The June 5, 1981 issue of the Center for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report contained the first reports of what was to become acquired immune deficiency syndrome, or AIDS (Shilts, 1987). With this news, the AIDS epidemic descended on America. In the ensuing years AIDS has, in some way, affected almost every person in the United States. The magnitude and scope of the AIDS epidemic is clear.
As of December 31, 2001, there were 807,075 diagnosed cases of AIDS in the United States. Of this total number, 462,653 (57%) have died (CDC, 2001). Another 161,976 are estimated to be living with the human immunodeficiency virus (HIV) infection and not yet diagnosed with AIDS. Globally, the World Health Organization (WHO) estimates 42 million people are living with HIV and AIDS, and an additional 5 million people were infected with HIV in 2002 alone (WHO, 2002).
Since the AIDS and HIV epidemic was first noted, enormous strides have been made in scientific understanding of the disease pathology and treatment in a relatively short period of time. Behavioral and social scientists have studied groups at risk for and with HIV to gain understanding and direction for possible interventions. However, the scientific community at large has generally ignored older people with HIV.
Although the definition of an "older" person is often defined as one older than 60 years of age, the HIV literature has included those older than 50 in this category. In this review, older people with HIV are those older than 50, regardless of when the actual HIV infection occurred or was documented. The purpose of this article then, is to explore the extant literature related to HIV and AIDS in older Americans.
EPIDEMIOLOGY AND RISK BEHAVIOR
Approximately 75,270 people older than age 50 have been diagnosed with AIDS in the United States. This number represents approximately 11% of the total cumulative cases of people diagnosed with AIDS (CDC, 1999). The proportion of total diagnoses represented by older people has remained stable since 1982 (CDC, 1999; Stall, Catania, & Pollack, 1989). However, there have been changes in the number of AIDS cases by exposure category in older adults over time.
The incidence of AIDS diagnoses in men who have sex with men (MSM) and MSM who inject drugs is decreasing. These risk categories represented almost 75% of people with AIDS in 1985, but decreased to 49% of AIDS cases by the end of 1998 (CDC, 1999; Stall et al., 1989). The number of heterosexually transmitted cases of AIDS increased throughout the epidemic and now represents approximately 11% of the total cases of AIDS in people older than 50.
Additionally, the number of cases related solely to injection drug use (IDU) is slowly increasing (CDC, 1999). These statistics mimic the current national trend in increasing heterosexual and IDU-related transmission of HIV. Interestingly, transfusion-related AIDS cases represented 2.9% of diagnoses in older people in 1987 and 2.4% of cases in 1998. This constant proportion is paradoxical to the rate of transfusion-related AIDS in people younger than 50.
Transfusion-related HIV infection in those younger than 50 has decreased since the late 1980s to just more than 1% of all cases (CDC, 1999). Continued transfusion-related HIV cases in older Americans might be associated with the fact that people older than 60 receive almost 70% of blood transfusions in America, thus increasing possible exposure or risk of transfusion-related HIV infection (Nokes, 1996).
Although the risk of receiving HIV-infected blood per unit transfused is similar in younger and older adults, the fact that older adults are more likely to receive multiple blood transfusions increases risk for HIV infection. Stall and Catania (1994) reviewed the National AIDS Behavioral Surveys and revealed some interesting facts related to HIV and AIDS risk-taking and testing behavior in older Americans. This telephone survey was conducted in 1990 through 1991 on a large random probability sample.
A national sample of the 48 contiguous states (n = 2,673) that included older respondents (n = 1,114) was obtained through random dialing methods. This group was compared to a sample chosen from the 25 metropolitan cities with the highest prevalence of HIV and AIDS (n = 11,429); again with inclusion of older adults (n = 2,074). Analyses were completed on each individual group as well as the comparison data.
Approximately 10% of the older adults in both groups reported at least one activity that placed them at risk for HIV infection. Additionally, the greatest behavior potential for further spread of HIV infection among late middle-aged or older Americans derives from sexual behavior. This fact negates the myth that people older than 50 decrease their sexual contacts.
