Older Americans and AIDS: transmission risks and primary prevention research needs

The growing number of AIDS cases among older Americans (50 years and older) is of increasing concern. In the context of primary prevention, findings are reviewed that bear on the modes of HIV transmission (blood transfusion, sexual) among older individuals and knowledge of the magnitude of the AIDS problem represented by these routes of infection. Lastly, a proposed research agenda is focused on questions of primary prevention of HIV transmission.     

HIV in the elderly

Greater than 10% of persons with AIDS in the United States are over 50 years of age, and the number of elderly persons in their 60s and 70s living with HIV/AIDS is increasing. Contrary to the perceptions of some within the health-care community and the general population, the elderly are at risk for HIV infection and carry a high mortality if diagnosed. Many older persons with AIDS are less likely to practice safe sex; others go undiagnosed and therefore untreated due to perceptions that the elderly are not at high risk for HIV infection, and treatments may be less efficacious. As age increases, the incidence of mortality does as well; 37% of individuals 80 years and older have been reported to die within a month of diagnosis. The history of a 62-year-old HIV-positive woman is presented as a case representative of many of the issues confounding timely diagnosis and treatment. Initial complaints of an undiagnosed elderly person can vary from nonspecific constitutional symptoms to those resembling an AIDS-defining disease. Both normal age-related changes in immune function and poor nutrition may confound the differential diagnosis or contribute to disease progression. Although the perception exists that the elderly are not at great risk for HIV disease, data from the National AIDS Behavior Surveys indicates that 10% of persons over 50 years of age have, at minimum, one risk factor for infection. Further education needs to be directed at physicians and their elderly patients, research on HIV/AIDS pharmacotherapy in the elderly should be extended, and the impact of the HIV/AIDS elderly population on the health-care system needs greater recognition and study.     

Aging with HIV: a practical review

The worldwide elderly population is expected to grow by an additional 694 million people by 2025. By that time, there will be approximately two billion elderly people in the world, most of whom (80%) will be living in developing countries. Based on recent estimates, this population will number over 40 million in 2030 in Brazil and a consequent increase in governmental spending for this population can be expected. Since highly active antiretroviral therapy became available in the mid-1990s, the life expectancy of people living with HIV has increased significantly. Approximately 12 million life years were added to the world between 1996 and 2008 as a consequence of wider access to highly active antiretroviral therapy. In Brazil, the incidence of AIDS among the population aged ≥50 years doubled between 1996 and 2006. The development of antiretroviral therapy has allowed individuals diagnosed at a younger age to live longer, which partially explains the aging tendency associated with the HIV/AIDS epidemic. It is estimated that by 2015, subjects aged ≥50 years will represent 50% of the people living with HIV undergoing clinical treatment. This scenario presents some challenges, including the fact that the diagnosis of HIV tends to be delayed in older patients compared to younger patients because the symptoms of HIV can be confused with those of other common diseases among the elderly and also because healthcare professionals do not consider this population to be at high risk for HIV infection. In regard to the individuals diagnosed with HIV, a further challenge is presented by the morbidity normally associated with aging. Finally, the elderly also exhibit higher susceptibility to the toxic effects and pharmacological interactions of medications. The present article reviews the literature regarding the profile of HIV infection among individuals aged ≥50 years focusing on practical features related to the clinical approach and long-term follow-up of this population.     

HIV and aging

Approximately one in five individuals living with HIV infection in the United States is 50 years of age or older. This proportion continues to increase as HIV incidence remains stable and potent antiretroviral therapy has reduced the morbidity and mortality associated with HIV infection. Newly identi.ed HIV-seropositive older individuals are proportionately more likely than younger persons to have AIDS at the time of diagnosis. Clinicians have to think about the possibility of HIV infection in older persons to avoid delays in diagnosis and treatment. Immunologic recovery in older individuals initiated on combination antiretroviral therapy is less robust in some studies compared with younger individuals. However, virologic suppression on treatment in young versus old antiretroviral naïve patients is comparable. Co-morbid conditions and their treatment pose a special challenge to health care providers with regard to drug metabolism and interactions with HIV medications. HIV prevention should be discussed with all at risk individuals. The HIV epidemic will only worsen if medical practitioners neglect to discuss sexual risk behavior with their older patients.     

