WASHINGTON -- The face of AIDS is aging. Thanks to major scientific advances in antiretroviral drugs, people with HIV are no longer condemned to early death, and can live near-normal lifespans. But as the epidemic enters its fourth decade, healthcare providers must face the unique challenges and complications that arise when aging and HIV intersect, according to experts.
Throughout the International AIDS Conference this week, speakers said we were just starting to understand the medical and other needs of the aging HIV/AIDS population. And, they cautioned, these individuals must not be forgotten amid increased attention on preventing and treating HIV in the young.
Older adults are a sizable portion of the HIV-positive population in the United States. In 2008, 20% of people living with HIV were over 50, and experts estimate that this age group will constitute half the HIV-positive population by the year 2020.
Researchers have long been interested in the relationship between aging and HIV because both take a similar toll on the immune system. As people age, cells of the immune system reach a point where they can no longer divide, said Rita Effros, an immunologist from UCLA who spoke on Monday.
“There’s a limited number of cell divisions programmed into all normal cells,” Effros said. In people with HIV, immune cells working on overdrive to combat the virus reach this end point much sooner and start causing inflammation that contributes to many age-related diseases.
Many researchers wonder “whether aging with HIV is a double hit to the immune system,” Dr. Judith Currier, co-director of the UCLA Center for Clinical AIDS Research and Education, said in a plenary address on Friday. These changes to the immune system may explain why people with HIV are more likely to develop other chronic conditions as they age.
The “big four” such diseases affecting people with HIV are cardiovascular disease, cancer, diabetes and chronic respiratory disease, Currier said. People with HIV are also vulnerable to frailty and osteoporosis, chronic liver and renal disease, and depression. While antiretroviral drugs are live-saving, Currier said, many have been linked to decreased bone density and an increased risk of fracture.
Other conference speakers noted that healthcare providers are currently unprepared to address the unique and complicated conditions that older HIV patients acquire.
Depression is particularly problematic among older adults with HIV, Stephen Karpiak of the AIDS Community Research Initiative of America in New York said Wednesday. A 2005 survey of older people with HIV in New York found that 50% suffered from depression, he said.
Depression in this community “is chronic, and it is endemic, and it’s not being managed, be it in the U.S., the U.K. or the rest of the world,” Karpiak said. “It’s the single most important cause of non-adherence to all medications, including HIV medication.”
Antidepressants alone are not the answer, Karpiak said. Depression can arise through the deterioration of social networks of older adults with HIV. These people are less likely to have family or children to support them, and may depend primarily on friends who also often have HIV. Losing loved ones through aging and the disease can deepen depression.
As the HIV population continues to age, more unknowns will inevitably surface. “We really don’t know much about those 65 and over,” said Dr. Amy Justice, a director at the Center for Interdisciplinary Research on AIDS at Yale, who spoke Monday. Until now, there just haven’t been many people of this age living with HIV.
Another reason we know so little about older adults with HIV is that we simply don’t count them, said Joel Negin, a public health researcher at the University of Sydney, who also spoke on Monday. Most surveys designed to gather information on HIV around the world cut off data collection at age 49.
Such shortsightedness hinders efforts to prevent the spread of HIV among older adults, researchers said. One in 10 new HIV infections in the United States occurs among people 50 and older, a reminder that “age is not a condom,” Currier said.
The Centers for Disease Control and Prevention only recommends HIV testing up to age 65, which prevents many older individuals from learning their HIV status. Some may find themselves in new relationships later in life but not realize their risks for contracting HIV.
“Physicians may miss an AIDS diagnosis because symptoms in older patients can mimic those of normal aging,” said Dr. Kevin Fenton, director of the National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention at the CDC, who addressed the conference Wednesday.
“Across the federal government, we are behind” in trying to respond to the needs of older individuals, Fenton said.
But while addressing the HIV needs of senior citizens presents many challenges, no one would have imagined 30 years ago that people with HIV would ever reach that point in life. Facing such challenges is a privilege, Currier said.