HIV Prevention and Care

Older adults remain sexually active but are less likely to use condoms for HIV prevention. They are equally less likely to be involved in HIV risk reduction behaviors as well as in carrying out routine HIV testing. As such, they are usually diagnosed at late stages of the disease. Older adults who acquire HIV are likely to have persistent low CD4 count and poor response to ART, and, of course, higher morbidity and mortality. Therefore, HIV prevention among older adults ought to be taken seriously.

More than 50% of PLWH in the United States are over age 50. Because of the advent of ARTs, PLWH are living longer, and life expectancy between HIV-infected and HIV-uninfected persons has become very similar. So a lot of people are now aging with HIV, and this number will continue to rise in ensuing years. These persons aging with HIV have a number of additional challenges to deal with, including multimorbidity, polypharmacy, physical inactivity, nonproductivity, social isolation, and dementia. Care of older adults with HIV has not been sufficiently studied. Therefore, more research is needed to explore how care of older adults with HIV can be ameliorated.

BACKGROUND/STATEMENT OF THE PROBLEM

Preventing HIV Transmission Among Older Adults

  1. Acquisition of HIV is possible in all age groups, including older adults. Sexual transmission remains the most common method of transmission among young and older adults. Older adults remain sexually active, and perhaps even more so when pregnancy may not be an issue after women reach menopause (Eden & Kevan, 2009).
  2. About 58% of all cases of HIV in adults over 50 are acquired through sexual intercourse (CDC, 1999).
  3. Adults over 50 are less likely to be engaged in HIV risk behaviors compared to younger persons (Costagliola, 2014) as well as being less likely to use condoms, that is, a low-cost and easily accessible method to decrease transmission if used properly (UNAIDS, 2014).
  4. Considering that sexual intercourse is the principal mode of HIV transmission among adults aged 50 and over reaffirms the likelihood of the need to address sexual risk behaviors in prevention efforts among older adults (Chiao et al., 1999).
  5. Older adults often usually consider HIV testing very late in the acute phase of the infection compared to younger persons (Negin et al., 2012).
  6. Persons who acquire HIV who are over 50 years old usually have persistently low CD4 counts (little immunity strength) and thus poor response to treatment compared to younger persons (Costagliola, 2014; McDonald et al., 2013).
  7. Even when older adults have initiated treatment for HIV, they maintain a lower CD4 count for a sustained period of time before any improvement is noticed, putting them at higher risk for disease progression and death (Costagliola, 2014).

Caring for Older Adults Living With HIV

  1. In the population of PLWH, the burden of multimorbidity is higher than expected with regards to age alone (Brown & Guaraldi, 2017).
  2. The longer one lives with HIV, the higher the likelihood that he/she suffers from the chronic inflammatory response.
  3. With the advent of ART, PLWH are now living longer to reasonable old age (WHO Regional Office for South-East Asia, 2013), thus, giving room for prolonged HIV inflammatory response.
  4. Multimorbidity is associated with polypharmacy, which is the need for more than five different drugs within a given time (Gleason et al., 2013).

NURSING STRATEGIES

  1. HIV prevention among older adults must take sexual transmission into strong consideration because it is the major mode of transmission in this age group.
  2. More studies are needed on HIV attitudes, awareness, testing, and prevention among older adults (Sprague & Brown, 2017).
  3. Nurses caring for older adults with HIV must include mental health to their package of care. This should take into consideration the substantial impact of sociodemographic variables which interlace to affect mental well-being among older PLWH such as class, gender, race, and sexual orientation (Furlotte & Schwartz, 2017).
  4. Having acute care units for the older adults only has been found to produce better results than caring for older adults in acute care units for the general population (Krall et al., 2012).
  5. To improve personal control among older adults with HIV: (a) there should be improvements in nurse-patient communication in order for the nurse to become more aware of the psychological needs of the patient; and (b) Nurses should be trained on identifying patients with very low personal control as well as delayed psychological adaptation (McVey, Madill, & Fielding, 2001).
  6. Increase community awareness on the importance of palliative care for older PLWH through sharing of best practices (Shorthill & DeMarco, 2017).
  7. Make members of the community recognize the value of higher quality of life among older PLWH, which can be attained through palliative care (Kovacs et al., 2006).
  8. Establish more opportunities for interdisciplinary studies with focus on older PLWH (Harkness & DeMarco, 2016).
  9. Promote comprehensive follow-up care of older PLWH in the community (Greene et al., 2015).