Sexual desire and activity do not necessarily decrease with age. In some cases, sexual activity may increase (Grossman, 1995). In fact, 40% to 65% of older adults between ages 60 and 71 reported being sexually active (Whipple & Scura, 1996). Almost 58% of all cases of AIDS in people older than 50 report that sexual contact is the sole risk factor for infection (CDC, 1999). However, high-risk older individuals are less likely to have adopted AIDS prevention strategies, including use of condoms and regular HIV testing, than younger high-risk individuals (Stall & Catania, 1994).
More recent research (Mack & Bland, 1999) on a large probability sample (n = 94,339) of the 1996 Behavior Risk Factor Surveillance System indicated that people older than 50 were less likely to ever have been tested for HIV, to have changed sexual behavior in the last 12 months, or to believe a condom was very effective at preventing HIV infection. Also, participants older than 50 were more likely not to know that a condom is effective in preventing HIV transmission.
Binson, Pollack, and Catania (1997) in another review of the National AIDS Behavior Surveys, noted that 8% of the women older than 40 reported sexual activity that could place them at risk for HIV infection. Yet safer-sex practices were rarely reported. Almost 95% of the women had not used condoms in the last 6 months and almost 90% of these risk-taking women did not perceive themselves to be at risk.
Black and Hispanic women were significantly more likely to report higher levels of risk taking behavior. This risk behavior and lack of prevention efforts continued at the same rate at a 2-year follow-up survey completed in 1992. Again, the trend in this data for minority women to engage in more HIV risk behaviors is supported in more recent statistics noting the increasing rates of new HIV infections and AIDS diagnoses in minority women (CDC, 1999).
Summary of the statistical and behavioral or risk data clearly outlines the continued problem of HW risk behavior and infection in people older than 50 in the United States. The number of people older than 50 with AIDS has remained stable while the number of AIDS cases nationally has decreased. Parroting national statistics, women and minorities are at everincreasing risk for HIV and AIDS. Additionally, lack of perceived risk for ?G? infection in this age group has led to less adoption of safer sex behaviors than in similar risk taking groups of younger ages. Prevention efforts have either not reached or not worked with this risk group.
Despite continually representing 9% to 11% of AIDS cases, older people with HIV are largely ignored in the biomedical, social or behavioral, and prevention literature. By far, the largest portion of published material related to HIV and AIDS in people older than 50 represents non-research review articles with offered expert opinion. These articles, while providing insight and direction for clinicians, are not research-based and, thus, limited in generalizability and applicability.
Quantitative research is virtually limited to physiologic differences noted in HIV disease progression and presentation in older people. The few sociologie or behavioral studies examine risk taking and adoption of risk reduction behavior as reviewed previously. Recent qualitative research related to this population could not be located.
The majority of published literature related to HIV and AIDS in people older than 50 appeared greater than 3 years ago. Few articles published since 1998 could be located. Despite these limitations in timeliness, lack of qualitative research and narrow scope of quantitative research, several articles deserve review.
To fully appreciate the scope of the epidemic in people older than 50, an understanding of the HIV disease process is necessary. The human immune system is a complex collection of cells that must work together to fight off foreign proteins and infection. One of the most crucial communicator cells of the immune system is the CD4 lymphocyte (T-cell).
This cell functions in a primary role in both cell-meditated and humoralimmune response. It serves as principal communicator, initiating and directing antibody and cell-related immune responses (Sompayrac, 1999). Unfortunately, HIV has a specific affinity for CD4 cells. After infection, the cell is no longer able to complete its immune function and eventually is destroyed. While the immune system initially is able to maintain a relative steady state of CD4 production to combat CD4 destruction, eventual loss of CD4 cells will occur.
As cells are lost, the immune system begins to falter and the host becomes susceptible to a number of infections common in many people, but which are usually controlled by an intact immune system. Advanced stages of HIV infections with loss of CD4 cells to fewer than 200 or presence of an opportunistic infection is termed AIDS. In the person with HIV, these opportunistic infections cause significant morbidity and mortality. Common opportunistic infections include Pneumocystis pneumonia, cytomegalovirus retinitis or colitis, chronic recurrent severe herpes infections, and mycobacterium infections.
