HIV/AIDS and Older Adults Henry Pacheco, M.D. Medicine & Public Health Director National Hispanic Council on Aging (NHCOA) Washington, DC National Hispanic Council on Aging (NHCOA) Working to improve the lives of Hispanic older adults, their families, and caregivers

Learning Objectives Review of aging trends in the US A brief overview of the HIV/AIDS in the US A review of sexual and other HIV risk factors for older adults Understanding barriers that prevent healthcare providers from recognizing and treating older adults living with HIV/AIDS The role of stigma and discrimination in HIV prevention and treatment

Profile of the Older US Population In 2010 Persons 65 + represented 13.1% of the population ( 40 million) (a 15.3% increase since 2000) Persons 85 + represented 1.8% of the population Future Growth of the Older population The 65+ population is projected to increase by 36% within a decade, reaching 55 million by 2020 The 85+ population is projected to reach 6.6 million by 2020 representing an increase of 19% By 2030, people 65+ will represent 19.3% of the population Source (HRSA, 2011)

Growth of the 65+ Population, 1900 – 2030 (numbers in millions)

Two Decades of HIV/AIDS  

State of the HIV Epidemic in the US •Newly infected with HIV: 48,100 (annually) •People living with HIV/AIDS: 1.1 million • HIV infected but don’t know it: 18% • People diagnosed with HIV not in regular care : 50% HIV has evolved from an acute disease into a chronic disease due to the success of treatment (HAART) and prevention efforts AIDS can be considered a complication of HIV (Source: CDC,2012)

HIV Disparities

HIV among Older adults By 2015, HIV OVER FIFTY: EXPLORING THE NEW THREAT HEARING BEFORE THE SPECIAL COMMITTEE ON AGING UNITED STATES SENATE 109th CONGRESS FIRST SESSION WASHINGTON, DC MAY 12, 2005 By 2015, 50% of the people living with HIV will be 50 or older (Effros et al., 2008) Preventing the spread of HIV/AIDS among this population poses many unique challenges. 1 out of 3 sexually active older adults infected with HIV has unprotected sex, according to a study …. , most were male, took Viagra and were in a relationship. (Source: Medical News Today 4.30.2007)

HIV and Older Adults (50+) The fastest growing HIV population HIV grew by 77% from 2001-05 in this population (CDC, 2008) Older adults comprised 15% of all new HIV infections in 2007 in the US (CDC, 2010) HIV is 12 times higher among African-Americans and 5 times higher among Latinos compared to Whites

Why is HIV Growing Among Older Adults? Improved survival of persons living with HIV due to success of HAART Large numbers of older adults become infected with HIV annually The presence of multiple and significant risk factors that places older adults at risk for HIV

HIV Risk Factors in Older Age Lack of awareness of HIV risk factors Perception that HIV is a disease of the young Least likely to practice safe sex (unprotected intercourse) Not free from drugs of abuse and alcohol PCPs don’t consider their older patients at risk for HIV Viagra and similar drugs has extended their sexual vitality Late or no HIV testing as part of routine health care Older women free of pregnancy risk see no need for condoms Vaginal mucosa in post –menopausal women is easily irritated/ injured, more likely to become infected by HIV

Why is HIV Often Not Recognized in Older Adults by Health Care Providers? Stereotypes of older adults as sexually inactive Primary care Providers often do not take sexual histories or inquire about drug abuse Consider their married patients involved in “safe” monogamous relationships, not at risk of HIV or STIs Consider them in heterosexual relationships unaware of potentially high risk sexual life styles Low index of suspicion – low rate of testing Symptoms of HIV are often similar to those of aging

The Older HIV Patient: Challenges for Primary Care Providers Comorbidities are more common Learning a new “specialty”, drug interactions, side effects of ARV regimens in older patients Are symptoms due to aging, HIV or effects of ARV? The importance of adherence and continuity of care Need to understand and address the impact of stigmas (HIV, sexual minorities, ageism, drug abuse) Older adults suffer more poverty and social isolation Age-related disabilities along with HIV complications Sources: HIV infection in the elderly, G. Kelly , et al, Current Infectious Disease Reports, 2009

More PLWH are Dying of Non-AIDS Causes In NY study: 26% of deaths were non-AIDS (alcohol/drugs (31%), CVD (24%), Cancer (21%)) Barcelona: 60% were non-AIDS Liver(23%), Infection(14%),cancer, (11%),CVD (6%) CASCADE Study, UK: 63% were non-AIDS , Liver(20), Infections(24%), Unintentional (33%), Cancer (10%), CVD, (9%) Source: (Amy Justice, May 2010)

Many of the Challenges are not Clinical Care of the elderly requires more provider and other staff time including coordinated care A team approach is necessary when caring for PLWH HIV is a complex disease: care can be costly Clinicians productivity is slowed HIV patients may require support services that can be difficult to arrange and pay for Minority and non-English speaking HIV patients require culturally and linguistically competent care

Stigma: A Major Barrier to Eliminating HIV/AIDS 23 %of HIV+ patients had physicians with negative attitudes toward injection drug users. M. Ling Harvard Study (MNToday:2005) Some factors that lead to stigma and Discrimination : HIV is often related to stigmatized behaviors or life styles (i.e., injecting drugs, homosexuality) HIV is still a feared disease The belief that HIV can be caught via casual contact The belief that having HIV/ AIDS is a sign of moral failure that merits punishment Stigma in HIV is a persistent and pernicious problem It destroys the familial, social, and economic lives It is a major barrier to accessing prevention, care and treatment ( A. Mahajan, Stigma & HIV/AIDS , AIDS. 2008 August; 22(Suppl 2):

Resources for Primary Care Providers An increasing number of primary care providers (PCPs) will be expected to care for PLWH HIV is already a chronic disease, along with diabetes, hypertension and others that primary care providers will have to address Sources of Training for Clinicians: The HRSA /HAB AIDS Education and Training Centers (AETC): www. Aidsetc.org A current review: HIV and Aging: State of Knowledge, JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 July 2012 - Volume 60 - Issue - p S1–S18 (on-line)

Thank you !