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Transcript
HIV INFECTION-WHAT’S DIFFERENT ABOUT OLDER PATIENTS
INTRODUCTION
In Sub-Saharan Africa [SSA], HIV among older adults has largely been ignored,
though there has been some emerging interest in this topic.1 A recent study estimated
that there are three million HIV positive people in SSA aged 50 and older
representing more than 14% of those over the age of 15 infected 2suggesting that
increased attention is warranted for older age groups. Homosexual or bisexual
behavior remains the predominant risk factor for human immunodeficiency virus
[HIV] infection up to age 70. The proportion of AIDS cases diagnosed in the same
month as death rises with age, suggesting that delays may be occurring because
clinicians do not consider HIV infection as readily in older patients. The five most
common opportunistic infections in older HIV-infected patients are Pneumocystis
carinii pneumonia, tuberculosis, Mycobacterium avium complex, herpes zoster, and
cytomegalovirus. A number of features of HIV-related dementia may help to
distinguish it from Alzheimer’s disease.
Examining HIV-related knowledge and attitudes among people over 50 in SSA is
important for a number of reasons. Older adults remain sexually active and therefore
remain at risk of HIV infection. As anti-retroviral therapy [ART] is rolled out, more
HIV positive individuals are living longer thus furthering the ageing of the epidemic.
Older adults in SSA also play a critical role as educators and caregivers and older
people remain influential community members and leaders.Many older people are
involved in taking care of young adults and children and act as gatekeepers of
information, playing a major role in reinforcing attitudes and normative behavior.
Recent work has noted that caregivers perceive a lack of skills to provide information
to and care for dependents.3 HIV/AIDS effects older people in two main ways: it
places a burden on them as carers, and it poses a direct infection risk. A study
conducted by the World Health Organization [WHO] in Zimbabwe found that over
70% of carers of people with HIV- relate illnesses are over 60 years of age. Research
by Help Age International in Thailand found that 70% of people living with HIV were
older parents or relatives shortly before their death.
OLDER PEOPLE ARE AT RISK OF INFECTION
HIV/AIDS prevention and awareness campaigns almost exclusively target younger
people and adolescents, despite the fact that people are still sexually active. Analysis
of infection data collected in Uganda between 1992 and 2002 found that the over-50s
4,6% of those who attended voluntary testing and counseling centers of these, one in
five tested HIV-positive [23,9% of women, 18% of men]. By and large, the risk of
infection and spread of HIV among older age groups goes undetected and unreported.
In Cambodia people identified television, radio and neighbors, especially young
adults, as their primary source of information on HIV/AIDS
AGEING WITH HIV/AIDS
With the success of antiretroviral medications, longevity has increased for those with
HIV and AIDS. As a result, the number of older adults living with these conditions
will likely increase in the years to come. However, some outcomes for older adults
[ages 50 and older] with HIV/AIDS are not as good as for younger adults. Mortality
rates are higher for older adults with AIDS, and survival time after diagnosis is
shorter. Older individuals with HIV or AIDS also report more chronic medical
conditions and limitations in physical functioning. Researchers reviewed what is
known about clinical aspects of HIV infection and ageing in a workshop summarized
in clinical Infectious Disease.4 In short, they found that HIV infection may compress
the ageing process, accelerating co morbidities and frailty a condition of the elderly
that makes people more vulnerable to illness, injury, and death. The presence of
multiple diseases is more common in HIV-infected patients than in other patients, and
age-associated co morbidities compound this problem for older HIV-infected people.
In addition, treatment may not be as effective or may have more adverse effects on
older people. One study showed that ever while receiving highly active antiretroviral
treatment HAART, middle – aged men with HIV had a reduced ability to exercise and
lower functional performance, both indicators of increased frailty.5As they age,
individuals receiving HAART also face increased risk of adverse reactions to drugs
and drug interactions.
SEXUALLY-ACQUIRED AIDS
Nevertheless, homosexual or bisexual behavior remains the predominant risk factor
for AIDS. Elderly patients, however, are likely to hide their sexual preferences, and
thus older men engaging in homosexual activities may not be readily identifiable. In
addition, heterosexual activity should not be overlooked as a risk factor for HIV
acquisition in any age group.
PREVENTION CHALLENGES
Persons over the age of 50 may have many of the same risk factors for HIV infection
that younger persons have.
