January/February 2009

A New Purview for HIV/AIDS
By Jennifer Van Pelt, MA
Aging Well
Vol. 2 No. 1 P. 24

Successful therapies and improved lifestyles contribute to increased longevity for patients with HIV/AIDS.

HIV/AIDS research, treatment, and prevention have come a long way since the early 1980s when AIDS and its causative virus, HIV, were first identified. The development of highly active antiretroviral therapy in 1996 has led to reduced rates of morbidity and mortality, resulting in extended life spans for individuals with HIV/AIDS. According to the Centers for Disease Control and Prevention, in 2005, 24% of those living with HIV/AIDS and 29% with AIDS were adults aged 50 and older, as were 15% of all those with a new HIV/AIDS diagnosis. These percentages are expected to continue to increase, while longer life expectancy with HIV/AIDS catalyzes changes in healthcare, social supports, and risk-reduction strategies.

In a recent press release, Rowena Johnston, PhD, vice president of research at the Foundation for AIDS Research, said, “One of the most striking successes of HIV/AIDS research has been the development of antiretroviral therapy that significantly extends the lives of people living with HIV. It has transformed HIV/AIDS from an early death sentence to a manageable chronic illness. … Longer life expectancies are shifting what has been the traditional portrait of AIDS, such as body wasting along with numerous rare infections, into a condition that is increasingly associated with some of the manifestations we traditionally think of with older age, such as cancers, heart disease, kidney and liver disease, and insulin resistance.”

There are positives and negatives associated with this new perspective on aging and HIV/AIDS. While the acceptance of HIV/AIDS as a chronic condition for older adults may help to improve its medical treatment and perceptions of life expectancy, older adults with HIV/AIDS still have many hurdles to overcome. Aging with HIV/AIDS is more difficult than aging with chronic age-related conditions such as heart disease and diabetes because of medical complications, associated social stigma and subsequent social isolation, and difficulties with medication compliance and drug-drug interactions. Researchers are investigating the benefits of support groups dedicated to older adults, the effects of multiple drugs for various chronic medical conditions, and the lingering unique prejudices faced by older adults with HIV/AIDS.

Living Longer
“Before protease inhibitors, back in the 1990s, we were just trying to get people to survive. The thought of aging with this disease did not even enter anyone’s mind then,” says David E. Vance, PhD, MGS, a gerontologist and an assistant professor at the School of Nursing at the University of Alabama at Birmingham. “Now, we don’t even put a prognosis with the diagnosis anymore. Doctors are no longer saying, ‘You could live up to a certain number of years,’” he says. Although resources for professionals working with the older adult HIV/AIDS population have not yet been well developed, interest and research efforts are growing, says Vance, who has conducted extensive research on the cognitive aspects of aging with HIV/AIDS. “Aging with HIV/AIDS has become a hot issue now because we realize that people can age well if they adhere to their medications and have a healthy lifestyle,” he says.

However, even when older adults comply with highly active antiretroviral therapy and adopt a healthful lifestyle that includes proper diet and exercise, they often focus too much on their HIV/AIDS treatment, neglecting other important aspects of aging-related health. Vance and Timothy G. Heckman, PhD, a professor of geriatric medicine/gerontology and director of the Center for Telemedicine Research and Interventions at the Ohio University College of Osteopathic Medicine in Athens, warn that older adults with HIV/AIDS must also pay attention to screening for age-related diseases such as breast, prostate, and colon cancers and care for other conditions such as hypertension, heart disease, diabetes, depression, and osteoarthritis. For women, osteoporosis and menopause add to the list of potential comorbid conditions, says Arlene Kochman, LCSW, a research project consultant for studies of HIV/AIDS in adults over the age of 50 and a psychotherapist in private practice working with the gay/lesbian community in New York City.

“We have to be sure that they will receive comprehensive healthcare, not just for HIV, but for all these other age-related conditions,” Heckman says. Early diagnosis of these common conditions of aging can contribute to improved quality of life in the case of comorbid conditions and HIV/AIDS. Infectious disease specialists treat most older adults with HIV/AIDS, but it may become necessary to involve primary care physicians or other geriatric physicians in the treatment of comorbid conditions. Therefore, the medical care of older adults with HIV/AIDS can become very complex, with multiple physicians and multiple medications, say Vance and Heckman. In fact, a new clinical specialty in geriatric HIV/AIDS medicine is emerging and is expected to evolve over the next several years as the older adult HIV/AIDS population continues to grow.

HIV/AIDS, combined with other chronic medical conditions, results in a very complicated scenario for both physicians and patients. In addition to highly active antiretroviral therapy, older adults may need antihypertensive drugs, diabetes medications, antidepressants, statins, arthritis pain medications, and other drugs for age-related conditions. Medication compliance, often a problem with many HIV/AIDS patients, becomes even more important and more difficult for older adults. “All the symptoms, their medications, and their interactions can quickly become overwhelming,” Kochman says. She currently works in intervention and program design for rural HIV/AIDS patients who don’t adhere to medication regimens, using one-on-one home video phone sessions.

