AS WE ENTER the fourth decade of AIDS, the crisis continues largely unabated. About 1.1 million Americans live with hiv/aids, as do 33 million people around the world. Every year, about 56,000 more Americans are newly infected; roughly half are gay men and half are African American. While the overall HIV incidence in the U.S. remains flat, infections among gay and bisexual men are increasing—the only risk group for which this is the case. Infections are increasing especially among young black gay men.
Globally, 2.7 million people were newly infected in 2008, down from a peak of 3.5 million in 1997. Despite this progress, for every two HIV-positive people who get into treatment globally, another five are newly infected. Most of the 33 million people living with HIV around the world don’t have access to anti-retrovirals (ARVs), the HIV medications that revolutionized treatment in the mid-1990’s, and are not likely to any time soon. In sub-Saharan Africa, where most of these people live, access to something as basic as palliative care (pain medication) is often beyond reach.
On a more positive note, thirty years after the Centers for Disease Control reported on the first cases of pneumocystis carinii pneumonia among five homosexual men who appeared to have a “cellular-immune dysfunction” and a “disease acquired through sexual contact,” scientific advances have transformed HIV from a probable death sentence to a condition people can live with for many decades. In fact, a twenty-year-old who initiates ARV treatment with a CD4 cell count of at least 200 has an estimated life expectancy of seventy. In the past couple of years we have also begun to see the first-ever promising results in vaccine research, pre-exposure prophylaxis (PreP) research, and rectal and vaginal microbicides research.
About one-third of all people living with hiv/aids in the U.S. today are fifty years of age or older, and that figure that will grow to one-half by 2017. The main reason is that people with HIV are living much longer than ever before, a welcome development that has brought new challenges for this population, including a suite of health problems that involve complex interactions between the virus, antiretroviral therapies, the natural aging process, and in some cases other behavioral risk factors. Some evidence suggests that HIV accelerates the aging process, which itself is associated with higher risk of chronic diseases. Both aging and HIV infection significantly influence the immune system, often increasing the risk of illness.
We have limited knowledge about the effects of long-term exposure to antiretroviral therapy and the effects of drug toxicity. We also have limited understanding of the effect of HIV medications on aging bodies, how HIV and other health conditions interact, and how medications to treat HIV and other health conditions, such as diabetes and high cholesterol, interact. Recently, Gay Men’s Health Crisis and the AIDS Community Research Initiative of America surveyed 180 of GMHC’s HIV-positive clients age fifty and older. The average client had been diagnosed with AIDS at some point and had on average 3.5 co-morbidities, such as depression, arthritis, neuropathy, and hepatitis C. (Thankfully, the National Institute of Allergy and Infectious Diseases, headed by Dr. Anthony Fauci, is funding significant research in the area of HIV and aging.)
Many older adults living with HIV are long-term survivors, but about one in six of all new infections in the U.S. affects an older adult (fifty or over). In general, doctors tend not to question older patients about their sexual health risks or sexual activity. A national study found that adults over fifty at risk for HIV were eighty percent less likely to be tested for the virus than were at-risk adults twenty to thirty years of age. Most newly diagnosed older adults learn that they are positive while hospitalized for other medical reasons. Older adults are disproportionately diagnosed many years after becoming infected. Unprotected same-sex intercourse appears to be the most widely reported transmission route among older men newly diagnosed, with unprotected heterosexual sex the most common route of transmission for women in the U.S. There is a dearth of sex education and prevention messages aimed at people over fifty.
HIV-positive people on antiretroviral therapies can live well into old age, even if they started therapy with severely depleted immune systems. The need for culturally competent senior services for older adults living with HIV is growing as baby boomers hit retirement age starting this year. Significant anti-gay bias has been found in senior centers and services, among both providers and clienteles. Many seniors have reported unauthorized disclosure of their HIV status by peers in senior settings. Older adults are also more likely to believe that HIV can be casually transmitted, for example, by a handshake or by touching a door knob. Lambda Legal is suing an Arkansas nursing home for kicking out an HIV-positive gay man after telling his daughter that they could not serve him and protect the safety of their staff working in the dining room and laundry. Clearly, HIV stigma remains widespread. Policy makers must ensure—through the Older Americans Act, state aging plans, Medicare regulations, and other mechanisms—the availability of culturally competent treatment of older adults with HIV in senior services and congregate living facilities.
