1. San Francisco HIV Health Services Persons 65 & Older Living with HIV/AIDS in San Francisco: An Introduction Prepared by Robert Whirry, Program Development Consultant A Study Funded by the Flowers Heritage Foundation

2. Part I.10 Key Issues in Aging Populations with HIV/AIDS: A Brief Review of the Literature

3. Both epidemiology and the research literature consistently define “older persons with HIV/AIDS” as persons 50 and above, despite the fact that 65 is the traditional starting point for geriatric medicine. This may be the case because the CDC has consistently used “50 and above” as its highest-end age category.

4. Because of the “50 and older” definition, there is virtually no research literature that specifically addresses persons 65 and older living with HIV/AIDS.

5. While evidence of new potential early aging symptoms make it important to look at 50 and older populations, it is also useful to focus on persons with HIV 65 and older because of the intersections with geriatric medicine and the importance of Medicare reimbursement issues.

6. 10 Key Lessons from the Literature

7. 1. Preliminary research indicates that older age does not significantly diminish the long-term effectiveness of Anti Retroviral Therapy (ART). However, untreated HIV infection may have more dramatically detrimental effects among older as compared to younger adults.

8. 2. While older age has been associated with higher rates of antiretroviral adherence, there is also evidence to suggest that older individuals with some form of cognitive impairment could be at increased health risk as a result of inconsistent medication adherence, meaning that older adults on ART require continual cognitive monitoring.

9. 3. There is some evidence to suggest earlier and more frequent onset of aging-related conditions among older persons with HIV taking ART. This includes diabetes, heart disease, anemia, osteoporosis, and early Alzheimer’s symptoms. The issue of chronic inflammation is receiving increasing attention as the potential root cause of many of these effects.

10. 4. An emerging area of research suggests that persons over 50 on HAART may be aging more rapidly than their non-HIV-infected older counterparts. In the words of Dr. Ardis Moe of the UCLA Center for Clinical AIDS Research and Education, “I have a population that, having survived this terrible illness, is now getting illnesses of old age 10 or 20 years sooner than normal.”

11. 5. The misdiagnosis of HIV conditions may be relatively common among older adults because many physicians may assume that symptoms are related to aging rather than HIV. Older patients also may receive an HIV diagnosis later in their infection because they are not tested as frequently for HIV due to assumptions about older adults’ HIV risk behaviors.

12. 6. The prevalence of misdiagnosis and delayed testing among older persons with HIV may be closely related to providers’ pre- conceived attitudes and prejudices regarding risk behaviors of older individuals. The CDC’s own HIV testing guidelines recommend routine testing for persons only up to age 64, noting that persons 65 and above should be counseled to receive HIV testing only if they have specific identified risk factors for HIV prevention.

13. 7. The availability of erectile dysfunction medications that help individuals engage in more frequent sex at older ages is almost certainly increasing sexual activity among older adults, and may in turn be increasing levels of HIV risk within this population. This is an under-explored area in HIV behavioral research.

14. 8. Some studies suggest that persons 50 and older may engage in more frequent risk behavior in part because they do not perceive themselves to be at risk for HIV, do not use condoms, and do not get tested for HIV. One report among a cohort of women 50 years and older with AIDS found that 86% had never used a condom within five years of knowing their HIV status, a proportion significantly higher than that of younger women

15. 9. An increasing proportion of women are becoming infected with HIV/AIDS at an older age. According to the CDC, the number of women age 50 years and older with a new diagnosis of HIV more than doubled between 1990 and 2000 alone. Yet Carol Thomas (2003) notes that older women are often ignored in discussions about HIV prevention and care and that senior women are generally not included in HIV educational programs.

16. 10. Social support networks have been consistently acknowledged as critical elements in the lives of persons with HIV/AIDS. Inadequate social support has been associated with lower physical functioning, while strong social support has been associated with psychological well- being and mental health, better coping skills, and higher quality of life. These factors may be compromised or reduced for older PLWHA who often face isolation, loneliness, and lack of social connection.

17. Part II.Profile of Persons 65 & Older with HIV in the U.S. and San Francisco

18. According to the CDC, a total of 8,842 persons 65 and older were living with AIDS in the US at the end of 2003, but by the end of 2007, the number had risen to 17,005 – a nearly 50% increase in five short years.

20. The United States Senate Special Committee on Aging predicts that by the year 2015, 50% of all persons living with HIV/AIDS in the US will be older than 50 years.

22. As of April 30, 2009, a total of 785 persons age 65 and older were living with HIV/AIDS in San Francisco, representing roughly 5% of all persons living with HIV/AIDS (PLWHA) in the city.

23. Age of PLWHA 65 & Older in SF (as of 4/30/09) AgeNumber% 65 – 6950264% 70 – 7417723% 75 – 79648% 80 – 84334% 85 +91%

32. Contact Information: Michelle Long Director, Contract Development & TA San Francisco Dept. of Public Health Office: (415) 255-3409 E-Mail: michelle.long@sfdph.org Robert Whirry Program Development Consultant Office: (323) 666-4633 / Cell: (415) 515-5567 E-Mail: roblink@aol.com