Signs and Symptoms of HIV in Older Adults

So! what happens when one is infected with HIV?  Is it the same for everyone?  Hmmm . . .

Well, signs and symptoms of HIV in older adults can, in fact, be similar to that of younger adults in the early stages of infection.  However, when we add in common complications that occur with aging as well as a variety of chronic illnesses that can come with age, it’s not always so easy to distinguish between HIV and other problems.  Unfortunately, HIV is usually the last thing that is addressed in older adults or, in many cases, missed completely.

Many people have no symptoms when they first become infected with HIV. It can take as little as a few weeks for minor, flu-like symptoms to show up, or more than 10 years for more serious symptoms to appear. Signs of HIV can include headache, cough, diarrhea, swollen glands, lack of energy, loss of appetite, weight loss, fevers and sweats, repeated yeast infections, skin rashes, pelvic and abdominal cramps, sores in the mouth or on certain parts of the body, and short-term memory loss.  In the table below from Smith et al., you can see the frequency that one might see of the most common signs and symptoms.

Many HIV symptoms in older adults can resemble symptoms associated with a number of other illnesses that are commonly seen in the population.  Most commonly, these include fatigue, flu-like symptoms, respiratory problems, weight loss, chronic pain, night sweats, skin rashes, swollen lymph nodes, and neurological problems.

In addition, as the disease progresses, the effects of HIV may have a much greater impact on the aging adult.  According to Stoff et al. as found on the UNC website listed below, “Compelling evidence exists that natural history and symptom manifestations of HIV infection in the elderly substantially differ from those seen in younger cohorts. Relative to their younger counterparts, older adults living with HIV/AIDS have a more severe HIV disease course and a shorter survival rate; have less desirable health indices at diagnosis (e.g., lower CD4+ cell counts); have shorter AIDS-free intervals; have a higher number of opportunistic infections; and have earlier development of tumors and lesions.”

I think the take home message here is: while it may appear on the surface that everyone's response to HIV infection is the same, there may actually be much more we aren't seeing.  Of course, everyone is different and reacts differently but, with older adults, there can be many other things going on that can steer us away from HIV infection.  All in all:  remember to look outside the box! :D

Fitzpatrick, L. K. (2011). Routine HIV testing in older adults. American Medical Association Journal of Ethics, 13(2), 109-12. Retrieved from http://virtualmentor.ama-assn.org/2011/02/cprl1-1102.html

Smith, D. K., Grohskopf, L. A., Black, R. J., Auerbach, J. D., Veronese, F., Struble, K. A., Cheever, L., & Onorato, I. M. (2005, January 21). Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to hiv in the united states. Retrieved from http://www.thebody.com/content/art17171.html

The citation below is a great resource for medical matters!  They cover issues related to HIV in older adults in a variety of systems and disease states including the immune system, heart and blood vessels, high cholesterol and triglycerides, body weight, diabetes, the senses, the nervous system and mental health, bones, urinary system, liver, kidneys, skin, and cancer.

Ernst, J., Hufnagle, J., Karpiak, S., & Shippy, A. (2008). HIV and older adults. AIDS Community Research Initiative of America (ACRIA). [booklet]. Retrieved from http://www.acria.org/files/hiv-older-adults.pdf

Very cool website from the University of North Carolina.  The learning module walks you through aging and HIV; worth taking the time to work your way through. http://www.med.unc.edu/aging/elderhiv/welcome.htm

Pathophysiology

So!  How does this thing - HIV - work?  Well, this is what it looks like! =)

Unfortunately folks, there is no real easy way to explain HIV so forgive me while I get a little technical for a bit here!

HIV is not the common type of virus most people have heard of, but rather, a lentivirus or a “slow” virus.  Like viruses, which must use the mechanisms of a cell to reproduce, HIV can’t act of its own accord – it too must have a host.  What distinguishes these retroviruses from other viruses is their mode of replication.  They use a combination of RNA and what is called a reverse transcriptase.  This genetic material is encased in a series of proteins that not only protect it, but allow it to dock and gain entry into its victims.