During the course of HIV infection as CD4 cells are depleted, medication to prevent opportunistic infections is prescribed. Therapy often continues for the remainder of life in the person with HIV (Flaskerud & Ungyarski, 1999). More recent research indicates that medications used to prevent infections (prophylaxis) may be discontinued if a sustained improvement in immune function accompanies HIV treatment (Benson, 2000).
Advances in treatment and disease monitoring have drastically reduced AIDS-related morbidity and mortality. However, significant side-effects related to treatment and the complex nature of the drug "cocktails" make lifelong adherence difficult. These issues may be exacerbated for the person older than 50 with HIV and AIDS for reasons that will be further explored.
Aging is a natural lifelong process causing several biophysical changes. These changes, while natural, create special health care needs for older adults. These needs are especially true for those older adults with HIV. Specific to immune function, involution of the thymus gland occurs by approximately age 50. While this does not affect the number of mature CD4 cells, the function of the cells is inhibited. Additionally, CD4 cell regeneration slows with aging (Nokes, 1996; Pinka, 2002).
Theoretically, these facts support the belief that older people with HIV are at greater risk for disease progression. This theory has been supported through empirical research. A number of studies have indicated that older people with HIV are at greater risk for disease progression than younger people with HIV (Carre et al., 1994; Chen et al., 1998; Ferro & Salit, 1992; Hu, Byers, Flemming, & Ward, 1995; Rosenberg, Goedert, & Biggar, 1994).
There is evidence of increased risk of autoimmune disorders as one ages, adding to the already higher incidence of these disorders in people infected with HIV (Bachus, 1998). Lung and renal function also decrease with aging, further increasing risk for HIVassociated pulmonary problems and nephropathy (Pikna, 2002). Neurological and psychological changes in elderly individuals with HIV, including dementia and depression, can be difficult to ascribe to aging or HIV. Treatment for these disorders is related to the suspected underlying cause and may be delayed secondary to unknown or unclear etiology.
Older adults with HIV may experience more psychological distress than their younger counterparts. Meadows, Maréchal, and Catalan (1998) compared 52 adults older than 54 who had HIV to a random sample of younger people with HIV. They discovered that older adults were more likely to have AIDS, suffer from an organic brain syndrome, and experience social isolation. This cohort was less likely to have used psychiatric services than younger people with HIV. The authors postulate that the prevailing ethos among elderly individuals is that illness is something to be suffered in isolation. They often believe illness is a personal matter and asking for help is often perceived as an admission of weakness.
Drug treatment for HIV disease can also be complicated secondary to aging. Changes in drug distribution related to loss of lean body mass and total body water may lead to under- or over-dosing of medications. Treatment regimens for HIV are complex and often require significant life planning related to meals and fluid consumption. Given the frequent presence of co-morbidities requiring medications in older adults (e.g., diabetes, hypertension), polypharmacy becomes a significant concern. Multiple treatment regimens increase risk for adverse drug reactions, drug interactions, and difficulties with adherence. Other physiological changes occurring with the normal aging process increase risk for both acquiring HIV and for faster progression of disease in those already infected. Specifically for post-menopausal women, drying and thinning of the vaginal mucousa may result in tears and abrasion during sexual intercourse. If exposed to HIV, trauma to the vaginal walls may facilitate infection (Bachus, 1998). Loss or decrease of estrogen and progesterone related to menopause further decreases immune function (Nokes, 1996). Finally, it is estimated that 40% to 80% of older adults have inadequate caloric intake, and vitamin or mineral deficiencies are not uncommon (Nokes, 1996).
Summary of the literature related to physiological implications of aging and HIV reveal increased risk for HIV infection, and after acquired, increased risk for rapid disease progression. Comorbidities confound an already complex disease presentation and may interfere with appropriate treatment.
