HIV Among Older Adults: Age-Specific Issues in Prevention and Treatment

Nathan L. Linsk, PhD

Disclosures

AIDS Read. 2000;10(7) 

In This Article

HIV Incidence in Later Life

CDC data have consistently reported that substantial numbers of older adults are being infected. Current data show that on average, 10% of AIDS cases nationally occur in individuals older than 50 (Table 1). In communities with larger populations of older adults (eg, Broward County, north of Miami, and suburban Cook County, outside of Chicago), this number increases to as high as 15% of AIDS cases. Current HIV prevention priorities quite correctly focus on younger adults and adolescents; however, compared with middle-aged and older adults, a very low percentage of persons reported to have HIV/AIDS are younger than 20 -- about 1% nationally for males and about 7% for females.

How many people with HIV/ AIDS are in their later years? McCormick and Wood[10] assert that in the next decade, 10% of persons with HIV/AIDS will be in their sixth decade or older. Early years of the epidemic were marked by very little separation of data for persons in the later years, but by the late 1980s it was clear that about 10% of persons with AIDS were older than 50. Age 50 is relevant to older adults for a number of reasons. The age breakdown of persons with HIV/AIDS over 50 is presented in Table 2. It is notable that women with HIV infection tend to be older than men in this age category, with more than one quarter over age 65. The difference between men and women is related to the large numbers of younger men who have been exposed through drug use/needle sharing or through risky sexual behaviors with other men. Among men over 50, a quar- ter are over age 60, representing substantial numbers of older per- sons with HIV infection. It appears that at least 3% of the total number of persons with AIDS have consistently been over age 60 during the last several years.[8]

Almost all information about HIV and older adults has been based on data specifically about AIDS cases, which suggest advanced infection. The number of older adults who are living with HIV infection is difficult to ascertain. In 1989, Stall and colleagues[11] estimated that there were 125,000 persons infected with HIV over age 50. Ory and Mack[12] estimated the number of people living with AIDS by subtracting those cases with a documented cause of death from the estimated cumulative number of people with AIDS and found that at the end of 1996, there were 33,601 documented deaths due to AIDS in persons over age 50. If we apply a 5% estimate of AIDS cases in individuals over age 60 to the conservative CDC estimate of 800,000 to 1 million people living with HIV infection in this country, it is possible that as many as 60,000 people over age 60 are now living with HIV infection. The current number represents about 1 to 1.5 older adults for every 1000 in the United States over age 60 (based on 42,000,000 persons over age 60).[13]

Table 3 presents CDC data on the transmission sources of HIV for persons over age 50 and how these have changed in the past 15 years. HIV/ AIDS cases in persons over age 50 originally occurred predominantly in men who have sex with men; however, these differences have flattened over time. The percentage of gay/bisexual men over 50 reporting gay/bisexual contact or both gay/ bisexual contact and injection drug use exposure is 55%. A significant number of the 12% who report no identified risk behavior may also be men who have had sex with men. This sug-gests that perhaps as many as two thirds of the cases in men over age 50 are in men who have had sex with other men, whether or not they identified themselves as "gay." In larger US cities, the percentage of older people with HIV infection who are gay men is lower than the pecent- age of those who are injection drug users, but the number of older people infected continues to grow.[14] In fact, gay men in general, and certainly those over age 50, represent a disproportionately affected population.

The CDC data on injection drug users are notable. Initially, few or no older drug users were reported. By 1988, the percentage of persons over age 50 who reported infection through drugs had increased to 8%, rising to more than 11% by 1991 and to 17% from 1996 to the present. What is remarkable about these data is the challenge to conventional gerontologic wisdom that the elderly seldom use nonprescription recreational drugs. On the contrary, injection drug use appears to be an increasing risk behavior in older persons, a fact that has consequences for HIV prevention education. Similar to the increase in injection drug use is the increasing percentage of heterosexual transmission-related risks reported in older adults, from 6% in 1992 to 13% by the end of 1997. This increase parallels trends in other adult age groups.

To date, an older adult's transfusion history is the most distinctive transmission source for this age group. By the end of 1997, 46% of the cumulative transfusion-related cases were in individuals over age 50; 21% of these were over age 65. Table 3 reveals that the percentage of persons over age 50 who reported transfusion as the risk related to infection was 17% of all reported HIV/AIDS cases in 1988, declining to 11% by 1991 and to about 6% since 1996. This 6% compares with fewer than 1% of all adults who cite transfusion as a risk. Of persons over age 70 with HIV/AIDS, 64% received transfusions, with the oldest in this sample being age 90.[15] Why this disparity? After blood supply screening began in 1985, we would expect very few infections by blood transfusions. However, a large proportion of transfusions of HIV-infected blood in the mid-1970s to mid-1980s were given to persons who were then or are now in the later years of life. During the years when the blood supply was not being tested, 70% of all red cell transfusions were given to persons over age 49.[16] Although some elders may be aware of transfusions received during illness or surgery, many may have received transfusions unknowingly, because hospitals and insurers are not obligated to report transfusions to patients. The result is that any elderly person who had surgery during the 1970s or early to mid-1980s may have been transfused with infected blood.

One other risk category deserves attention, particularly in terms of risk assessment and collection of medical histories. A substantial number of persons over age 50 who have AIDS do not identify any of the risk categories as a source of transmission. Table 3 shows 14% of cases in people over age 50 in the "other/undetermined" category. Some of these cases may reflect older adults who have monogamous sexual partnerships with persons they believe are not at risk. As noted above, others may be reluctant to report they have engaged in stigmatized risk behaviors. Some may have engaged in risky behavior while intoxicated and may not recall or acknowledge their behavior. Some may not be aware of their transfusion history. Given the substantial numbers in the "other/ undetermined" category, sensitive risk assessment is imperative.

A different source of similar data is a study by Gordon and Thompson[17] of patients whose HIV infection was diagnosed between 1985 and 1992 at Grady Memorial Hospital in Atlanta. These investigators conducted chart reviews of individuals with positive HIV antibody tests and identified 32 patients older than 60 with HIV infection (0.5% of 6493 charts reviewed). The mean age was 65 years, 16% were female, and 81% were black. Risk factors for men included homosexuality (37%), undetermined (22%), injection drug use (16%), contaminated blood products (11%), heterosexual sex (7%), and unknown (7%).

Overall, the risk of HIV infection is significant for older adults. The major source of risk has been male-to-male sex; however, heterosexuality-related risk and injection drug-related needle sharing are increasing. Transfusion-related risk is somewhat higher for older adults compared with younger adults. The alarming incidence of untreated HIV infection in older adults relates to stigma, marginalization, inadequate information directed to this age group, and possible association with substance abuse.

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