Behavioral prevention study gauges HIV/AIDS and depression in the older US population

According to the National Institute of Health (NIH, 1997) the number of older Americans with HIV or AIDS is growing. Cumulative estimated number of HIV/AIDS cases in the US for ages 50-54 was 56,950. Furthermore, the number of newly-infected persons 65 years and older has grown considerably in the last ten years. Several reports indicate that the attitudes and knowledge of older Americans appears be less responsive compared to other age cohorts (CDC, 2003, 2007). This may be attributed to the lack of prevention programs geared towards older persons and physician comfort levels with geriatric patients in discussing sexuality. While it is important to attribute this longevity to the emergence of highly active antiretroviral therapy, consideration must also be made for the mental well-being of this cohort, as evidenced by the effectiveness of antiretroviral chemotherapy and the prevalence of depressive disorders unique to older populations. The unique co-morbidity of clinical depression and HIV/AIDS presents unique challenges to the physician and other healthcare providers. The NIH awarded $1.6 million to the University of Ohio Health Psychology Program in 2006 to examine how older Americans are coping with HIV/AIDS.     

Report from the AIDS Impact Conference: the post-AIDS era and the effect of treatment advances

This article presents highlights of the AIDS Impact Conference. The effects of HIV treatment advances and the concept of a "post-AIDS era" were major topics of the conference. As highly active antiretroviral treatment (HAART) improves therapy outcomes, many AIDS agencies are shifting focus from physical health issues to mental health concerns and prevention efforts. However, in developing countries, drugs, physicians, and a medical infrastructure are often inaccessible. Therefore, focusing on prevention, nutrition, and family relationships may be the better approach for dealing with AIDS and HIV in these countries. Related conference topics included HIV prevention programs directed toward HIV-positive individuals, challenges to adherence, and whether HIV is a chronic manageable disease. Due to lack of scholarships, many individuals from developing countries could not attend the conference and most presentation pertained to the effects of HIV in developed countries and to gay men.     

HIV/AIDS and older adults in Cameroon: Emerging issues and implications for caregiving and policy-making

The burden of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) on the elderly population in three divisions within the Northwest Region of Cameroon was examined. Data for this paper were extracted from a larger study which had been conducted concerning the burden of HIV infection and AIDS on the older adults in the Northwest Region of Cameroon. Using in-depth interviews (IDIs) and focus group discussions (FGDs), data were collected from 36 participants who were purposively selected from the three divisions which had been chosen randomly. 6 FGD sessions were held with 30 women aged 60 years and above and who were affected by HIV infection and AIDS, while IDIs sessions were held with 6 male community leaders. The results revealed that HIV infection and AIDS has added another dimension to the role of older persons. HIV infection and AIDS affects older people in diverse ways, as they have to look after themselves, their sick children and are often also left to look after their grandchildren orphaned by HIV infection and AIDS. These emerging issues in their lives make them vulnerable to health, social, economic and psychological challenges, and place a burden on them as caregivers instead of being cared for in their old age. Apart from increased direct expenditures, taking care of victims of HIV infection and AIDS requires older people to stay away from social, religious and community activities. The results showed that the loss of a child to HIV infection and AIDS affects the economic/financial well-being, participation in social/religious interactions as well as the community activities of older people participants. The implications of these findings for caregiving and social policy are discussed.     

