Treatment Issues

So treatment!  I'm not going to go into a lot of detail here about specific drug regimens since they would be the same as we would see among other age groups and vary greatly from practitioner to practitioner.  If you are interested in specific therapies and new innovations though, here is a great link to check out all the latest: http://www.hivatis.org/

What I would like to address here is some of the issues that are pertinent to older adults when it comes to treatment; what are the things that we need to be think about when we are treating our patients who are HIV positive and older?

The first thing that we need to take into consideration is drug interactions.  Antiretroviral therapies tend to have a lot of bad drug interactions.  In particular the protease inhibitors, which are a key part of most modern therapies, are metabolized in the liver and inhibits the metabolization of other drugs.  This increase the likelihood of  bad drug interactions.  Though this is, of course, as issue for all ages it becomes even more so for older adults because they tend to already be taking a great deal more medicines than younger folks because of any mixture of age related medical reasons.

And, speaking of these age-related illnesses; another problem we find with ART is that they tend to exacerbate these common ailments that we find in older adults.  Examples of this might include heart disease, high blood pressure, high cholesterol, diabetes, high triglyceride levels, kidney stones, inflammation of pancreas, liver damage, and bone loss which can lead to fracture.  In addition, it is common for older adults to already have a weakened immune system, which could make it difficult for them to respond to ART as a younger person might.

Another aspect that might also be considered is memory issues.  While some might suggest that we need to consider the fact that it may be more difficult for older adults to remember to take their ART, there are those who suggest that this population is already accustomed to taking several pills a day and adding a few more won't make that big a deal.  Thsi still needs to be on the table though simply because of the importance of adherance in ART.

There is still a LOT that needs to be understood about how these drug therapies work in older populations.  Most studies that have examined ART in the past have failed to include older adults as a population of concern.  These interactions and exacerbations will only continue to pose numerous challenges for both practitioners and patients alike until more attention given to this population.

http://www.bidmc.org/YourHealth/TherapeuticCenters/AIDS.aspx?ChunkID=14570

http://www.gmhc.org/files/editor/file/fall09.pdf

http://www.thebody.com/content/art14281.html

Prevention

Phew!  It's been awhile! :D  So this post is gonna look at issues of prevention that are specific to older adults.  The CDC has a great section on this exact topic so I just wanted to paraphrase some of the issue that come up with prevention in older adults here but I wanted to give you the link as well so you can explore a bit on your own: http://www.cdc.gov/hiv/topics/over50/resources/factsheets/over50.htm

As I have pointed out in earlier posts and whether we want to go there or not, your baby boomer parents are likely to be sexually active.  This can pose a problem when we think of HIV prevention because - well really - who's gonna get pregnant over the age of 50?  As such, older adults are rarely thinking of condom use when they become involved in an intimate relationship.  This becomes even more of an issue for women as they age because the lining of the vagina becomes much more fragile from dryness and thinning increasing the likelihood of tearing.  In addition to this, women face the reality (similar to that of younger women) of being in the sometimes uncomfortable position of having to negotiate condom use.

There is also the thought that older generations may be less informed about sexually transmitted infections such as HIV compared to that of younger folks partly because HIV was not a big part of their world when they were sexually active in their younger years and partly because they don't see themselves as being at risk.  This can lead to the misconception that condom use and regular testing for HIV is not something they need to worry about.  I, personally, would add here that the baby boomer generation has also been identified as a highly informed group when it comes to their health so it is important to take all of this into consideration.  Regardless, openly talking about sexual activity, regular testing for HIV, and promotion of condom use should be come a regular part of caring for older adults in primary care so we can break down the walls of stigma built up around sex in this population!

Which is a superb segue into issues of stigma as an obstacle to prevention.  While there are scattered articles about HIV related stigma we are a long way from knowing exactly how it affects older adults who are at risk for HIV.  Some believe there is little difference between older and younger populations and then there are those believe the exact opposite.  The CDC, for example, states that older adults may indeed be more highly affected by stigma robbing them of key emotional and spiritual support systems that might lead to early detection of HIV as well as prevention support.  On top of HIV related stigma it is prudent to be aware of other forms of stigma including age, race, as well as sexual and gender identity.  All of these can lead to decreased likelihood of seeking care and support from both family and the health care system.

This gives you a general idea of what we need to consider when we think of HIV prevention in older adults! I was very pleased to see amongst my browsing (some links will be posted below) to see that the general trend in prevention programs are now using a multifaceted approach in that, rather than simply telling a person to use condoms and get tested, the idea now is to use variations of prevention such as safer sexual practices, behavioral interventions, and medicinal considerations.

Anyway, here are some interesting sites to check out and browse!

http://www.thebody.com/content/64420/hiv-prevention-and-older-adults.html

http://www.med.unc.edu/aging/elderhiv/act.htm

http://www.med.unc.edu/aging/elderhiv/act.htm

http://aids.about.com/cs/aidsfactsheets/a/seniors.htm

http://caps.ucsf.edu/uploads/pubs/FS/over50.php

ENJOY!!  :D