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HIV/AIDS and the Aging Population: What's Going On?

September 19, 2012

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Kellee Terrell: James, that's a perfect segue into what we're about to talk about next. There are so many other issues that people living with HIV who are getting older have to deal with: Is it age, or AIDS or both? What are the some of the other health issues that older people living with HIV/AIDS have to grapple? Sean?

Sean Cahill: We did a survey at Gay Men's Health Crisis with about 200 older clients, 50 and above; and we found that most of them had an AIDS diagnosis. And they had, on average, three-and-a-half comorbid conditions. The most common conditions were depression, hepatitis C and hypertension. We also noted a very high rate of liver-related mortality among older people living with HIV.

So we're really just beginning to understand the sort of long-term effects of antiretroviral use and long-term effects of living with HIV on the body. But we have some preliminary sense that there are a lot of complications that come with aging, into old age, with HIV.

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Frances Meléndez: Right. A lot of complications that may also be exacerbating the normal aging process, but may be exacerbated with the long-term use of the medications.

James Masten: And when people don't know what is causing: Is this HIV? Is this normal aging? Is this something I need to be concerned about that's a side effect of the medication that I've been taking?

Not knowing the cause directly affects how you address it. And a lot of people are very confused about what to do when a new symptom erupts.

Frances Meléndez: On the heels of that, there are a lot of wonderful doctors out there working with our clients. But there are also doctors that, who feel that,as long as the patient is responding to medication -- their viral load is undetectable, their CD4 is good, but their quality of life is not good -- that that's OK. They tend to have an attitude of "If it ain't broke, don't fix it."

In the meantime their patients are having increased physical symptoms, lipodystrophy: these types of issues that are not addressed. And also, patients do not feel that they can advocate on their own behalf. So this is the other issue with the aging population. It's quality of life versus just having a great viral load So they shut down when they do say something.

Kellee Terrell: I see this happen a lot regardless of age and even among some HIV advocates who only see HIV as the primary issue. There seems to be an inability to regard people in the community as holistic beings.

James Masten: I'm going to make a really important point about advocacy. And we look at depression, and the high rate of depression in this community. We're asking people to advocate for themselves at a point when they're ...

Frances Meléndez: When they can't.

James Masten: Exactly. They're feeling depressed and unempowered. And they have so few supports available.

I sometimes feel like we are in many ways, this period of time is like the early days of the epidemic, where there were a lot of mixed messages. It was very hard to hold on to everything that there was to be known about the virus, when there was new information coming out all the time, and some of the new information contradicted what it is that we thought we knew. And patients needed to be on top of things. They needed to get as much information as they could. They needed to listen to their bodies and advocate for themselves. And in many ways they needed to: on some level, they needed to partner with their doctor; and in some ways, they needed to educate their doctors. Because they were as much experts as the doctors were.

And I think we're going back to that because no one knows what it means to age with HIV. You know, we're just beginning to understand the medical complexities.

Sean Cahill: The New York Times had a piece, a month ago on cardiac issues among old people living with HIV, particularly long-term survivors. And they got into this issue of how a lot of doctors are up to speed on the latest research. And so there was a doctor who said, "You know, a decade ago, I didn't realize that this was an issue. And now I realize it was."

So sometimes the patients really do have to be advocates and have to bring in, you know, something and show their doctor; and say, "Hey, I need an EKG," or, "I need to have some kind of a monitoring of my heart health. Because I'm learning that long-term survivors of HIV are at higher rates of heart attack, and other kinds of cardiac issues."

And there's also things that people can do to lower their risk. We know that there's higher rates of smoking among people living with HIV, in this country, at least. And that's, a behavior that you can try to stop. And it can dramatically reduce your risk of heart problems.

Frances Meléndez: Well, also, obesity, which complicates all the other medical issues.

Sean Cahill: Yeah, there was an article in Current HIV/AIDS Reports in 2008. And it was about HIV and aging. But it talks about the association of HIV infection and antiretroviral therapy with obesity. So it's definitely an emerging issue that, 20 years ago, we didn't see. You know? Because people had trouble keeping weight on before the antiretrovirals came along. But this is definitely an issue that we're seeing.

Kellee Terrell: And what about mental health? James briefly mentioned that -- I want to revisit that. Is there enough focus or effort from clinicians to really be screening for depression when we're looking at older people? Frances?

Frances Meléndez: Speaking on my own work as a psychologist; I'm always looking for depression. But I think when you look at funding, that's looking for outcomes. A lot of it is outcome-driven; it's numbers-driven. So a quick screening that often is not enough; and it's a quick fix. Depression is complicated. It's on a spectrum.

Many places don't want to pay to have a psychologist. Like I said before: Funding dictates what a lot of organizations, community-based organizations, can do. So I think some of them provide screening, which is great; and then do a referral to place to refer their clients to for services.

And I think they're beginning to realize that you can't treat the body without treating the mind.

Kellee Terrell: And what are some of the dangers around depression, and seniors living with HIV, in terms of their own health , especially when it's not treated?

Sean Cahill: I think one of the biggest dangers is people not being treatment adherent. Depression, isolation and living alone, can sometimes correlate with people going off their treatment. That can be connected to substance use too, which can affect treatment adherence.

One of the great things about the Affordable Care Act is that one of the essential health benefits that will be provided to people was no copay, and that's a guaranteed benefit that will be provided in all 50 states, is mental health services.

So we have an opportunity. We have to work at the state level with people designing the health insurance exchanges, and so on. But we can ensure that there are culturally competent and clinically competent mental health services that are using harm reduction models that are clinically competent to provide services to people who are gay, or lesbian, or bisexual, or transgender; and help to address some of these root causes of treatment non-adherence.

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