-Many older persons are sexually active but may not be practicing safer sex to reduce
their risk for HIV infection.6 Older women may be especially at risk because agerelated vaginal thinning and dryness can cause tears in the vaginal area.7
-Some older persons inject drugs or smoke crack cocaine, which can put them at risk
for HIV infection. HIV transmission through injection drug use accounts for more
than 16 of AIDS cases among persons aged 50 and older.8
-Some older persons, compared with those who are younger, may be less
knowledgeable about HIV/AIDS and therefore less likely to protect themselves. Many
do not perceive themselves as at risk for HIV, do not use condoms, and do not get
tested for HIV.9,10
-Older persons of minority races/ethnicities may face discrimination and stigma that
can lead to later testing, diagnosis, and reluctance to seek services. 11
-Health care professionals may underestimate their older patients risk for HIV/AIDS
and thus may miss opportunities to deliver prevention messages, offer HIV testing, or
make an early diagnosis that could help their patients get early care.6
-Physicians may miss a diagnosis of AIDS because some symptoms can mimic those
of normal ageing, for example, fatigue, weight loss, and mental confusion. Early
diagnosis, which typically leads to the prescription of HAART and to other medical
and social services, can improve persons chances of living a longer and healthier life.
-The stigma of HIV/AIDS may be more severe among older persons, leading them to
hide their diagnosis from family and friends. Failure to disclose HIV infection may
limit or preclude potential emotional and practical support.
OPPORTUNISTIC INFECTIONS
PCP The most common life-threatening opportunistic infection in HIV-infected
patients is Pneumocystis carinii pneumonia [PCP].
TB Among HIV-negative patients, exposure to Mycobacterium tuberculosis [TB]
rarely [<1% of cases] causes acute primary illness.
MAC Mycobacterium avium complex [MAC] occurs in 25% of HIV-infected
patients.
HERPES ZOSTER Among homosexual men, those who are HIV- positive develop
poster 15 times more frequently than in age matched HIV- negative controls. Thus,
elderly HIV- positive patients should be expected to have a high occurrence of zoster.
CMV Cytomegalovirus [CMV] is the most common life-threatening opportunistic
viral infection that occurs in HIV-infected patients.
IS IT ALZHEIMER’S OR AIDS?
Neurologic dysfunction occurs in approximately 60% of patients with AIDS, and may
be the initial manifestation of HIV infection. The most common neurologic problem
is diffuse sub acute encephalitis that causes a progressive dementia. This AIDS
dementia complex should be included in the differential diagnosis of older patients
with diffuse cognitive dysfunction.
HIV/AIDS IN AFRICA AND ASIA
The global burden of HIV/AIDS is predominantly in Africa and Asia. In these
countries, older adults are affected by HIV/AIDS mainly because they care for their
HIV-infected adult children and for AIDS orphans and experience emotional and
financial costs when an adult child dies.
CONCLUSION
HIV infection is increasingly affecting the older population. Knowledge of the
common manifestations of HIV infection and the management of HIV-infected
patients is essential for physicians caring for these patients. HIV infection and AIDS
should routinely be included in the differential diagnosis of ill elderly patients.
REFERENCES
1.Mills EJ, Rammohan A., Awofeso N. Ageing faster with AIDS in Afrca. Lancet
2011Apr2; 377[9772]:1131-3
2.Negin J, Cumming RG. HIV infection in older adults in sub- Saharan Africa:
extrapolating prevalence from existing data. Bull
World Health Organ. 2010;88:847–53.
3. Boon H., Ruiter RAC., James S., Van Den Borne B., Williams E., Reddy P.The
impact of a community-based pilot health education intervention for older people as
caregivers of orphaned and sick children as a result of HIV and AIDS in South Africa.
J.Cross Cult Gerontol. 2009;24 :373-89
4.Rita B. Effros,1 Courtney V. Fletcher,2 Kelly Gebo, et al.Workshop on HIV
Infection and Aging; What is known and Future Research Drections, Clinical
Infectious Diseases 2008 ;47[4]: 542-53
5. Oursler KK, Sorkin JD, Smith BA, et al. “Reduced Aerobic Capacity and Physical
Functioning in Older HIV-Infected Men,” AIDS Research and Human Retroviruses
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6. Lindau ST, Schumm LP, Laumann EO, Levinson W, O'Muircheartaigh CA, Waite
LJ. A study of sexuality and health among older adults in the United States. N Engl J
Med. 2007 Aug 23;357(8):762-74.
7. Center for AIDS Prevention Studies. What are HIV prevention needs of adults over
50 [fact sheet 29E]. University of California, San Francisco. (September 1997) 15
March 2009, date last accessed
8. Linsk NL. HIV among older adults. AIDS Reader 2000;10(7):430-40.
9. Lindau ST, Leitsch SA, Lundberg KL, Jerome J. Older women's attitudes,
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