Treating people with intercurrent infection in HIV prevention trials. Report from a WHO/UNAIDS consultation, Geneva 17-18th July 2003

While broad agreement now exists among sponsors of HIV prevention trials that antiretroviral therapy (ART) and a clinical care package should be provided to those who become infected during the conduct of a trial, certain practical issues remain unresolved, including Who should pay for ART? How long should ART be provided for? Does treatment extend outside of ART? What else should be included in the standard of care package and who should pay for it? Who should provide treatment and care? This report summarizes the discussions from a consultation held in Geneva (17-18 July 2003) organized by the World Health Organization (WHO) and the joint United Nations Programme on HIV/AIDS (UNAIDS). The group discussed issues related to the various types of HIV prevention trials covered - vaccines, microbicides, behavioural - the ethics and legal rational for providing treatment and care as well as relevant economic issues and developments around scale-up of treatment and care in middle- and lower-income countries. Also discussed were policies of certain research agencies, countries and international funding agencies. The implementation of the conclusions which came out of these discussions on the treatment and care for people who become infected during HIV prevention trials requires the active participation of members of the research community, funders of research, local and national governments and industry as well as the individuals or communities participating in the trials.     

Are sexually active older Americans your next high-risk group?

Older Americans are becoming infected with HIV through sexual contact, more often than they have in the past. Doctors do not routinely question older patients about their sexual practices, and these patients often do not suspect that they are infected with HIV. In many cases, both doctors and patients may attribute some symptoms to the aging process. In addition, since older Americans are not as highly effected by HIV infection as are other populations, Federal agencies will often not support research on this population. Despite the lack of Federal support, some agencies such as the American Association of Retired Persons (AARP), are beginning to focus on educating older Americans about HIV/AIDS.     

Developing and implementing an HIV/AIDS educational curriculum for older adults

PURPOSE: Recent data (2002) from the Centers for Disease Control and Prevention indicate that almost 11% of all cases of AIDS were diagnosed in people 50 and older. Despite the steady rise and future projections of increase, there is still a paucity of education and prevention programs targeting this population. This article reports on the development and piloting of an HIV/AIDS education prevention program. It describes an educational curriculum that provides older adults with accurate information about the relevance of HIV/AIDS to their lives. DESIGN AND METHODS: A purposive sample (n = 249) of ethnically and economically diverse adults 50 years and older was selected from 14 organizations in rural and urban settings in California. They were surveyed to determine their interest in participating in HIV/AIDS education prevention programs. RESULTS: A majority of participants reported interest in an HIV/AIDS prevention program for older people, with female respondents more likely to attend than male respondents. Participants who were moderately or very religious were also more likely to attend. Participants expressed preference for prevention education through presentations at centers serving older adults, and from physicians and other health care providers. On the basis of these findings, a specialized curriculum targeting older adults was developed, presented, and disseminated. IMPLICATIONS: People 50 years and older are sexually active, lack accurate information about HIV/AIDS, and are in need of HIV/AIDS education.     

Understanding of the risk of HIV infection among the elderly in Ga-Rankuwa,South Africa

Abstract

The literature pertaining to the elderly shows that HIV infection among this population is on the increase, suggesting that the elderly population engages in activities risky for HIV infection. Reports on such behaviour include frequent sexual relations with much younger people and having multiple partners. A study was carried out in Ga-Rankuwa, a black township in Gauteng Province, South Africa to explore and describe the understanding of these elderly people regarding their risks of HIV infection and AIDS. Using a qualitative, exploratory design, three focus-group interviews were conducted with 32 women aged over 50 years. Findings revealed that older persons have knowledge about transmission of HIV infection and AIDS. However, a few had misconceptions as to how HIV infection is transmitted, as they believed that poor nutrition and sharing facilities play a role. Knowledge of mechanisms of protecting themselves against infection, such as use of a condom during coitus and wearing gloves when caring for infected family members, was also evident. The elderly indicated that they would prefer an older person, who they could identify with, to educate them more about HIV infection and AIDS. Although majority of participants had knowledge of how HIV is transmitted, and issues that put them at risk of transmission, a few the older persons had misconceptions about how HIV is transmitted due to lack of knowledge, as they believed that poor nutrition and sharing facilities can transmit infection. The lack of knowledge underscores the importance of addressing sexual risk with older people. It was very clear that more needs to be done in terms of education campaigns to dispel the myths of HIV infection and to empower the elderly.     

