to their wives and steady partners,” says Gallagher. And postmenopausal women, says Karpiak, “are not thinking about using condoms or any specific barrier. They don’t perceive themselves to be at risk.”
And no one is telling them otherwise. “Despite the increasing numbers of persons 50 and older at risk for or living with HIV/AIDS, there have been very few targeted prevention messages or programs for middle-aged and older adults,” says Marcia G. Ory, a sociologist at the School of Rural Public Health at Texas A&M University in College Station. “It would be such a very simple thing to do to provide a gray-haired face in a prevention campaign,” adds Campbell.
And many health professionals are uncomfortable asking people over 50 about their intimate relationships. “It’s like asking your mother or grandmother,” says Gallagher. “And it goes both ways,” says Campbell, who is 58. “Older people don’t feel comfortable talking to 20-year-olds about their sex lives either.”
The lessons we’ve learned thus far from the AIDS epidemic apply to people of all ages. First, protection is key. As Bender says, “If history has taught us anything about infectious diseases, it’s that prevention is better than treatment.” Second, it’s important to get diagnosed as early as possible. HIV is a virus that’s spread primarily through sex, says Campbell, so anyone who’s engaging in risky activities should be tested–even if it means postponing lunch with the grandchildren.