Two strands of RNA lie within what is called a capsid which is made up of about two thousand viral proteins called p24 and protects the delicate material until it is within the host cell and able to insert itself.  Next to these strands are the reverse transcriptases which will eventually allow the creation of a strand of DNA.  Two other proteins make up the interior of the virus: p7, which makes up the nucleocapsid and envelopes the strands of RNA; and p17, which makes up the matrix and borders the lipid membrane.  This viral core, as mentioned, houses this genetic strand, which is made up of nine genes.  Three of the genes – called gag, pol, and env – serve as the creators of the parts which will eventually make up new viruses.  The remaining six perform regulatory actions and are called tat, rev, nef, vif, vpr, and vpu.  These tend to deal with how the virus interacts with other cells and how the virus goes about replicating itself.

Surrounding the outer membrane of the virus is a series of proteins derived from a special protein made by the env gene called gp160.  This protein is broken into binding molecules of glycoproteins called gp120 and gp41.  These are what allow the virus to bind to receptors on the cd4 T-helper cells and eventually fuse with and penetrate the membrane.

So, in essence, what happens when the virus is introduced into the human body is that it is virtually served to its victim on a silver platter.  The most commonly known route of entry for HIV is transfer by sexual interactions whereby the virus enters the system through mucous membranes where it is picked up by macrophages and dendritic cells.  These escorts then proceed to the lymph nodes where they present their invaders to the cd4 T-helper cells allowing for the initial establishment of infection.

Once they have breached the system, they begin their hostile takeover.  The glycoprotein 120 receptors on the surface of the virus bind to specific receptors on the surface of the cd4 cells where they then begin the process of fusing with the cell’s membrane.  This is accomplished with the aid of the glycoprotein 41 unit which pierces the cells membrane allowing the two membranes to become one and introducing the capsid into the cell cytoplasm.  In the process the remaining gp120/gp41 complexes spread out across the surface of the new host cell.

This is where the reverse transcriptase comes into play.  Once inside, the capsid surrounding the viral RNA is dissolved and the p31 transcriptase is used to create an actual piece of DNA with all the complimentary encoding.  This string of DNA then forms a circle and enters the nucleus where it is inserted into the cell’s DNA, with the help of a protein enzyme called integrase, and is now termed a Provirus.  At this point, the virus can lie in wait for several years or it can proceed to duplicate itself with the help of its host.

There are two methods by which this new virus driven cell can take over other cells in its vicinity: budding and syncitium.   Budding can be quite devastating to the host cell.  To bud, the virus must replicate a new set of proteins to form new copies of its self.  This is accomplished with the help of its host using an RNA polymerase to create a messenger RNA, which is then moved out into the cytoplasm where it can be translated by a host ribosome into a variety of proteins.  This is one of the areas of production that cause HIV to be so tricky for researchers to get the best of this virus.  It seems that HIV tends to make a lot of slight errors when it replicates, pumping out hundreds of thousands of different variations of its self.  In other words, even if there isn’t a mix up in the translation there can certainly be a blending when they are put back together.

These proteins are reassembled to form the viral RNA and the capsid.  The outer membrane encompasses the new capsule, which then fuses with the outer membrane of the cell.  The receptor complexes merge with the rest of the membrane of the host and the new viral cell is ready to bud off and find a new host cell to take over.

The other method, by which the virus can usurp a neighboring cell, is by a process called syncitium.  In this case the infected cell literally absorbs what it comes in contact with.  When the viral host cell comes in contact with the new cell, their membranes fuse becoming one big cell.  All in all, this invader will overwhelm and virtually consume the entire immune system.

The pictures up above here are from the virtual patient reference library at the Carl J. Shapiro Institute of Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center.  The information gathered here came from my days in the BSN program; specifically from Pathophysiology: The biologic basis for disease in adults and children, 5th ed. by McCance and Huether.  Also from a particularly enlightening lecture in my Care in Illness class from a graduate student and now an HIV ARNP clinician name Karen Dykes.

