The unexplored story of HIV and ageing

[Guest guest]

Dear All,

Please access the link as below and go through an interesting article published

by the WHO about HIV/AIDS in reference to the elderly.

______________________

http://www.who.int/bulletin/volumes/87/3/09-064030/en/print.html

The unexplored story of HIV and ageing

P Schmid a, G b, Jesus -Calleja a, Chris

c, Segar c, Southworth c, Tonyan c, Jocelyn Wacloff c

& c

a. Department of HIV/AIDS, World Health Organization, 20 avenue Appia, 1211

Geneva 27, Switzerland.

b. Independent Consultant, Geneva, Switzerland.

c. St Olaf College, Northfield, MN, United States of America.

Correspondence to Schmid (e-mail: schmidg@...).

Bulletin of the World Health Organization 2009;87:162-162. doi:

10.2471/BLT..09.064030

As people in developing and industrialized countries increasingly live longer,

healthier lives, why do the scant data that exist suggest a surprisingly high

prevalence and incidence of HIV among individuals 50 years of age and over

(“older individualsâ€)?

Older individuals are rarely included in Demographic Health Surveys (DHS). In

the last 5 years, only 13 of 30 surveys included older males and none included

older females. The National Health and Nutrition Examination Survey in the

United States of America (USA) does not collect data from people older than 49.

There is a dearth of prevalence data; what about incidence?

Incidence could be determined via case reporting, serologic incidence assays or

modelling. Developing countries have limited case-reporting systems, but

industrialized countries do better. In the USA, case reporting from 2003 to 2006

shows the proportion of older HIV-positive individuals has climbed from 20% to

25% and numbers of cases have risen in all 5-year age bands from 45 years to 65

years and older;1 using serology, 11% of 2006 incident cases are in older

individuals.2 In WHO’s European Region, 8% of reported cases in 2005 are

older.3 Similar data from the developing world are unavailable, and modelled

incidence data are not publicly available.

We have calculated prevalence by age, using UNAIDS’ estimated numbers of cases

of HIV and United Nations population estimates, by country. One finds a

consistent pattern that prevalence in older individuals is one-quarter to

one-third that of the 15–49-year age group. We have debated with our

colleagues whether these findings are surprising. Most of us think “yesâ€.

This is particularly so because prevalences for this age group are deceptively

low. There is little appreciation that the older the individual, the faster the

progression from HIV infection to AIDS.1,4,5 The effect is considerable, linear

and remains after adjusting for all-cause mortality.4,5 For example, there is a

life expectancy of more than 13 years in people infected at age 5–14.

This declines to 4 years in those infected at age 65 or older.5 Waning immunity

with age may be the reason. Since incidence is indirectly related to duration of

disease, prevalence in those aged 50 and above should be approximately doubled

to be compared with those in the 15-24 year age group. While long-available

antiretroviral therapy (ART) could increase prevalence among older individuals

in industrialized countries, this is not true of the developing world, where ART

was introduced later.

Is the epidemiology of HIV in older individuals of purely academic interest? No,

because understanding risk factors leads to interventions. Intriguingly, the

Alpha Network in Africa has shown that in many sites, secondary peaks of HIV

incidence appear at older ages.6 Why might older individuals be becoming

infected? We can only conjecture. In a systematic literature search, we found

only one, limited, epidemiological study exploring HIV acquisition in older

individuals, from urban USA.

Sexual activity of older individuals in the developing world is barely

researched. Many older individuals everywhere are sexually active, although

interest in sex and frequency of vaginal intercourse decline with age.7 Since

1998, erectile-dysfunction drugs have been extending the sex life of many older

individuals and, at the same time, may be extending the HIV epidemic into older

age groups.

Many studies show that older individuals are less likely than their younger

counterparts to practise safer sex. While erectile dysfunction is common and

erectile-dysfunction drugs are widely distributed in developing countries,8 no

study has been done of their possible impact on the HIV epidemic, although their

use in industrialized countries has been associated with risky sexual

practices.9 Whether HIV-positive men should be prescribed these drugs has been

debated.10

If sex is the main cause of HIV infection in older individuals and many older

individuals are not having penetrative intercourse, then the risk of acquiring

HIV per sexual act in these individuals must be high. We can only speculate what

the reasons may be.

