Please find an article ,a personal message and an institutional communication (from NIH,USA) on the gradually increasing burden of HIV amongst the older people.
The unexplored story of HIV and ageing
As people in developing and industrialized countries increasingly live longer, healthier lives, why do the scant data that exist suggest a surprisingly high prevalence and incidence of HIV among individuals 50 years of age and over (“older individuals”)?
Older individuals are rarely included in Demographic Health Surveys (DHS). In the last 5 years, only 13 of 30 surveys included older males and none included older females. The National Health and Nutrition Examination Survey in the United States of America (USA) does not collect data from people older than 49. There is a dearth of prevalence data; what about incidence?
Incidence could be determined via case reporting, serologic incidence assays or modelling. Developing countries have limited case-reporting systems, but industrialized countries do better. In the USA, case reporting from 2003 to 2006 shows the proportion of older HIV-positive individuals has climbed from 20% to 25% and numbers of cases have risen in all 5-year age bands from 45 years to 65 years and older;1using serology, 11% of 2006 incident cases are in older individuals.2 In WHO’s European Region, 8% of reported cases in 2005 are older.3 Similar data from the developing world are unavailable, and modelled incidence data are not publicly available.
We have calculated prevalence by age, using UNAIDS’ estimated numbers of cases of HIV and United Nations population estimates, by country. One finds a consistent pattern that prevalence in older individuals is one-quarter to one-third that of the 15–49-year age group. We have debated with our colleagues whether these findings are surprising. Most of us think “yes”.
This is particularly so because prevalences for this age group are deceptively low. There is little appreciation that the older the individual, the faster the progression from HIV infection to AIDS.1,4,5 The effect is considerable, linear and remains after adjusting for all-cause mortality.4,5 For example, there is a life expectancy of more than 13 years in people infected at age 5–14. This declines to 4 years in those infected at age 65 or older.5 Waning immunity with age may be the reason. Since incidence is indirectly related to duration of disease, prevalence in those aged 50 and above should be approximately doubled to be compared with those in the 15-24 year age group. While long-available antiretroviral therapy (ART) could increase prevalence among older individuals in industrialized countries, this is not true of the developing world, where ART was introduced later.
Is the epidemiology of HIV in older individuals of purely academic interest? No, because understanding risk factors leads to interventions. Intriguingly, the Alpha Network in Africa has shown that in many sites, secondary peaks of HIV incidence appear at older ages.6 Why might older individuals be becoming infected? We can only conjecture. In a systematic literature search, we found only one, limited, epidemiological study exploring HIV acquisition in older individuals, from urban USA.
Sexual activity of older individuals in the developing world is barely researched. Many older individuals everywhere are sexually active, although interest in sex and frequency of vaginal intercourse decline with age.7 Since 1998, erectile-dysfunction drugs have been extending the sex life of many older individuals and, at the same time, may be extending the HIV epidemic into older age groups. Many studies show that older individuals are less likely than their younger counterparts to practise safer sex. While erectile dysfunction is common and erectile-dysfunction drugs are widely distributed in developing countries,8 no study has been done of their possible impact on the HIV epidemic, although their use in industrialized countries has been associated with risky sexual practices.9 Whether HIV-positive men should be prescribed these drugs has been debated.10
If sex is the main cause of HIV infection in older individuals and many older individuals are not having penetrative intercourse, then the risk of acquiring HIV per sexual act in these individuals must be high. We can only speculate what the reasons may be. The thinning of vaginal mucosa with age may play a role; for both sexes, the prevalence of antibodies against herpes simplex virus 2 increases with age,11 indicating continual risky sexual behaviour and enhanced risk of HIV transmission.
While sexual activity is the most likely mode of transmission, research is required to establish the relative contribution of different risk factors and modes of transmission.
One consistent finding is the failure to consider HIV as a cause of illness in older individuals. These individuals have a shorter time from diagnosis to onset of AIDS,1 reflecting both age-related faster progression to AIDS and doctors’ failure to consider HIV as a diagnosis. Screening is less common for older adults, who are assumed not to be at risk.
HIV prevalence and incidence in the over-50-year-olds seem surprisingly high and the risk factors are totally unexplored. Understanding the epidemiology of HIV infection in older individuals can lead to interventions to make these years safer and more enjoyable.
Dear Dr. Rajesh Gopal,
I am the Principal Investigator on a study of older adults and HIV and we have done quite a bit of work in this area. I must say that in our population of older low income adults, risk behavior was low, and the infection rate was less than the national rate for older adults.
There are, in the U.S. several specific pockets of older adults at risk for HIV. They include:
a. middle class older men and women living in retirement communities or clusters who are unmarried or unattached and "dating", or having experimental sex. There has been the occasional worrisome note about this group but generally they use condoms.
b. injection drug users who became infected through their drug use and are aging with HIV
c. gay men who are also aging with HIV
Both groups could also become infected later in life if they continue their sexual and drug related activities without protection. So you might see these groups in India, especially in Mumbai and Chennai and northeast for injectors, and in club circles that cater to all ages gay men and their friends in the big cities.
d. older men who have less income and/or who see commercial sex workers. The women tend to use condoms, and the men tend to avoid penetrative sex, but the women have other partners and sex with them is risky. The men, on the whole, do not have other partners.