HIV/AIDS in Women and Racial/Ethnic Minorities in the U.S.

The clinical issues affecting women with HIV/AIDS differ little from those affecting men. However, current research shows that treatment and outcome disparities affect many women with HIV, hypothesized to result from a complex interplay of socioeconomic and gender role influences. These disparities are also a reflection of racial/ethnic differences in treatment and outcome, since 80% of women with HIV/AIDS are black or Hispanic. Women have unique needs for HIV prevention — both prevention of sexual transmission to or from sexual partners and prevention of perinatal transmission. Racial/ethnic minorities continue to be disproportionately affected by the HIV/AIDS epidemic in the U.S. Minorities are less likely to be in care and on HAART than others with HIV/AIDS. These disparities result in poorer outcomes for minorities, especially blacks, with HIV/AIDS. New strategies for optimizing engagement and retention in care, and for prevention hold great promise for women and minorities with HIV in the U.S.     

Providers not diagnosing HIV in older women

Females over the age of fifty are the invisible victims of the HIV epidemic. The Federal Centers for Disease Control and Prevention (CDC) reported that ten percent of all women diagnosed with AIDS by June 1994 were over fifty years of age. Midlife-and-older women with AIDS are not being diagnosed until late in the disease process, sometimes after death. CDC statistics show that the mode of transmission is changing. Women in these age groups are acquiring the disease through heterosexual contact, rather than transfusions. The difficulty remains with the health care providers who are often not adequately prepared to diagnose and treat midlife-and-older women with HIV/AIDS. A seminar, co-sponsored by the American Association of Retired Persons (AARP) and the Center for Women's Policy Studies (CWPS), has raised several issues regarding HIV in older women. Many behavioral and physiological risk factors are overlooked. In addition, diagnosis and treatment of HIV infection in older women is complicated by other aging factors, and socioeconomic and cultural factors limit access to care and treatment. The AARP and CWPS recommend developing programs to educate physicians about primary and secondary HIV prevention counseling. They also recommend developing partnerships with institutions that have access to older women in order to transmit prevention messages.     

Estimating the extent of underreporting of mortality among HIV-infected individuals in Rio de Janeiro, Brazil

Non-HIV-related causes of death have been increasing after the introduction of highly active antiretroviral therapy. Underlying and contributing causes of death were assessed in respect to the presence/absence of HIV/AIDS among HIV-infected/AIDS patients in Rio de Janeiro, Brazil. Demographic variables (age, gender, ethnicity, and schooling) and CD4?cell counts closest to death were assessed through logistic regression models comparing those who did not have with those who had HIV/AIDS mentioned on the death certificate. The linkage with the two cohorts identified 1249 records, of which 370 (29.6%) did not have HIV/AIDS listed on any field of the death certificate [77 (20.8%) attributed to undefined and 72 (19.5%) to external causes]. After excluding external causes, 25.3% still did not have HIV/AIDS listed on the death certificate. Multiple logistic regression analysis showed that age >40 years (OR?=?2.09; 95%CI?=?1.49-2.93; p?相似文献   