Since 2009, there have been significant advances in HIV vaccine research, pre-exposure prophylaxis (PreP), and rectal and vaginal microbicides research. In September 2009, for the first time, a vaccine clinical trial reported partial efficacy in preventing HIV transmission. The HIV Vaccine Trial in Thai Adults reported that, among over 16,000 participants, the vaccine regimen (alvac hiv and aidsvax b/e) reduced infection risk by about 30 percent. While an hiv/aids vaccine will not be available any time soon, the fact that the Thai vaccine regimen showed partial efficacy—the first of many attempts over the years—is a promising development that has reinvigorated the search for a vaccine.
In March 2011, the Microbicide Development Program at UCLA and the Microbicide Trials Network revealed findings of the first clinical study of a rectal microbicide. Microbicides are gels or creams used in the rectum or vagina that are designed to prevent or reduce the sexual transmission of HIV or other sexually transmitted infections. The study, known as RMP-02/MTN-006, proved that a tenofovir gel applied rectally is effective in preventing HIV transmission. Eighteen sexually abstinent, HIV-negative men and women participated in the study, which allowed researchers to directly compare the anti-HIV activity of oral tenofovir dosing to rectally-applied tenofovir gel, as well as whether protection was provided by the drug using different dosing regimens: single oral, single gel, or seven day gel (or placebo). Small biopsies were taken from the rectal lining of each participant and sent to a lab, where each sample was exposed to HIV. The study concluded that HIV was significantly inhibited in tissue samples from participants who used the rectal microbicide gel daily for one week compared to tissue from participants who used a placebo gel.
This tenofovir gel is the same microbicide gel used in the caprisa-004 study, which proved effective against HIV transmission when used vaginally. The caprisa vaginal microbicides study, results of which were released in July 2010, showed that women using the gel were 39 percent less likely to have been infected with HIV. More research is necessary to determine if the vaginal gel is optimal for rectal use.
Imagine if you could take a pill and that would protect you against getting HIV. This is the idea behind pre-exposure prophylaxis, or PreP: that one could take HIV medications to prevent the transmission of the virus. In November 2010, for the first time, a PreP clinical trial showed significant partial efficacy. A trial conducted among 2,500 HIV-negative gay and bisexual men and transgender women in six countries, including the U.S., found Truvada to be partially effective in preventing HIV transmission. (Truvada is a combination of tenofovir and emtricitabine.) Those taking Truvada in the trial had 44 percent fewer infections than did a control group. Those who took Truvada at least ninety percent of the time—i.e., those who were the most treatment–adherent—showed 73 percent fewer cases of transmission.
These findings are quite promising, and other PreP trials are underway among heterosexuals. For now, however, with tens of millions already living with HIV worldwide, access to anti-retrovirals is still their best hope. Given the large unmet need for ARV treatment in Africa, it’s not clear how wider distribution of these drugs for the purpose of preventing HIV transmission can be achieved. In the U.S., more than 7,000 people are currently on waiting lists for the AIDS Drug Assistance Program, which helps low-income HIV-positive individuals pay for haart medications. A number of policy and budgetary issues remain to be sorted out before PreP becomes a reality for gay men and other vulnerable groups. Also, prevention interventions that are not 100 percent efficacious raise ethical questions for public health officials.
Still, these recent advances in clinical trials research into HIV vaccines, microbicides, and PreP are exciting, and they hold great potential for increased reliance on biomedical prevention strategies to complement the use of condoms. As more people live longer with HIV, we must ensure that safer sex messages effectively target older adults, and that senior service systems adapt their training and policies to serve older gay men and others living with HIV.
Sean Cahill, a managing director at Gay Men’s Health Crisis, is a co-author of “HIV and Aging: Growing Older with the Epidemic.”