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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 22, no. 11 (2006): 1113-21. 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, behavior, and communication about sex and HIV: a community-based study. J Womens Health (Larchmt) 2006;15:747-53. 10. 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