Epidemiology

So how does HIV effect older populations?  Who does it effect and where? Let's start with a quick definition; if you are anything like me, you want a good idea of what we need to look at. 

According to dictionary.com:

ep·i·de·mi·ol·o·gy [ep-i-dee-mee-ol-uh-jee, -dem-ee-]  noun

The branch of medicine dealing with the incidence and prevalence of disease in large populations and with detection of the source and cause.

Medline's definition is similar:

1: a branch of medical science that deals with the incidence, distribution, and control of disease in a population
2: the sum of the factors controlling the presence or absence of a disease or pathogen


What about incidence and prevalence?  Medline tells us that incidence is the rate of occurrence of new cases of a particular disease in a population being studied while prevelance is the percentage of a population that is affected with a particular disease at a given time.  WHAT . . . . ?!?

Let's break that down!  How many adults over 55 years old in the United States were newly infected with HIV in 2010 - this is your incidence.  What is the total number of adults over 55 years old in the United States who have HIV in the year 2010 (this includes new infections and people who were already infected) - this is you prevelance.

Alright!  This gives us a good start!

Unfortunately, until very recently, finding these numbers was not such an easy task.  As it is, they are still not readily available outside the United States.  Many organizations from around the world, such as the CDC, WHO, and UNAIDS who usually tally these numbers for us, have not considered adults over 55 to be a population at risk for HIV so they have not included them in their gathering of data.


A few things have happened over the past couple of decades that have changed things and made older adults a population of interest for HIV.  First, scientists developed a special drug therapy called Antiretroviral Treatment.  I'm not going to go into detail about the therapy itself but for those of you who are interested, this link is a good place to start: http://www.who.int/topics/antiretroviral_therapy/en/
Anyway, what this therapy has done is allow people who are infected with HIV to live longer.  To put it simply, this infection, which was originally a certain death sentence is now a chronic disease kind of like diabetes or hypertension.  So now, all of a sudden, all these people who have been infected with HIV are no longer dying at an early age but are living well into old age.  Second, scientists stumbled across a special kind of drug they were developing to help patients with hypertension and angina pectoris (chest pain) called Sildenafil or, as you may be more likely to have heard it called, Viagra - the little blue pill.  As I am sure you are aware, this has allowed men and women of all ages to enjoy the pleasures of intimacy.  In our situation here, that means there are many more men and women having sex well into old age.  Unfortunately, this also means that these older adults are at risk for HIV infection much later in life as well.

SO . . . as you can see in some of the graphs here (I know they aren't the best of clarity but there will be a list of references and websites at the end of this post that will take you to several more statistics and relevant data), the United States certainly has become aware of the rising problem of HIV in older adults.  From 2001 to 2007, the percentage of older adults who make up the total prevalence of HIV in the United States has increased 61%, going from 17% of the HIV-positive population to about 27%.  They also account for 16% of all new cases or incidence in the United States.

I would also point out here that - very similar to that of younger populations - gay men, Hispanic and African American men, and African American women are disproportionately affected by HIV in this age group.  African-Americans are 12 times as likely as their white peers to have HIV and Latinos are five times as likely.  African American women over the age make up 65% of all cases of HIV among women in this age group and incidence among them has increased by 40%.  Gay men make up nearly 48% of all HIV cases!

One final point I would like to mention here is that, among older adults, most new cases of HIV are transmitted through sexual contact as opposed to IV drug use.  As for sexual contact, the most common mode of transmission is through men who have sex with men though heterosexual contact is a persistant source of infection.  Interestinly, as you can see in the graphs that show risk categories in New York City, the perecentage of unknown transmission is particularly high among men.

These diagrams and the above information came mostly from a brochure called Growing Older with the Epidemic: HIV and aging from the Gay Men's Health Crisis and from an article in the Journal of the American Academy of Physician Assistants by Jeffery Myers called Growing Old with HIV: The AIDS Epidemic and an Aging Population.  There will plenty of other sources that you can check out at the end of this though!



