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AIDS marches on

by Matthew S. Bajko .
Thursday Jun 2, 2011

Greg Edwards will turn 60 this August. It is an age he could hardly imagine he would ever celebrate when he was diagnosed with having HIV in 1992.

At that time the country's AIDS epidemic was entering its second decade. And it would be another four years before the introduction of breakthrough medications that would turn HIV into a manageable, chronic illness.

"A lot of the anxiety and fear has dissipated over the years. But so many people over 50 were infected in the late 1980s or early 1990s but clearly are no longer around," said the openly gay San Francisco resident who is the director of the Oakland-based Flowers Heritage Foundation, which supports HIV and AIDS services.

As the AIDS epidemic now enters its fourth decade, older Americans represent the fastest growing age group among HIV-positive people. In San Francisco the majority of AIDS cases are already in this age bracket. As the Bay Area Reporter reported in February, 53 percent of AIDS cases in 2010 were among people 50 and older.

And one in six people are over 50 when diagnosed with being HIV-positive, city data shows. By 2015 the Centers for Disease Control and Prevention estimates that half of the people with HIV in America will be over the age of 50.

That will be "a pretty big milestone," said Dr. Bradley Hare, medical director of the UCSF Positive Health Program at San Francisco General Hospital. "For those of us working in the field, this happened right under our noses."

The main reason people are surviving longer, said Hare, is due to "the success of treatment for people who are HIV-positive. The current antiretroviral treatment is keeping people alive much longer."

But as this population ages, they face a barrage of health issues that are complicated by their having compromised immune systems. And health officials are increasingly turning their attention to address the needs of older HIV patients.

"The dialogue in a lot of medical visits has shifted from HIV to other chronic health conditions because the new medications control HIV infection more effectively," said Hare. "These other diseases take up a bigger portion of the health care visit."

A study published in April by the Journal of the National Cancer Institute found that between 1991 and 2005 increases in non-AIDS-defining cancers were mainly driven by the growth and aging of the country's AIDS population. Researchers discovered that compared with the general population, HIV-positive people are at greater risk of AIDS-defining cancers such as Kaposi's sarcoma, non-Hodgkin's lymphomas, and cervical cancer.

The researchers also concluded "a growing number of HIV-infected people, with or without AIDS, are at risk of non-AIDS-defining cancers that typically occur at older ages."

Researchers have also documented that people infected with HIV who are over the age of 50 progress to AIDS more rapidly than adults in their 20s or 30s. How to treat such patients presents its own complications when they may be facing a variety of health issues.

AIDS and geriatric care

UCSF's California HIV/AIDS Research Program awarded a three-year grant to Hare and his colleagues aimed at developing and evaluating programs that integrate HIV/AIDS and geriatric care for HIV-positive people age 50 and older. The new initiative, launched in conjunction with the San Francisco Department of Public Health, will focus on age-related conditions such as cardiovascular disease, neurocognitive impairment, and osteoporosis.

It will also examine the premature aging of the immune system in HIV patients, which is a growing concern as people with HIV live longer due to antiretroviral therapy.

Over the last decade, Hare said researchers have noticed that HIV-positive people are at greater risk of developing conditions such as heart disease, kidney disease, osteoporosis, dementia, and cancers at an earlier age than HIV-negative people.

"You tend to see these conditions in older populations but they are occurring much younger, on average 10 to 15 years younger, in people who are HIV-positive. We don't exactly understand why that is," said Hare. "If you look in the laboratory at the immune cells from someone HIV-positive they behave similar to people HIV-negative but older, so something is happening at the cellular level."

Six months of insomnia

The Flowers Foundation's Edwards said when he first learned of his HIV status, he had six months of insomnia wondering not if but when he would die.

"I got an entire scenario from my doctor not so much if, it is when. You need to go and start talking to your family and make arrangements," recalled Edwards.

Having lived so long with the virus, Edwards said his health worries are no longer so morbid.

"Today, yeah, my concern is high blood pressure, high cholesterol, and heart disease," said Edwards. "Not only those co-morbidities as the result of aging in general but also what are the long-term affects of the drugs I am taking for HIV infection."

Realizing that he and his peers likely had long lives yet ahead of them, Edwards two years ago saw there was a need for more attention to issues facing people 65 and older living with HIV. Working with San Francisco's Office of AIDS, the nonprofit helped fund a review of the pertinent academic literature available at the time of issues facing people in that age bracket.

As noted in the paper, people 65 and older have the lowest survival rates following an AIDS diagnosis of any age group, according to the CDC. And in San Francisco, the review found that between 2001 and 2008 the percentage of people 60 older living with AIDS had increased more than 11 percent.

The "relatively large numbers of local long-term survivors" was due to the city's being a leader in caring for people living with HIV and AIDS, said the report. And it stressed the need for health officials to change their focus from merely keeping people with HIV and AIDS alive to better managing "the quality of the extended life that older persons with HIV now have."

Dr. Victor Valcour, an internist and geriatrician at the Memory and Aging Center at UCSF, has spent the last three years studying the effect of HIV on the brain in adults ages 60 and older. He is also a member of the newly formed Office of AIDS research working group on HIV and Aging at the National Institutes of Health.

"I think there are two emerging and congruent priorities in the field related to aging. The population of HIV patients is getting older as a whole. Secondarily, there has been some speculation either HIV or the medications or some factor associated with those may be accelerating the aging process in HIV individuals," said Valcour. "There is a fair amount of urgency to study these issues so we can provide the best care for people living with HIV."

In his work with patients, Valcour said he is seeing more cardiovascular disease, heart attacks, and cognitive issues such as Alzheimer's and dementia.

"We need to think about aging and HIV together, what that will look like and how you can maximize somebody's quality of life," he said. "It is a large and emerging problem."

Older people with HIV show "a fair amount" of cognitive impairments, said Valcour.

"Fifty percent of people living with HIV test in the range considered impaired. Some patients who test in the impaired range don't feel they have any problem," he said. "If you brought them into a clinical setting and asked them to do some common tests, like balance a checkbook, make change, or manage their medications, they are at higher risk for not doing that well."

More research is needed to better understand how HIV impacts a person's aging process, said Valcour, as well as what, if any, consequences come from taking HIV medications over the course of decades.

"There is some speculation the medications might be contributing to some of this aging. There is a lot of concern the medications are not sufficiently suppressing the virus, so low-level inflammation is going on so adding to the aging acceleration," said Valcour. "We have made great success for life expectancy. But current treatment approaches don't appear to be sufficient to completely protect from the co-morbidities occurring."

Despite the growing attention being paid to older PWAs, Edwards said he believes health departments and AIDS agencies need to do more to better understand the needs of their aging clienteles.

"I think local agencies need to do more work to find out what those needs are. There is need for more assessment of how they are getting care, where they are getting it, and how they feel about it," he said. "How are they best treated in the context of these co-morbidities? I think there is a lot to learn there."

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