As HIV Turns 30, Attention Turns to an Aging Epidemic

hiv ribbon(BlackDoctor.org) — Just two months before the 30th anniversary of the first reported cases of HIV in the United States, the Leadership Council of Aging Organizations (LCAO )—a network of national aging organizations—released its official recommendations for the upcoming reauthorization of the Older Americans Act, the country’s primary vehicle for delivering services to older people at the local level.

Addressing Needs of Older Americans Living with HIV

At the urging of SAGE, in partnership with several diverse aging and HIV organizations, the LCAO is promoting seven recommendations to include lesbian, gay, bisexual and transgender (LGBT) elders in the provisions of the Older Americans Act, and a critically important recommendation to help address the needs of older people living with HIV.  LCAO is encouraging the federal government to address the service needs of “the growing number of older adults living with HIV and the related health disparities, discrimination and stigma.”

Why are these recommendations happening now? Our country is witnessing two major demographic shifts. First, as a large wave of Baby Boomers begins entering retirement age, we’re concurrently seeing larger and larger numbers of “out” LGBT older people. Second, thanks to the medical advances in HIV-related treatment, many people who have HIV/AIDS are living longer lives—and, thus, the “graying” of HIV in this country.

Today, approximately 28% of people living with HIV in the U.S. are over 50. By 2017 that number is projected to grow to 50%. In addition, it is estimated that 15% of all new HIV infections occur in people over 50. And the available data clearly documents that the AIDS epidemic has disproportionately affected men who have sex with men, gay and bisexual men, people of color and transgender people—of all ages, including elders. More than 1,000 diagnoses of HIV infection were reported among MSM age 55 and older each year from 2006-2009, according to CDC data (PDF 260KB).

Trends Creating Greater Health Risks for Older Adults

As a direct service provider with a long history of supporting LGBT older people living with HIV/AIDS, SAGE is deeply concerned about the severe challenges that face our elders. For example, in one study, 80% of LGBT older people with HIV lived alone, compared to 67% of older heterosexuals living with HIV[1].  We know from our experience working with LGBT older people living with HIV that the harmful effects of such social isolation include depression, poor nutrition and premature mortality. In addition, fear of discrimination often prevents LGBT elders from seeking the health care they need until it is too late, which means they can first present with advanced HIV infection (i.e., AIDS) leading to worse health outcomes.

And, too often, HIV prevention messages ignore LGBT older people or assume that older people are not sexually active. Together, these trends create greater health risks for older adults.

Earlier this month, the U.S. Department of Health and Human Services’ Administration on Aging addressed some of these issues in their special webinar, Positive Aging: HIV Turns 30. The webinar, featuring Kathy Greenlee, Assistant Secretary for Aging at HHS, and SAGE’s Doreen Bermudez, among others, focused on educating the Aging Network about HIV prevention and treatment specific to older adults. If you were not able to participate live, please consider viewing the archive, available at AoA’s Older Adults and HIV/AIDS webpage. The National Institute on Aging at NIH also has an Age Page on HIV, AIDS and Older People.

As we reflect on the past 30 years of the AIDS epidemic and its impact on the LGBT community, SAGE is focused on working with partners across the aging and HIV fields, and government, to address the needs of older people living with HIV, many of whom are LGBT. Solutions to these issues include improved research and data collection on older people living with HIV; prevention messages that target elders of all sexual orientations and gender identities; more programs that acknowledge and address the fact that LGBT older people and/or older adults living with HIV often have inadequate support from their communities or families of origin; and training, such as that offered by SAGE’s National Resource Center on LGBT Aging , for aging services and healthcare providers about the unique needs of elders living with HIV/AIDS.

These are only the first steps to improving the quality of life for older people living with HIV. But they’re critically important ones.

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Hepatitis C Spreads Rampantly Amongst HIV-Positive Men

(BlackDoctor.org) — There is an ongoing “explosion” of deadly hepatitis C among men who have sex with men.

It’s spread mainly by anal sex, often enhanced by methamphetamine, according to a report in the July 21 issue of the CDC’s Morbidity and Mortality Weekly Report.

“We are having an explosion of sexually transmitted hepatitis C,” study researcher Daniel S. Fierer, MD, of New York’s Mount Sinai School of Medicine. “We have uncovered an emerging epidemic of sexual transmission of hepatitis C. And the main reason is men having anal sex without a condom.”