Now, so far we have been focusing specifically on the United States.  There are many who would say that this rising problem of HIV among older adults is only a problem in the United States.  Not so fast though!  While there is still very little information to draw from and a long way to go in knowing and understanding the real rates of incidence and prevalence, I was able to find some articles that give us a n idea that the US is not the only place in the world that is seeing a rise in the epidemic among older adults.

According to bulletin of the World Health Organization (WHO), researchers were able to predict  the prevalence of HIV, using extrapolated data, for adults over 50 years of age in sub-Saharan Africa.  The calculated the prevalenc rate at 4% compared to that of 5% for men between 15 and 49; nearly 3 milion people!  In a 2008 survey found in Older People & HIV/AIDS In Africa that was performed by Carol Ngare, the VCT Manager for the Kenya National AIDS Control Programme, it was found that men older than 55 have a higher infection rate than that of young men 15 to 25 years old. 

This is really not nearly enough evidence to show there is a definitive problem world wide but it certainly shows that researchers should be looking into it.  It should be a wake up call to world organizations that this population needs to be included in surveys that estimate and record incidence and prevelance!

SO!  Enough for this installment! Hope you have learned something new here!  I know I have!

Center for Disease Control and Prevention, Division of HIV/AIDS Prevention. (2011, April 22). HIV surveillance - Epidemiology of HIV infection (through 2009). Retrieved from http://www.cdc.gov/hiv/topics/surveillance/resources/slides/general/

Gay Men’s Health Crisis. (2010). Growing older with the epidemic: HIV and aging [brochure]. Retrieved from gmhc.org

HelpAge International. (2009). HIV prevalence rates amongst older persons in Kenya. Older people & HIV/AIDS in Africa 3, 3.

Klimarx, P. H. (2009). Global epidemiology of HIV. Current opinion in HIV/AIDS, 4, 240-5. DOI:10.1097/COH.0b013e32832c06db

Myers, D. M. (2009). Growing old with HIV: The AIDS epidemic and an aging population. Journal of the American Academy of Physician Assistants, 22(1), 20-4.

Negin, J. & Cumming, R. G. (2010). HIV infection in older adults in sub-Saharan Africa: Extrapolating prevalence from existing data. Bulleting of the World Health Organization [publication]. DOI: 10.2471/BLT.10.076349

Pratt, G., Gascoyne, K., Cunningham, K. & Tunbridge, A. (2010). Human immunodeficiency virus (HIV) in older people. Age and Ageing, 39, 289-94. doi: 10.1093/ageing/afq009

http://hivinsite.ucsf.edu/InSite?page=kbr-01-03

http://www.kff.org/hivaids/3029.cfm

http://www.aidsinfonet.org/fact_sheets/view/616

It begins!

Greetings!  Welcome to my first ever blog - I hope that I do it justice!  If you are reading this, you obviously share my passion for HIV research and education particularly amongst older adults.  My goal at this stage is to provide you with a portal to sites and general information about HIV and the epidemic as it effects older adults.

For this first post I just wanted to start things out by giving you a few links to some national organizations that will give you a brief introduction to the current issues at hand for this population.

http://www.aarp.org/giving-back/local-heroes/info-01-2011/educating_older_adults_about_hivaids.html?CMP=KNC-360I-GOOGLE-GIV-LHR&HBX_PK=hiv_older_adults&utm_source=GOOGLE&utm_medium=cpc&utm_term=hiv%2Bolder%2Badults&utm_campaign=G_LGBT&360cid=SI_259704010_9327313141_1

• Good article and some links to more information about condom use and other prevention promotion ideas.

http://www.nia.nih.gov/healthinformation/publications/hiv-aids.htm

• Note there is a link to a spanish version for this page in the right hand column.

http://www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm

• There are some great statistics here.