Ambivalence Surrounding Elderly Widows’ Sexuality in Urban Uganda

The elderly are commonly stereotyped as asexual beings. Alternatively mainly negative images abound about the sexual activities of elderly people. Based on ethnographic data this article explores diverse sexualities of elderly widows and widowers in an urban periphery of Kampala city. Widowhood is socially constructed as an asexual period in this patriarchal society where heteronormativity and marriage prevail as the accepted norms. While widowers are generally encouraged to remarry after observing proprieties of mourning, sexual activity among elderly widows is heavily proscribed against particularly because it is not procreative. Adult children control the sexuality of their elderly parents, often by discouraging sexual liaisons. Adult children may also arrange for new spouses with utilitarian value such as providing healthcare for ill elders. Post-menopausal widows have less sexual appeal than younger widows for whom reproduction is a viable outcome of sexuality. Widowers and younger widows are more likely to remarry than elderly widows. Consequently for some older widows, the cultural institution of widow inheritance provides an opportunity to resume sexual activity, and benefit from the levirate guardian’s support. However other older widows rejected inheritance by levirate guardians because of fears of catching HIV/AIDS. HIV does infect elderly Ugandans, although prevention and care interventions generally exclude targeting the elderly. Loneliness was widespread among elderly widows. Many felt isolated, dislocated from former social circulation and missed being relevant. However there were a few elderly individuals who were actively engaged in providing sexual education, advocating for sexual health promotion, and defending the sexual rights of the younger generations in their immediate environs. There is an urgent need for more research about the realities of elderly people’s sexualities, sexual health and sexual rights particularly in resource-poor contexts.     

HIV prevalence and sexual behaviour at older ages in rural Malawi

Research on HIV infection and sexual behaviour in sub-Saharan Africa typically focuses on individuals aged 15-49 years under the assumption that both become less relevant for older individuals. We test this assumption using data from rural Malawi to compare sexual behaviour and HIV infection for individuals aged 15-49 with individuals aged 50-64 and 65 and over years. Although general declines with age were observed, levels of sexual activity and HIV remained considerable: 26.7% and 73.8% of women and men aged 65+ reported having sex in the last year, respectively; men's average number of sexual partners remained above one; and HIV prevalence is significantly higher for men aged 50-64 (8.9%) than men aged 15-49 (4.1%). We conclude that older populations are relevant to studies of sexual behaviour and HIV risk. Their importance is likely to increase as access to antiretrovirals in Africa increases. We recommend inclusion of adults aged over 49 years in African HIV/AIDS research and prevention efforts.     

HIV-Infected African Americans are Willing to Participate in HIV Treatment Trials

Background Despite the high prevalence rates of HIV infection in the African-American community, African Americans remain underrepresented in HIV treatment trials. Objective (1) To develop a questionnaire that measures attitudes and concerns about HIV treatment trials among HIV-infected African Americans at a university-based clinic. (2) To determine actual participation rates and willingness to participate in future HIV treatment trials among HIV-infected African Americans at a university-based clinic. Design Questionnaire development and cross-sectional survey. Setting, Participants, and Measurements In a sample of 200 HIV-infected African-American adults receiving medical care at the Pittsburgh AIDS Center for Treatment (a university-based ambulatory clinic), we assessed research participation rates and willingness to participate in future HIV treatment trials, trust in the medical profession, sociodemographic characteristics, attitudes, and concerns about HIV treatment trials. Main Outcome Measures Research participation rates and willingness to participate in future HIV treatment trials. Results Only 57% of survey respondents had ever been asked to participate in an HIV treatment trial but 86% of those asked said yes. Prior research participation was significantly related to willingness to participate in future HIV treatment trials (P = .001). Contrary to previous studies, neither trust/distrust in the medical profession nor beliefs about the dishonesty of researchers was associated with research participation rates or willingness to participate in future HIV treatment trials. Conclusions Having never been asked to participate in research is a major barrier to the participation of HIV-infected African Americans in HIV treatment trials. African Americans who seek medical care for HIV infection should be asked to participate in HIV treatment trials.     

