World AIDS Day 2014 is here and there is an end to AIDS on the horizon. It's a functional end, not a cure, but to have the potential to reduce the number of new transmissions to near zero by 2020 across a nation is amazing. New York State, under Governor Andrew Cuomo's Plan to End AIDS by 2020, seeks to reduce new infections to below 750 per year from 3,316 in 2012.
Exciting and possible.
But, wake up.
Even without a cure HIV medications are helping people with HIV/AIDS live close to normal life spans. A generation of long-term survivors is waking up and finding themselves still alive and still productive. Now the rest of us need to wake up as well.
By 2015, less than one month from now, 50 percent of the US population infected with HIV will be age 50 and older. By 2020 that number will reach 70 percent.
Here's what the greying epidemic means.
One in six new HIV diagnoses occurs in someone age 50 and older. People 50 and over have sex. You may not want to talk about the sex lives of older adults or recognize that they exist, but it's time to deal with it. Human sexual development is a lifelong process, and though it may ebb and flow in intensity, it does not end. Older adults have the same risk factors as younger adults, from inconsistent condom use to multiple partners to the sharing of injection drug equipment. If you don't talk to them about risk behaviors they won't get needed prevention information.
Adults 50 and older have the largest number of AIDS diagnoses and concurrent diagnoses of HIV and AIDS. This means they're not getting tested until way too late. Health care providers and older adults must understand that age is not a condom, age is not clean injection equipment and age is not PrEP.
HIV care for older adults is complex. These older adults are developing multiple chronic illnesses 10-20 years earlier than would be expected. These include heart disease, cancers, diabetes, hypertension, kidney and liver disorders, osteoporosis and frailty. The key word here is multi-morbidity. Single disease focused treatment does not work; Integrated health care teams and an informed and empowered client does. With multi-morbidity comes the issue of polypharmacy (the use of multiple medications). With polypharmacy there are increases in adverse drug effects and dangerous drug interactions. These dangers increase when over-the-counter drugs are included. Adherence to medications becomes more and more difficult as the number of pills increase. In addition, the complicated aging process for many older adults with HIV requires clinical guidelines be tailored to meet these challenges. ACRIA's research team has been defining the clinical and social challenges of older adults with HIV for the last decade, but it's just a start
Our agency's research has brought into focus the need to address psychosocial issues. Older adults with HIV exhibit depression at five times the rate typically seen in the larger community. Depression is the most accurate predictor of non-adherence to HIV medications, in fact, to all medications. All programs should be screening for depression. The use of a simple screening tool like the PHQ-9 should be routine. Those high rates of depression are reinforced by circumstances. Upwards of 70 percent live alone with less than 20 percent having a spouse or partner. Most often older adults are devoid of family, exhibiting fragile social networks comprised mostly of friends many of whom also have HIV. Depression can be moderated by the support of social networks. But these older adults are more often socially isolated due to the impact of persistent AIDS based stigma. Research into interventions that help older adults develop more lasting social networks needs to be occurring now.
How many times in the history of the AIDS pandemic have we not seen what was right in front of us? If we wait until 2020 to see that the vast majority of people living with HIV are indeed 50 and older we will simply be too late.