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Aging GRACIE-fully

Facing the Challenges of Growing Older With HIV as a Community

January/February 2015

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Aging GRACIE-fully

They say it takes a village to raise a child. I would also say: It takes a village to support an elder.

I made this remark at a lecture on HIV and aging that I gave in New Orleans last year, sponsored by Merck, in conjunction with the United States Conference on AIDS. The audience consisted of about a hundred AIDS care professionals, mostly physicians, nurse practitioners, and pharmacists, in addition to case managers and patient educators.

I have to confess that I somewhat dread lectures on HIV and aging -- both hearing them and giving them. In the past few years, those of us working in HIV care and research and our patients have spent increasing amounts of time talking about this subject. Every time you turn around, it seems, there's another lecture or webinar about it, almost to the point I feel we hardly talk about anything else anymore.

On one hand, it's a definite privilege that we get to worry about aging with HIV, given where we were even 15 years ago. That doesn't allay our simultaneous concerns, however, about the special challenges we'll confront as adults living with HIV enter their "golden years." Maintaining the health and good function of aging adults -- all adults -- is a topic of active study, and we've barely begun to understand it. That goes double for the special case of adults also burdened with chronic HIV infection.


Working Together

Those of us working as health care providers of adults already can see over the horizon the "grey tsunami" approaching, as the Baby Boomer generation gets within a hand's reach of age 70 and beyond. We worry about the declining ability of our patients to care for themselves, and we worry about our ability to anticipate problems for these patients well enough to prevent medical catastrophe.

I would say, however, that as a former ACT UP'er who later became an AIDS researcher and HIV physician, my experience when facing seemingly overwhelming or unsolvable problems is that what seems impossible when faced alone becomes possible when faced with a community at your back. Much of what the AIDS community has accomplished in our 30-plus year history seems in hindsight quite remarkable. Activists dispatched problems of medicine, science, and policy again and again, working together. I remain optimistic that this same approach will pay off in meeting the latest set of challenges of aging HIV-positive adults, and this is the message I have strived to bring to audiences when I speak on the topic.

The generalities of the issue of HIV and aging came into sharp personal focus for me in the past five years, as I now live in the retirement community of the Coachella Valley, in Southern California. I work in a large medical group practice in Palm Springs, and my particular office caters mainly to the aging LGBT patient population, many of whom are also living with HIV.

I came to the valley almost five years ago to take a job helping create a new internal medicine residency at Eisenhower Medical Center. Eisenhower is one of the two largest hospitals in the region and the first to have any kind of academic medicine program. That, too, has brought with it its own set of challenges. But it did not take long for me to realize the special opportunities such a place offers to medical researchers interested in the problems of "successful aging" -- again, both in the general adult population and in those living with HIV.

In the article below, I will outline the nature of the problem posed by aging successfully with HIV, and then talk about how I and my research collaborators here in the Coachella Valley are taking advantage of the increasing numbers of HIV-positive adults living in the area to launch a project aimed at gaining insight into their special needs. Our hope, of course, is that the lessons we learn will assist service agencies and policy makers worldwide in better addressing the needs of our patient community.

HIV and Aging: The Scope of the Problem

"I have to deal with the reality."

-- Project GRACIE focus group participant

In the developed world, the face of HIV infection is growing older. Most of us have heard the statistic that by 2015, 50% of all HIV-positive adults in the U.S. will be over the age of 50. Going along with this trend, HIV patients today are not only living with HIV, but with the "diseases of aging." As people with HIV enter their 60s, more than half of them will demonstrate hypertension and high cholesterol. Nearly 20% will have documented coronary artery disease, the condition that gives rise to heart attacks; over 25% will have kidney disease and a similar number will have confirmed diabetes.

There are some special issues with HIV-positive adults dealing with other chronic medical conditions. For one, compared to their HIV-negative peers, adults living with HIV seem to be more likely to be dealing with more than one chronic medical condition at a time. In one study in veterans, for example, people living with HIV who were 50 years of age or older were much more likely to have multiple other chronic illnesses compared with their age-matched HIV-negative peers. For adults with HIV age 60 or older, the vast majority -- 70% -- had at least one other chronic medical problem. Coronary artery disease, at least until people reach their 70s, seems to be roughly three times more prevalent in HIV-positive adults compared to HIV-negative people of the same age, even when corrected for the presence of other risk factors such as smoking or obesity.

Besides the high rate of kidney disease previously mentioned, patients also have a high rate of liver disease -- often due to co-infection with hepatitis B or hepatitis C. Rates of bone density loss -- osteopenia and osteoporosis -- are much higher in HIV-positive adults when compared to HIV negative adults, and unsurprisingly, the rate of bone fractures is 50% higher.

Perhaps most worrisome to my audiences of HIV-positive adults is the higher rate of memory impairment and development of early dementia we are seeing. Even HIV-positive adults with no other HIV-related symptoms will more commonly experience a decline in brain function. One study found that the rate is nearly twice as high, with at least mild cognitive impairment -- problems with thinking or memory -- being found in 36% of HIV-positive adults, compared with 16% in HIV-negative people of the same age.

The neurocognitive issues of HIV-infected adults is a special research interest of our collaborators from UC San Diego, Drs. Ronald Ellis and David Moore, and we have been assisting them in reaching more elderly HIV-positive adults living in the valley for their important work in this area.

Not only do people with HIV contend with more medical problems compared to their HIV-negative peers, they also seem to have a rougher time with the conditions they do have. One of the most striking studies speaking to this was conducted by Kris Ann Oursler, a gerontologist at the University of Maryland with an interest in HIV-positive adults. Her project, analyzing health outcomes in veterans, found that patients' function in daily activities, as assessed by patients themselves, declined three times faster in HIV-positive adults compared to their HIV-negative peers living with the same conditions.

For example, for a person who had chronic obstructive lung disease (COPD, sometimes known to laypersons as "smoker's lungs"), his or her ability to manage daily tasks affected by that condition, such as limited walking due to shortness of breath, got worse over time at a faster rate if the person also had HIV infection.

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This article was provided by Test Positive Aware Network. It is a part of the publication Positively Aware. Visit TPAN's website to find out more about their activities, publications and services.

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