50岁及以上HIV／AIDS病人的抗病毒治疗效果

目的了解≥50岁艾滋病病毒（HIV）感染者／艾滋病（AIDS）病人（HIV／AIDS病人）的抗病毒治疗反应。方法2008年1月至2010年10月,在北京地坛医院艾滋病门诊开始抗病毒治疗时年龄≥50岁的HIV／AIDs病人作为观察组（老年组）;采用简单随机抽样法在同一时期内开始抗病毒治疗的805例年龄为18～40岁HIV／AIDS病人中,抽取168例作为对照组（青年组）。对两组病人的疾病状况、抗病毒治疗效果及不良反应进行回顾性比较分析。结果83例老年组和168例青年组的CD4＋淋巴细胞（CD4细胞）基线水平差异无统计学意义;老年组的肌酐清除率低于青年组（P〈0．01）,高甘油三酯血症、高胆固醇血症、高血糖发生率老年组高于青年组（P=0．044,P=0．004,P〈0．01）。抗病毒治疗6个月后：与基线CD4细胞水平相比,两组CDt细胞均明显增加（P〈0．01,P〈0．01）,增幅老年组为（112．65±107．04）个／μL,青年组为（128．39±113．85）个／μL（P〉0．05）;病毒完全抑制率老年组为82．92％,青年组为83．55％（P〉0．05）。无论是否接受基于D4T的初始治疗方案,老年组发生高血脂和高血糖的风险均高于青年组;两组接受基于AZT的初始治疗方案的病人的白细胞计数与血红蛋白变化幅度,以及两组接受基于NVP的初始治疗方案的病人的天冬氨酸转氨酶（AST）与丙氨酸转氨酶（ALT）变化状况,均无统计学意义。结论老年组与青年组相比,在接受抗病毒治疗后6个月免疫学反应和病毒学应答相同,但老年组病人易出现如高血脂和高血糖以及肌酐清除率下降等情况,因此,在≥50岁的HIV／AIDs病人的抗病毒治疗过程中应加以重视。     

广西农村60岁以上老年男性HIV感染因素调查

目的了解广西老年男性艾滋病病毒（HIV）感染者/病人的商业性行为特征,为老年人的艾滋病（AIDS）和性病防治策略和措施的制定提供科学依据。方法选择累计报告60岁以上老年男性HIV感染者/病人占当地所有HIV感染者和病人比例较高的某6个县作为本次调查的地区,分别对农村地区存活的60岁以上老年男性HIV感染者和病人进行问卷调查,每个县调查20例以上。结果接受调查的149名60岁以上老年男性HIV感染者和病人中,有35.4%（35/99）的人与配偶仍有性生活,26.3%（26/99）的人目前仍与配偶或同居者平均每月发生1～4次性行为,而最近1次与配偶或同居者发生性行为时48.1%（13/27）的人没有使用安全套。90.6%（135/149）的老年男性HIV感染者和病人曾与商业性伴发生过性行为,81.5%（110/135）的人在与商业性伴发生性行为时从未使用安全套。30.2%（45/149）的人使用过壮阳药。结论在广西农村老年男性人群中,商业性性行为是最主要的HIV感染途径,发生商业性行为时不使用安全套是感染HIV的主要原因,服用壮阳药在一定程度上增加了农村老年男性发生商业性行为的次数,同时也增加了感染HIV的风险。     

HIV infection in the elderly

In the US, an estimated 1 million people are infected with HIV, although one-third of this population are unaware of their diagnosis. While HIV infection is commonly thought to affect younger adults, there are an increasing number of patients over 50 years of age living with the condition. UNAIDS and WHO estimate that of the 40 million people living with HIV/AIDS in the world, approximately 2.8 million are 50 years and older. With the introduction of highly active antiretroviral therapy (HAART) in the mid-1990s, survival following HIV diagnosis has risen dramatically and HIV infection has evolved from an acute disease process to being managed as a chronic medical condition. As treated HIV-infected patients live longer and the number of new HIV diagnoses in older patients rise, clinicians need to be aware of these trends and become familiar with the management of HIV infection in the older patient. This article is intended for the general clinician, including geriatricians, and will review epidemiologic data and HIV treatment as well as provide a discussion on medical management issues affecting the older HIV-infected patient.