HIV/AIDS and Aging: The Situation and Central Issues

By Tom Smith, Ph.D.

 

The Situation

There was once a terrible time when a person living with HIV, the AIDS virus, had no hope of living very long at all. After major advances in treatment that include amazing new drug combinations that combat the Human immunodeficiency virus, people began to live almost normal lives and had the opportunity to grow old. It is expected that in the next 7 years more than half of all Americans with this disease will be over 50 years of age.

In the United States, at this time, one in five people are living with HIV and do not know they are infected. About every 15 minutes someone becomes infected. Since 1981, when the first case was reported, 1.7 million people are estimated to have been infected with HIV. Well over a half million have died and about 1.2 million are living with the disease as of 2008. People over 50 years of age accounted for 17% of the new HIV diagnoses in 2009 up from 13% in 2001 according to the CDC. There are two categories of people over 50 with HIV/AIDS: Those living with the disease for decades and the newly infected. Older people, men and women, are having unprotected sex.

For a long time, world health authorities did not even measure HIV in people over 49. HIV/AIDS was once perceived as a disease of the young. That is no longer the case. There is emerging a “second epidemic” of colossal proportions that presents heretofore unrecognized challenges. Evidence is surfacing that indicate those who have spent decades battling the virus may be aging prematurely and that heart disease, thinning of the bones, kidney and liver problems, dementia, cognitive impairment and other health issues typically seen in very elderly people are presenting in people in their 50s. Consequently, a “new subspecialty of medicine” is being created according to Anthony Fauci, M.D., the infectious disease chief at the National Institutes of Health.

Many questions remain unanswered. How much of the physiological burden of living with the disease is caused by the drugs taken to combat the illness and how much by the virus stimulating the immune system? How much did the virus impact the person when they were first infected and how does that relate to their condition when they age? When does taking antiretroviral medication right after being infected or waiting until after the virus establishes itself affect a person aging with it in their bodies? Are vital organs being quietly damaged as a person lives for years with HIV? Are people, after many decades of battling the disease, in a constant state of inflammation? What about early onset of cognitive impairment or dementia exacerbated by depression and anxiety?

Basic research is still lacking and there is dearth of information to answer these questions.

All of this “unknowing” is complicated by the ongoing stigma of HIV/AIDS. People still discriminate against those infected. Moreover, we live in ageist society where getting old is considered a liability and one’s worth decreases. How could an older person get HIV? Consequently, people do not want to know and do not come forward or bother to get tested or doctors ask about sexual history. It is a very sad state of affairs indeed.

Central Issues

From the above we can tease out some central issues that need to be addressed. They fall into five basic categories: Legal, social, psychological, medical and education and training.

In the legal arena, People with HIV/AIDS continue to be discriminated against in housing. Moreover, they have been thrown out of nursing homes and convalescent hospitals and the like. People remain ignorant regarding transmission of the disease even after 30 years of education efforts. It is against the law, particularly the ADA, to discriminate against people with HIV, who are old and who may be homosexual. According to Lambda Legal, an organization that works for the legal rights of LGBT people, in a landmark case of “Dr. Frank”, found this kind of discrimination as a specific problem in rural America not to say that it does not occur in cities. Moreover, we live in a graying society were older people are increasingly seen as a burden or having less worth. Two years ago it was a reported in the New York Times that Elder abuse is on the rise. The Senate Special Committee on Aging found that state agencies were seeing increasingly complex cases involving many types of abuse concurrently. Funding for Adult Protective Services is not keeping pace. Things continue to deteriorate.

Socially, this population faces issues regarding isolation. One group are those who have lost their friends early on in the epidemic and thus their social circle has narrowed considerably. These are people are long-term survivors or for some reason the disease did not progress, albeit, they are ill. The second group are those who have sero-converted; that is, became infected later on in life. These are older men and women who have unprotected sex or do not practice “safe sex”. Married men have sex with other men. Both groups can become isolated. Also, stigma and fear of telling people one is infected or homosexual can keep people from reaching out for help. There are fears regarding limited financial means and becoming homeless or not being able to gain access to health care and other benefits and being rejected by family or friends.

Such isolation can exacerbate emotional concerns related to depression and anxiety regarding not only HIV, stigma and co-morbid conditions, but also can leave undiagnosed dementia or cognitive impairment. Isolation leads to an increasing attrition of ADLs or the Activities of Daily Living. People stop regular hygiene, going out, eating well or maintaining their environment. Many people with HIV/AIDS live in a state of unmitigated fear and it is not the fear of dying. Not knowing the future, not having a financial safety net, homelessness, not having friends or a support system are fears that have been reported in over 80% of those aging with HIV/AIDS and drives some to despair and suicide. This can be a particularly difficult issue with Transgender people. It is a fact that they get less support and die at an earlier age than others.

Medical problems are legion. Not only must people with HIV/AIDS maintain a rigorous medication regimen to keep their health, but they must also deal wit h advanced aging and a plethora of co-morbid conditions such as heart disease, liver and kidney problems, arthritis, neuropathy, psychiatric problems and the infirmities of age that emerge much earlier than the general population. Wasting syndrome is a problem along with becoming increasingly frail. Getting care can be problematic, especially if the individual has no support system in place or are not enrolled in Medicare or have other health insurance. Moreover, and perhaps most importantly, there are no treatment guidelines for this population.

Finally, a renewed Education and Training Initiative for all people needs to take place on a national level to raise awareness again regarding transmission, prevention and discrimination as well as the training of doctors, nurses, nursing assistants, care providers, social workers, counselors and psychologists regarding treatment guidelines and the issues specific to those who are aging with HIV/AIDS. Notably, the San Francisco Health Services Planning Council reports the emergence of a “silver tsunami” in that city. Almost 20% of those living in San Francisco are over 60 years of age. About 50% of those people will have an HIV/AIDS diagnosis in the near future. We must educate, train and prepare ourselves for this impending crisis.