Several sociological factors affect the perceived risk of HIV and the initiation of risk reduction behaviors in people older than 50. Sociological factors contribute to the general lack of understanding and recognition of HIV in the older adult by the health care system. In a review article, Mueller (1997) described three interrelated sets of social factors that act as barriers to recognition of HIV and AIDS in older adults. This lack of recognition is not only within the health care system, but is a part of the older group of people at risk for HIV infection. The three sets of social factors include: * Socially defined meaning of HIV and AIDS.
* Social response to HIV and AIDS.
* Social organization of health care.
The author encompasses myriad social considerations affecting prevention, risk behavior, recognition of disease, and treatment. The organization of the social factors remains current and germane, and is reviewed here.
Socially Defined Meaning of HIV and AIDS
Since the beginning of the epidemic, HIV has been ascribed to certain social subgroups of the population, namely gay men and injection drug users. Even as the demographics of the epidemic changed and more women, children, and people of different races have been affected, the majority of new cases still occur in people younger than age 50. Little public acknowledgement of HIV and AIDS as a concern for older adults has occurred. Furthermore, behaviors including certain sexual practices, illicit drug activities, and blood transfusions have been used to socially define HIV and AIDS.
These social definitions have lead to the acceptance of the disease as "someone else's" problem and not a concern for elderly individuals. Though older adults engage in behaviors that put them at risk for HIV, lack of perceived risk leads to failure in adopting behaviors, such as safer sex and needle cleaning or exchange. This lack of prevention behavior increases risk for HIV transmission.
According to Mueller (1997), the extant social definitions of HIV and AIDS have prevented large-scale recognition and acceptance of it as a disease of older adults. Without this recognition, important prevention and treatment efforts completely ignore this risk group.
Social Response to HIV and AIDS
By defining HIV and AIDS as a disease of certain social groups or social practices, society has been able to separate those infected or suspected of being infected as "them" not "us." Separation fosters stigma of the affected groups. The stigma associated with HIV has led to overt and covert acts of discrimination against those infected. Additionally, viewing HIV as "their" disease fosters a social response of ignorance of the epidemic. While not overt discrimination, ignoring the effects and ramifications of the epidemic is just as damaging to those infected and affected by HIV and AIDS.
Mueller (1997) believes older people are particularly vulnerable to the social stigma associated with HIV infection. Prevailing myths about older adults as non-sexual, non-injection-drug using people may be a barrier to older adults receiving needed prevention education or HIV treatment. Older adults may resist revealing risk behavior information because they recognize that these behaviors are socially unacceptable.
Older adults with HIV may refrain from sharing important information related to health status with family, friends, or health care providers because of fear of the stigmatized social response. This resistance may be compounded by the fact that American society is inherently ageist. The stigma associated with aging is complicated by HIV-associated social issues.
Social Organization of Health Care
Defining HIV as a disease of young people has led to the development of public health efforts that often neglect the health needs of older adults (Mueller, 1997). Prevention and education programs, including HIV testing efforts, have been aimed at younger high-risk groups and do not adjust for the needs and expectations of older adults. Attributing HIV to certain social groups or social behavior has detrimental clinical effects for the older adult at risk for HIV. Health care professionals, including nurses, are less likely to suspect a diagnosis of HIV and AIDS in symptomatic and asymptomatic older men and women than they are in younger people (El-Sadr & Gettler, 1995). This fact, along with the advanced disease state at diagnosis and faster progression of HIV in elderly individuals, shows the clinical consequences of social stigma in the health care setting.
The literature on HIV and AIDS in older adults provides some insight into this unique risk group. Review articles are the most common, and provide guidance for research questions and review of the small amount of literature available. However, qualitative research exploring the meaning and the experiences of HIV infection in older adults is absent.
Additionally, quantitative research is mosdy limited to physiological or disease state measures. A few behavioral and sociological studies related to elderly individuals with HIV support the belief that older adults are engaging in risk behavior and have not generally adopted risk reduction behaviors. Further research using qualitative and quantitative methods is needed to fully explore the phenomenon of HIV infection in older adults.
Additional research related to the experiences of older men who are gay is necessary as well. Throughout the literature, social isolation has been noted more commonly in older adults infected with HIV. Also, prevention efforts aimed at older adults have been lacking. These problems may be compounded for the older men who are gay.