It’s no surprise to experts who treat hepatitis C. Liver cancer and cirrhosis caused by hepatitis C virus (HCV) already is the leading cause of death among people with HIV infection who have access to HIV drugs. Some 30% of Americans with HIV are co-infected with HCV.

Sexual transmission of HCV among people without HIV is rare, notes Eugene R. Schiff, MD, director of the Center for Liver Diseases at the University of Miami, who was not involved in the Fierer/CDC study. Among heterosexual couples, he says, only 2% of those with HCV infect their partners after 20 years of monogamous marriage.

The same may be true for men who have sex with men — if they practice safe sex.

“Our data do not support sexual HCV transmission between HIV-negative men,” Fierer says. “There is reasonable data that HIV-negative men are not part of this epidemic.”

But that’s not the case for HIV-positive men, notes Lynn E. Taylor, MD, of Brown University. Taylor was not involved in the Fierer study. In a study published last March, Taylor and her colleagues showed that new HCV infections are relatively common among HIV-positive men who do not use intravenous drugs — a phenomenon previously reported in Europe and Australia.

“We have robust evidence of increasing HCV incidence among men who have sex with men who do not inject drugs but do engage in high-risk sexual behaviors,” Taylor, who was not involved in the Fierer study. “It is the new sexually transmitted infection in this population. I am very concerned.”

Schiff notes that when HIV-positive men get HCV, they have much higher levels of the hepatitis C virus in their blood. Taylor and Schiff warn that hepatitis C infection progresses quickly in people with HIV infection.

“These men are sitting ducks for liver cancer,” Taylor says. “If they don’t get treated and get HCV eradication, they are at risk of cirrhosis or liver cancer. … We are seeing tons of gay men newly diagnosed with HIV, and then with HCV. I could go to a funeral of an HCV patient every week.”

Anal Sex, Methamphetamine Linked to HCV

Fierer and colleagues gave detailed questionnaires to 34 HIV-positive men with new hepatitis C infections, as well as to 67 closely matched HIV-positive men who tested negative for HCV. In detailed questioning and interviews, the men denied any form of intravenous drug use — even the use of prescription testosterone.

There was “quite a laundry list” of behaviors linked to new HCV infections. But careful statistical analysis revealed two factors that independently raised an HIV-positive man’s risk of HCV infection:

Receptive anal intercourse with ejaculation of the partner increased HCV risk 23-fold.
Having sex while high on methamphetamine increased HCV risk 28.5-fold.
“This is a smoking gun for classic sexual transmission with semen,” Fierer says.

Fierer warns that while the study implicates semen, it does not suggest that anal sex without ejaculation is safe. It isn’t. And a troubling study of outbreaks of HCV among HIV-positive German men suggested last March that prolonged or traumatic anal intercourse often exposes both partners to infected blood.

As for methamphetamine, Fierer says the problem is that it removes sexual inhibitions while prolonging the sex act.

“Crystal meth is an incredibly disinhibiting drug. This is very much used for sex, and judgment and all kinds of other things go out the window,” he says. “Patients tell me, ‘Well, now it seems like a very bad idea to take meth and have unprotected sex with a partner who ejaculates in you. But at the time it seemed like a great idea.”

Taylor warns that using erectile dysfunction drugs to prolong sex also appears to be a risk factor for HCV transmission among HIV-positive men.

Sex-Spread HCV Threatens New HCV Treatments

New HCV treatments make it much more likely that a person can be cured of hepatitis C. But there’s a catch.

Schiff notes that a person can be infected with hepatitis C over and over again. He’s already seen patients who seem to be getting better with treatment, and then suddenly are reinfected.

That’s going to be a problem, he says, because powerful new hepatitis C drugs have an Achilles heel — the virus quickly becomes resistant. If a person is reinfected with HCV during treatment with one of the new drugs, there’s a good chance the virus will acquire resistance to all similar drugs.

“If people are re-exposed to HCV after treatment with new antivirals, there will be resistant virus,” he predicts.

Taylor predicts the same thing.

“The rates of HCV reinfection in HIV-positive men appear to be much higher than in other groups,” she says. “So just like syphilis, they come in with hepatitis C again and again. … [It is] a definite reality we are going to be dealing with drug-resistant hepatitis C by the end of this year.”