Risk and Relationships
Kochman also participates in a research study with Heckman documenting the benefits of telephone support groups for older adults with HIV/AIDS. Because many HIV/AIDS support groups are comprised largely of younger individuals, the issues are often irrelevant to older adults. “Restricting support group members to similar older ages allows them to share relevant issues, discuss coping mechanisms, and build a social support network of peers,” Heckman says. “Many of these older adults are just glad that someone is recognizing and addressing aging and HIV/AIDS.”

While in-person support groups are easily accessible in many urban areas, older adults in rural areas are often unable to access such services or choose not to reveal their HIV/AIDS status to their small communities. “Phone support is ideal for older adults who have physical limitations, geographic limitations, and privacy issues,” Kochman says. Although their study revealed that older women, heterosexual men, and homosexual men have different concerns related to aging with HIV/AIDS, ranging from its impact on personal appearance to rejection by family and friends, they all suffer from feelings of social isolation due to the disease’s stigma. Discussing concerns in a phone group of peers without leaving the comfort of home can help them learn how to cope with medications, dating, relationships, and HIV/AIDS status disclosure.

Many older adults with HIV/AIDS experience more social prejudice than younger adults, says Vance. “HIV is considered a younger person’s disease. There is a prejudice associated with age and HIV. Older adults often hear, ‘You’re too old to have HIV. Shouldn’t you know better?’” he says. Although some older adults do contract HIV, most were infected at a younger age.

Age-specific support groups, via phone or in person, can help older adults better deal with societal stigmas. “Bonding occurs in phone groups, even though many have never even met. Nobody has to get out to go to group therapy, and no one sees how they look. It’s less stressful for them,” Kochman says. “Telephone support groups can now reach people who have previously been unreachable. It’s all about connecting. Healthy aging requires a social support system. And this is especially important for those with HIV/AIDS.”

Age-specific support groups can also address another critical issue in aging with HIV/AIDS: risk reduction and relationships. According to Heckman, the risks and the methods used to reduce them are quite different for older adults. With teens and young adults, risk reduction measures focus on reducing the number of sexual partners, eliminating careless sex, and avoiding risky behaviors, such as getting drunk at bars or parties. “Not a lot of older adults have that many different sexual partners. Risk for them relates to issues of intimacy and sex that emerge in a long-term relationship, particularly for older women,” Heckman says. Loneliness, difficulty finding intimate partners, and the reluctance of many older men to use condoms are issues that face older adults with HIV/AIDS, he says. In his support groups, he raises questions such as how well clients know their partners and risk profiles and whether clients and partners are prepared to and willing to talk about sexual history and risk or HIV status.

Internet dating and erectile dysfunction drugs have increased the likelihood of high-risk sexual behavior for all older adults, and older women are generally not prepared to address the issue of safe sex with older men, according to Heckman and Vance. Heckman’s support groups teach how to handle intimacy and safe sex because older adults are often ignored in HIV/AIDS interventions. “There is a lack of risk reduction interventions that are age appropriate and specifically tailored to older adults. I don’t know of any development of age-appropriate risk reduction measures that is happening now. Certainly, there have been no studies on how to reduce risky behavior in older adults already with HIV,” he says.

Opportunities for the Future
Professionals working in the aging field will find many opportunities for work, given the need for age-appropriate risk reduction programs, telephone and in-person group therapy and support sessions, and healthcare, as the older adult population with HIV/AIDS continues to grow. Kochman says, “I’ve been working with gay/lesbian older adults and HIV/AIDS since the 1980s, and finally, the field is coming into its own.” She believes that opportunities exist in community outreach, home healthcare, and counseling/cognitive behavioral therapy. In addition to knowing about HIV/AIDS issues, interested professionals need to know about aging with any chronic disease. “Chronic disease, whether it is HIV/AIDS or cancer, exacerbates all aspects of aging—loss, relationship difficulties, and depression,” she says.

— Jennifer Van Pelt, MA, is a freelance writer based in Reading, PA. She is also a certified fitness instructor with experience teaching older adults.

Suicidal Ideation
David E. Vance, PhD, MGS, a gerontologist and an assistant professor at the School of Nursing at the University of Alabama at Birmingham, recently published an article on suicidal ideation and HIV. “Compared with younger adults with HIV, older adults with HIV experience more suicidal ideation,” he says.

While older adults in general are more suicidal, HIV/AIDS may contribute to suicidal ideation in this population. “There are unique neurological/cognitive changes associated with HIV/AIDS that may impact one’s ability to cope. Coupled with factors like the social stigma of HIV/AIDS and financial distress associated with expensive medications and being on a fixed income, these cognitive changes make suicidal ideation more common in older adults with HIV/AIDS,” he says.

Clinical caregivers such as nurses are in an ideal position to observe symptoms of depression and suicidal ideation in the older adult HIV/AIDS patient and intervene appropriately, Vance says.

— JVP