The gay community is very youth oriented. As gay men age, social isolation becomes the norm. If prevention efforts for this high-risk group are focused within the community, they may entirely miss this still sexually active group. Also, treatment efforts are often community-based and may ignore the special needs of older men who are gay (Nokes, 1996).
The literature search for this manuscript revealed few articles written after 1998. A review conducted by Johnson, Haight, and Benedict (1998) illustrates the decreasing number of articles related to HIV in older adults published since 1989. Although a greater percent of articles are research-based, the yearly number of articles specific to HIV in older adults has dwindled to approximately one to two per year. Perhaps the treatment emphasis in both literature and colloquium in the recent years has obscured the need for continued study of these important issues.
Nurses are in a principal position to identify and intervene with older adults at risk for HIV and AIDS. In practice, nurses in any setting may be the first to identify older adults at risk and intervene with appropriate education, resources, and referrals. Specifically, nurses in home-care, skilled nursing facilities, or long-term care may be exposed to greater numbers of older adults who need HIV risk assessment and risk-reduction education.
The Association of Nurses in AIDS Care (ANAC), an international non-profit professional nursing organization recommends routine HIV risk assessment be incorporated into all nursing assessments regardless of any perceived risk on the part of the nurse (ANAC, 1998). Risk assessment requires a complete sexual and needle-using history. Nurse must be able to collect these data without judgment and in a sensitive manner. It is vital for nurses to understand the physiological and sociological factors affecting older adults at risk for and diagnosed with HIV disease.
Nurses working in the community may be the first to recognize a community-wide need for HIV and AIDS education and programming aimed at older adults. Often, nurses who identify a community in need are in a position to influence and direct program planning and health education development. Additionally, nurses may work on the local or national governmental level to lobby for the needs of older adults both for HIV prevention efforts as well as treatment programs.
Prevention and treatment programs must be inclusive of the special needs of older adults and should clearly address these multi-dimensional needs. Prevention efforts must assess the perceived risk as well as the educational needs of the older adult. Stigma associated with HIV and AIDS must be addressed to understand an older adult's perspective and belief system. Only when this understanding is accomplished can an individualized community care plan be developed.
Nurses are in the ideal position to conduct research, which might help identify and guide interventions for the older person with HFV and AIDS. They are often the only helping profession directly connected with the entire community. Because nurses in all areas of practice (i.e., acute care, long-term care, hospice care, community health, primary care nurse practitioners) are expected to provide quality, competent, and scientifically based care to older adults with and without HIV, they must initiate, assist with and conduct the research on which to base nursing practice. Additionally, it is imperative for older people to be allowed to participate in clinical trials of promising new medications. Nurses can help advocate for their client's full participation in the health care system.
The proportion of people with AIDS older than age 50 has remained constant since early in the epidemic. Given this fact, in comparison to the decrease in AIDS cases in other risk groups, it is clear that older adults remain a significant risk group. Despite engaging in behavior which puts them at risk for HIV, older adults are less likely to perceive themselves at risk and to adopt safer sexual and needle sharing behaviors.
Aging comes with physiological changes, which increase risk for any infection including HIV. Older adults with HIV are more likely to be diagnosed late in disease, experience progression more quickly, and survive for a shorter period than their younger counterparts. Co-morbidities are frequent in older adults with HIV infection and can complicate the disease process and management. Recent treatment and disease monitoring advances are extending the life of individuals with HIV. Therefore, the number of older American with ?G? and AIDS may increase even further, clearly defining a need for age-related interventions.
Beyond the physiological disease facts, sociological factors have greatly influenced older adult risk behavior, risk-reduction efforts, social response, and health care response to the epidemic. A clear understanding of these sociological factors is necessary in planning interventions for the elderly individual with HIV.
Finally, nurses are in a unique position to assist older adults at risk for or with HIV infection. However, a comprehensive understanding of physiological and sociological factors related to older adults is necessary for the most useful and acceptable interventions to be developed.
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