ABBREVIATIONS

ART            Antiretroviral therapy

CDC            Centers for Disease Control and Prevention

HIV             Human immunodeficiency virus

PLWH         People living with HIV infection

UNAIDS     Joint United National Programme on HIV/AIDS

WHO           World Health Organization

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Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 32:  DeMarco, R., & Manga, S. (2021) HIV Prevention and Care for the Older Adult.    In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 577-593).   New York: Springer.

REFERENCES

Brown, T. T., & Guaraldi, G. (2017). Multimorbidity and burden of disease. In M. Brennan-Ing & R. F. DeMarco (Eds.), HIV and aging (pp. 59–73). Basel, Switzerland: Karger. Evidence Level V.

Centers for Disease Control and Prevention. (1999). AIDS among persons aged>50 years: United States, 1991–1996. Atlanta, GA: Author. Evidence Level I.

Chiao, E., Ries, K., & Sande, M., (1999). AIDS and the elderly. Clinical Infectious Diseases, 28, 740–745. doi:10.1086/515219. Evidence Level V.

Costagliola, D. (2014). Demographics of HIV and aging. Current Opinion in HIV and AIDS, 9, 294–301. doi:10.1097/COH.0000000000000076. Evidence Level I.

Eden, K. J., & Kevan, R. W. (2009). Quality of sexual life and menopause. Women’s Health, 5(4), 385–396. doi:10.2217/whe.09.24. Evidence Level IV.

Furlotte, C., & Schwartz, K. (2017). Mental health experiences of older adults living with HIV: Uncertainty, stigma, and approaches to resilience. Canadian Journal on Aging, 36(2), 125–140. doi:10.1017/S0714980817000022. Evidence Level IV.

Gleason, L. J., Luque, A. E., & Shah, K. (2013). Polypharmacy in the HIV infected older adult population. Clinical Interventions and Aging, 8, 749–763. doi:10.2147/CIA.S37738. Evidence Level IV.

Greene, M., Covinsky, K. E., Valcour, V., Miao, Y., Madamba, J. Lampiris, H., … Deeks, S. G. (2015). Geriatric syndromes in older HIV-infected adults. Journal of Acquired Immune Deficiency Syndrome, 69, 161–167. doi:10.1097/QAI.0000000000000556. Evidence Level V.

Harkness, G. A., & DeMarco, R. (2016). Community and public health nursing: Evidence for practice. Philadelphia, PA: Lippincott Williams and Wilkins. Evidence Level V.

Joint United Nations Programme on HIV and AIDS. (2014). The gap report. Geneva, Switzerland: UNAIDS. Retrieved from http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report. Evidence Level V.

Kovacs, P. J., Bellin, M. H., & Fauri, D. P. (2006). Family-centered care: A resource for social work in end-of-life and palliative care. Journal of Social Work in End of Life Palliative Care, 2, 13–27. doi:10.1300/J457v02n01_03. Evidence Level V.

Krall, E., Close, J., Parker, J., Sudak, M., Lampert, S., & Colonnelli, K. (2012). Innovation pilot study: Acute care for elderly (ACE) unit-promoting patient-centric care. Health Environments Research and Design Journal, 5(3), 90–98. doi:10.1007/s10592-007-9394-z. Evidence Level IV.

McDonald, K., Elliott, J., & Saugeres, L. (2013). Aging with HIV in Victoria: Findings from a qualitative study. HIV Australia, 11, 13. Retrieved from https://www.afao.org.au/article/ageing-hiv-victoria-findings-qualitative-study/. Evidence Level IV.

McVey, J., Madill, A., & Fielding, D. (2001). The relevance of lowered personal control for patients who have stoma surgery to treat cancer. British Journal of Clinical Psychology, 40(4), 337–360. doi:10.1348/014466501163841

Negin, J., Nemser, B., Cumming, R., Lelerai, E., Amor, Y. Ben, & Pronyk, P. (2012). HIV attitudes, awareness and testing among older adults in Africa. AIDS and Behavior, 16(1), 63–68. doi:10.1007/s10461-011-9994-y. Evidence Level IV.

Shorthill, J., & DeMarco, R. F. (2017). The relevance of palliative care in HIV and aging. In M. Brennan-Ing & R. F. DeMarco (Eds.), HIV and aging (pp. 159–172). Basel, Switzerland: Karger. Evidence Level V.

Sprague, C., & Brown, S. M. (2017). Local and global HIV aging demographics and research. In M. Brennan-Ing & R. F. DeMarco (Eds.), HIV and aging (pp. 159–172). Basel, Switzerland: Karger. Evidence Level V.

World Health Organization Regional Office for South-East Asia. (2013). Regional health sector strategy on HIV, 2011–2015. -Geneva, Switzerland: Author. Evidence Level V.

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