The thinning of vaginal mucosa with age may play a role; for both sexes, the

prevalence of antibodies against herpes simplex virus 2 increases with age,11

indicating continual risky sexual behaviour and enhanced risk of HIV

transmission.

While sexual activity is the most likely mode of transmission, research is

required to establish the relative contribution of different risk factors and

modes of transmission.

One consistent finding is the failure to consider HIV as a cause of illness in

older individuals. These individuals have a shorter time from diagnosis to onset

of AIDS,1 reflecting both age-related faster progression to AIDS and doctors’

failure to consider HIV as a diagnosis. Screening is less common for older

adults, who are assumed not to be at risk.

HIV prevalence and incidence in the over-50-year-olds seem surprisingly high and

the risk factors are totally unexplored.

Understanding the epidemiology of HIV infection in older individuals can lead to

interventions to make these years safer and more enjoyable. 

References

Centers for Disease Control and Prevention. HIV/AIDS surveillance report 2006,

vol. 18. Atlanta, GA: Department of Health and Human Services, Centers for

Disease Control and Prevention; 2008. pp. 1-55.

Hall HI, Song R, P, Prejean J, An Q, Lee LM, et al., et al. Estimation of

HIV incidence in the United States. JAMA 2008; 300: 520-9 doi:

10.1001/jama.300.5.520 pmid: 18677024.

European Centre for Disease Prevention and Control/WHO Regional Office for

Europe. HIV/AIDS surveillance in Europe 2007. Stockholm: European Centre for

Disease Prevention and Control; 2008.

Babiker AG, Peto T, Porter K, AS, Darbyshire JH. Age as a determinant of

survival in HIV infection. J Clin Epidemiol 2001; 54: S16-21 doi:

10.1016/S0895-4356(01)00456-5 pmid: 11750205.

Collaborative Group on AIDS Incubation and HIV Survival. Time from HIV-1

seroconversion to AIDS and death before widespread use of highly-active

anti-retroviral therapy. A collaborative analysis. Lancet 2000; 355: 1131-7 doi:

10.1016/S0140-6736(00)02061-4 pmid: 10791375.

Zaba B, Todd J, Biraro S, et al. Diverse age patterns of HIV incidence rates in

Africa. Proceedings of the XVII International AIDS Conference, Mexico City,

2008.

u ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A

study of sexuality and health among older adults in the United States. N Engl J

Med 2007; 357: 762-74 doi: 10.1056/NEJMoa067423 pmid: 17715410.

Khalaf IM, Levinson IP. Editorial. Erectile dysfunction in the Africa/Middle

East Region: epidemiology and experience with sildenafil citrate (Viagra).. Int

J Impot Res 2003; 15: S1-2 doi: 10.1038/sj.ijir.3900967 pmid: 12825101.

Pantalone DW, Bimbi DS, Parsons JT. Motivations for the recreational use of

erectile enhancing medications in urban gay and bisexual men. Sex Transm Infect

2008; 84: 458-62 doi: 10.1136/sti.2008.031476 pmid: 19028947.

Sadeghi-Nejad H, R, Irwin R, Nokes K, Gern A, Price D. Erectile

dysfunction in the HIV-positive male: A review of medical, legal and ethical

considerations in the age of oral pharmacotherapy. Int J Impot Res 2000; 12:

S49-53 doi: 10.1038/sj.ijir.3900562 pmid: 11002402.

JS, NJ. Age-specific prevalence of infection with herpes simplex

virus types 2 and 1: a global review. J Infect Dis 2002; 186: S3-28 doi:

10.1086/343739 pmid: 12353183.

_________________________ 

Best wishes,

Dr. Rajesh  Gopal,MD

Joint  Director,

Gujarat  State  AIDS  Control  Society (GSACS),

O/1 Block, New  Mental Hospital  Complex,

Meghaninagar,Ahmedabad, Gujarat.

PIN 380016 Phone (O) 079-22680211--12--13,22685210 Fax 079-22680214

e-mail: <dr_rajeshg@...>