AIDS and Old Age

AIDS WAS STILL a strange new four-letter word when Steve Miles saw his first case. The patient was a baggage handler in his 60s who had been struggling with unexplained infections and exhaustion. Another doctor had diagnosed the man with multiple sclerosis, but Miles, then a geriatrician at Hennepin County Medical Center, wasn't convinced. He checked the patient's history and noticed that no one had bothered to ask about his sex life. It was the third AIDS case ever diagnosed in Minnesota.

Ten years later, the federal Centers for Disease Control and Prevention counts 7,200-plus AIDS cases in people over 65 (by way of perspective, there are just under 2,500 teenage AIDS patients). But the silence surrounding them is still as dense as it was when Miles diagnosed that first case. And that, say experts, will have to change--if only because of the raw numbers.

"Older" patients still make up only some 1.5 percent of the total AIDS population. But the numbers have been inching up, and they're set to explode as new drugs drastically increase patients' life expectancy. "What we're finding is the beginning of a new industry," says Dr. Keith Henry, who runs the HIV/AIDS clinic at St. Paul-Ramsey Medical Center. "It's the baby boomer aging with HIV. I tell my patients that pretty soon, I'm going to be a geriatrician."

The problem is no one has a good idea of what that might mean. In fact, says Miles, a faculty member at the University of Minnesota's Center for Bioethics, most of those involved are still struggling to grasp that older people not only get HIV, but get it the same way everyone else does. "For a long time, [HIV in seniors] was thought of as being related primarily to blood transfusion," he says. "But what we've discovered is that we can't assume that older people don't have sex or shoot up." And when they do, they may be at more risk than younger people: One study published in the Annals of Internal Medicine found that "at-risk Americans past the age of 50 were one-sixth as likely to use condoms during sex and one-fifth as likely to have been tested for HIV as... at-risk individuals in their 20s."

In many cases, doctors aren't much help. Medical schools have just begun teaching students how to ask older patients about things like sex, says Dr. Margaret Simpson, who heads HCMC's infectious-disease unit. "In the past, we often didn't bring it up thinking that they're going to be embarrassed. Actually, it turns out that most of the time, the patient is less embarrassed than the person asking the question."

One result of all this awkwardness is that by the time older patients learn their HIV status, the disease is often fairly advanced. Many, says Simpson, first show up with a dead-giveaway disease like pneumocystis carinii pneumonia. Throw in age-related health problems, she adds, and you've got patients whose treatment is extremely complicated. "When someone develops sudden right-arm weakness, especially if it's a man, usually you're going to say 'stroke.' But if they're HIV, you have to think about a lot of other things as well."

And that's nothing, says St. Paul-Ramsey's Henry, compared to the wholesale shift AIDS medicine will have to undergo if drugs like protease inhibitors live up to their promise. Soon, he says, it may become common for people to live with HIV for decades. "We have to do prostate exams and mammograms and ask about family members' history of heart disease. We're talking to patients about quitting smoking, where in the past it would be, 'Why bother?'"

So far, however, that shift is hard to detect outside of specialized clinics. Of the myriad AIDS education, prevention, and social-service programs, none are specifically targeted at seniors. New York City recently saw the founding of what seems to be the first support group for older AIDS patients in the nation. But nothing like that has yet developed locally. The Minnesota AIDS Project, which provides case management and other services, reports not a single senior among its caseload.

Which Henry says means that if older patients have any support at all, it's going to come from their families--or not. "Everybody's heard of people having to deal with things like AIDS and HIV in their kids. But turn that around, and it's a whole new set of issues. Especially with people who were deceptive for a long time. If grandpa has AIDS, that means grandma might have been put at risk. That's a hard thing for relatives to think about."

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