Individuals older than 50 who have HIV or AIDS confront a daily dilemma. How do they balance keeping the disease under control with treating other health issues that are common problems in middle age and older? It’s a juggling act that challenges healthcare providers as much as it does their patients.
HIV or Something Else?
Over time, the infection and treatment side effects can potentiate and mimic age-related illnesses. The overlap of signs and symptoms, coupled with false assumptions equating age with physical decline, make it easy to overlook other diseases.
“If HIV/AIDS doesn’t stimulate aging, it simulates it,” says Jeanine Reilly, RNC, LNHA, executive director of Broadway House for Continuing Care, Newark, N.J.
As patients live longer, experts are learning how aging, HIV, and HAART (highly active antiretroviral therapy) and other medications interact with other medications and about the disease’s long-term consequences.
Even when HIV is controlled, early onset can have a lasting impact. “In as few as six months, HIV medications can cause metabolic disorders, including diabetes, lipid changes, high blood pressure, and cardiac disease, even in younger patients,” says Donna Gallagher, RNCS, ANP, director of the New England AIDS Education and Training Center, Boston.“I keep on track, or the train will stop.” Terrry Powell, 56, a patient at Howard Brown Health Center in Chicago, who was diagnosed with HIV 24 years ago
As patients age, more issues can arise. “Living with HIV intensifies normal aging and impairments and increases the risk of other diseases, both from treatment and the disease process,” says Daliah Mehdi, RN, clinical operations manager at Howard Brown Health Center in Chicago.
In addition to metabolic disorders, health problems can include neuropathies, dementia, cognitive impairments, some cancers, lung disease, anemia, vaginal and urinary infections, and osteoporosis.
Comorbidities have moved these patients from the province of infectious disease specialists to specialists in primary care, med/surg, orthopedics, cardiology, and other areas. But healthcare providers can go off-course by either ignoring or concentrating on HIV.
“For the most part, we’re not dying, we’re living, and we need more specialty care as we age,” says Richard Ferri, ANP, PhD, ACRN, former president and national director for the Association of Nurses in AIDS Care and an HIV-positive nurse practitioner at Crossroads Medical, Harwich, Mass. “Many clinicians get so focused on HIV that they forget patients may have comorbidities. As long as my numbers or labs pertaining to my HIV stay good, they feel they have provided me with good care. I increasingly have to ask my nurse and primary clinician to do what I do as a practicing NP — take my vital signs, check my ECG, examine my prostate, update my immunizations, etc. I am lucky because I know what to ask and what to demand.”“I have a very good life, I have great friends and family, and I have my independence.” Dennis Kelly, 61, a patient at Howard Brown, who was diagnosed with HIV in 1985 and AIDS in 1997
Some people in their 60s and older have lived with HIV for decades, primarily because of HAART. The number of infected middle-age Americans quadrupled during the 1990s. By 2010, about half of HIV/AIDS patients will be older than 50.
Dennis Kelly, 61, a patient at Howard Brown Health Center in Chicago, was diagnosed with HIV in 1985, when little information was known about the disease. The virus converted to AIDS in 1997. He has been treated with the newest medications for the disease and almost died twice from opportunistic infections, but he now has an undetectable viral load and T-cell level that lingers around 150. “I live as close to a stress-free life as possible,” he says. “I have a very good life, I have great friends and family, and I have my independence.”
While Kelly has none of the chronic health conditions that often occur in middle age, he does have muscle wasting and finds it difficult to maintain his weight, common problems of AIDS and HAART.
“HIV is now a chronic disease and [patients[‘]] healthcare rests on primary care providers and specialists for comorbidities related to aging,” says researcher Stephen Karpiak, PhD, associate director at the AIDS Community Research Initiative of America in New York City. ACRIA research found 91% of older patients have one clinical comorbidity and 77% have two or more. Among them, about half are clinically depressed, and about 30% have arthritis, hepatitis, neuropathy, and/or hypertension, all of which can impact self-care.
Terry Powell, 56, another Howard Brown patient, knows he is depressed but prefers to deal with it on his own rather than taking antidepressants. He has been HIV positive for 24 years but has yet to convert to AIDS. He has chronic obstructive pulmonary disease from smoking when he was younger, peripheral neuropathy in his feet and hands, and wasting syndrome from HAART. But his viral load continues to remain undetectable. He credits his continuing HIV status to seeing the same physician at Howard Brown for many years and to following his medication regimen 99% of the time. “I keep on track, or the train will stop,” he says.
A mixed bag of health issues can lead to a complicated medication regimen. “Older patients may have complex regimens from multiple providers, increasing risks for side effects and interactions,” says Robert Skeist, RN, MS, ACRN, nurse manager at the Family Treatment Center of Newark (N.J.) Beth Israel Medical Center, an affiliate of the St. Barnabas Health Care System.
Helping HIV-positive elders manage medications is an essential nursing intervention. “If compliance falls below 95% — missing as few as two doses a month — there’s a significant risk of developing resistance,” says Mehdi.
“Although there are 27 approved HIV meds, they’re in only six different classes,” and resistance to one drug extends to the rest of its class, Mehdi continues. “Patients may take just one pill a day, and an aging patient may forget a dose. The slightest change can cause resistance, and it happens horribly often.”
Sometimes missing a dose is deliberate because side effects such as nausea, vomiting, diarrhea, fatigue, and pain mean patients feel “taking the medications can be, and often is, sheer hell,” says Ferri. Nurses can encourage adherence by explaining that side effects will dissipate over time or can be alleviated by taking doses at a certain time, watching their diet, taking other medications, or altering the HIV regimen.
Nurses also can intervene to offset gaps and delays when patients lose, lack, or switch insurance or public assistance programs and when formularies drop their particular regimens. “States have various drug distribution programs, and we’ve also worked with some drugstores to get patients on HIV medications before they get the complete paperwork or insurance coverage,” says Skeist, who was named Nursing Spectrum’s 2007 Nurse of the Year in the community service category for his work with patients with HIV/AIDS.
Specific antiretrovirals can impede or potentiate other drugs, sometimes critically. “In combination with HIV meds, the blood level of Viagra increases, dangerously, 10 to 20 times,” says Skeist. “A patient on protease inhibitors who takes a 50 mg prescription gets the equivalent of a 500 mg overdose, which can knock out cardiovascular function.”
Other products commonly taken by seniors can cause problems for HIV patients, including OTC medications such as proton pump inhibitors; prescription drugs such as erectile dysfunction treatments; and many herbs and supplements such as St. John’s Wort, milk thistle, gingko, niacin, and excessive Vitamin C. “They may block the effectiveness or potentiate HIV medications or increase side effects,” says Gallagher.
Many complementary therapies such as tai chi, massage, and meditation are safe and may enhance well-being, say Skeist and Mehdi.
Nurses should continue to have discussions with older patients about safe sex and healthy living. Just because people are older or have been HIV positive for years, they don’t stop having sex or using drugs, says Boone; to try to feel better, they may do more, and with more partners. “Older people, particularly men, won’t talk to each other about problems and prevention,” she says. “We need nurses to do it for them.”