Older adults can become infected more easily. They are understudied because they are a small part of the larger HIV picture, and because they tend not to infect others at the same rate. Also with respect to sex, there is the view that older adults are less sexually active. This may be true for some, but not for others.
So, In India it would be useful to find the pockets of older adults that might be getting infected late, or living and aging with HIV. I work in Mumbai and there are NGOs that work with drug users who both inject and chase heroin. Dr. Kumar works in Chennai and of course there are many others in Chennai working on HIV related issues.
Jean J. Schensul, Ph.D.
Senior Scientist & Founding Director
Institute for Community Research
NATIONAL HIV/AIDS AND AGING AWARENESS DAY
SEPTEMBER 18, 2009
HIV/AIDS began its deadly course in the United States mostly as a disease of young men, but today the epidemic touches people of all ages, including adults aged 50 and older. On September 18, the first National HIV/AIDS and Aging Awareness Day, we pause to recognize the importance of preventing HIV infection in this age group and understanding and addressing the unique health effects of the virus on older Americans.
Thanks to the advent of potent, multi-drug therapy against HIV in the mid-1990s, many HIV-infected Americans are living into their 50s and well beyond. Also, while the majority of new HIV infections are in younger Americans, individuals 50 years of age and older accounted for approximately 10 percent of all new HIV infections in the United States in 2006. As a consequence of these trends, approximately one quarter of HIV-infected adults in the United States in 2007 were at least 50 years old.
Older adults with long-term or new HIV infection experience complex interactions among HIV, antiretroviral therapy, age-related changes to the body, and, often, treatment for illnesses associated with aging. These interactions affect the health care needs and quality of life of older adults. It is imperative that we in the research community decipher the medical implications of aging with HIV and continue developing more sophisticated treatment approaches so these older adults can live longer, healthier lives.
It also is critical to prevent new HIV infections in older Americans by educating them about the importance of routine HIV testing and early diagnosis; how the virus is transmitted; behaviors that place them at risk for acquiring or transmitting the virus; and strategies, such as condom use and needle exchange, that can reduce their risk. Since early diagnosis of HIV is key to optimal treatment, the Centers for Disease Control and Prevention recommends routine HIV testing for all adults up to age 64. CDC also recommends HIV testing at least annually for adults aged 64 and over who have risk factors for HIV infection, such as injection drug use.
The U.S. Department of Health and Human Services this month proposed that Medicare cover HIV screening tests for beneficiaries at increased risk for acquiring the virus, including women who are pregnant, and Medicare beneficiaries of any age who voluntarily request the service. Medicare provides health insurance coverage to people who are aged 65 and over or who meet other special criteria.
Aging is an important and expanding focus of HIV/AIDS research at the National Institutes of Health and the NIH-sponsored Centers for AIDS Research. The National Institute of Allergy and Infectious Diseases (NIAID), part of NIH, funds a range of studies to understand the biology of HIV infection in older adults with the goal of improving their medical care. Scientists are studying the interaction between HIV and aging in areas as diverse as diseases of the liver, kidney, brain, heart and lung; cancer; bone density; physical activity; mental health; balance; hearing; response to antiretroviral therapy; immune function; and adherence to medical care.
For example, researchers with the Multicenter AIDS Cohort Study have shown that HIV infection accelerates the development of frailty, a condition of the elderly that makes people more vulnerable to illness, injury and death. Scientists now want to determine which HIV-infected individuals are at highest risk for developing HIV-associated frailty with the hope of identifying factors to mitigate or prevent its development. NIAID and the National Institute on Aging (NIA), also part of NIH, are planning a workshop for late 2009 to identify current knowledge and research gaps in the areas of HIV and frailty, bone health, muscle health and vitamin D production.
Still, many gaps remain in scientific knowledge about the effects of HIV and antiretroviral therapy on aging. To that end, NIAID, NIA, the National Institute of Mental Health and the National Institute of Nursing Research, all part of NIH, are soliciting research proposals to explain and prevent a spectrum of biomedical problems faced by older adults with HIV infection. More information about these funding opportunities is available at , , and .
When AIDS and then its cause-HIV-were recognized in the early 1980s, no one imagined that individuals with HIV infection would eventually survive for decades. Now, with a quarter of the HIV-infected U.S. population age 50 years and older, the biomedical and public health communities face new challenges at the intersection of HIV and aging. In the absence of a cure for HIV, this first annual National HIV/AIDS and Aging Awareness Day marks an opportunity to rededicate ourselves to research aimed at preventing HIV infection in older adults and improving the health and quality of life of those who are infected.