Source: Samir Parmar, MPH, HIV & Opioid Epidemiologist at Marion County Public Health Department; Michael Butler, Director of Ryan White HIV Services Program at Marion County Public Health Department
The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) manages Part A, Minority AIDS Initiative (MAI), and Part C funding to address the needs of people living with HIV (PLWH) in central Indiana. The RWSP works in the Ryan White Part A transitional grant area (TGA). TGA counties include Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby County. The primary goal of this summary is to provide insight to providers on current disparities among the aging PLWH in Central Indiana to target disparities and improve health outcomes among the sub-population of aging PLWH in the TGA.
- In 2016, CDC reported that 61.0% of PLWH in the US were over 45+ years old, and 28.5% were 55+ years old.
- In 2018, 55.3% (n=3,399) of the TGA’s PLWH were 45+ years old and 27.3% (n=1,682) were adults 55+ years old.
- The majority of 55+ PLWH in the TGA are male, White, or MSM.
- It is vital that support services are provided to improve the health of aging PLWH, so that they remain healthy and engaged in care.
The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) manages Part A, Minority AIDS Initiative (MAI), and Part C funding to address the needs of people living with HIV/AIDS (PLWH) in central Indiana, including those out of care or historically underserved or uninsured. The RWSP has received Part C funding since 1991, and Part A/MAI funding since 2007. The program helps out-of-care clients gain access to points of entry, provides a comprehensive HIV continuum of care, and complies with the National HIV/AIDS Strategy (NHAS). 1 RWSP is designed to address the needs of PLWH in the Indianapolis Transitional Grant Area (TGA). TGA counties include Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby County. Rates were calculated per 100,000 TGA residents at risk. The primary goal of this summary is to provide insight to providers on current disparities among the aging PLWH in Central Indiana to target disparities and improve health outcomes among the sub-population.
Older People Living with HIV in Central Indiana
People with HIV are living longer, healthier lives. Many PLWH who are diagnosed in a timely manner, with access to medical care and treatment adherence, can expect to live as long as their peers who do not have HIV. 2 In 2018, there were 6,149 total PLWH in the TGA. Adults 45 years and older accounted for over 55.3% (n=3,399) of the TGA’s PLWH and adults 55 year and older for 27.3% (n=1,682). Similarly, in 2016, CDC reported that 61.0% (n=509,905) of PLWH in the US were 45 years and older and 28.5% (n=238,075) were 55 years and older. 3
The majority of 55+ PLWH in the TGA are male, White, or MSM. By gender, the majority of PLWHA over 55 were male (83.0%; n=1,396). By race/ethnicity among PLWH over 55 year old, 55.2% (n=928) were White, 37.3% (n=627) were Black, 3.7% (n=627) were Hispanic, and 1.1% (n=65) were Asian/Pacific Islander. By exposure, 62.3% (n=1,048) of PLWH over 55 were men who have sex with men (MSM).
Approximately 63.6% of adult 55 years and older living with HIV have been diagnosed with AIDS at some point in their lives. 76.6% (n=36) of all deaths for people with HIV (regardless of cause) were among individuals 45 years and older in 2018. When examining the death rate by age groups of PLWH (per 1,000 PLWH), 25-34 year olds had 4.8, 45-54 year olds had 5.8, 55-64 year olds had 13.9, and 65+ year olds had 20.5. In comparison, the whole TGA (per total living TGA population) had a death rate for 25-34 year olds of 1.73, 45-54 year olds of 4.27, 55-64 year olds of 9.47, and 65+ of 44.7. Death rate among all TGA PLWH compared to the general population is greater than the general population until age 65 and then it is lower. This is likely due to the impact of late diagnosis or poor treatment adherence within the first year of HIV diagnosis resulting in early death. 2 Additionally, similar to other age groups, of PLWH 55 and older over a quarter (24.8%; n=418) did not have a viral load test in 2018. In comparison, 29% (N=501) of 45-54 year olds, 26% of 35-44 year olds (N=336), 27% (N=327) of 25-34 year olds, and 28% (N=59) of 20-24 year olds did not have a viral load test. Of PLWH 55 years and older with a viral load test, 91.3% of 55-64 year olds and 92.3% of 65+ year olds were virally suppressed.
Public Health Significance
Evidence suggests that a majority of PLWH living in the TGA are over the age of 45. It appears that individuals over 55 who get a viral load test are more likely to be virally suppressed compared to younger age groups. Unfortunately, nearly a quarter of 55+ PLWH did not obtain a viral load test in 2018. Such cases are generally presumed to be unsuppressed. It is recommended that PLWH obtain annual viral load tests. Many may opt to not do so and still remain adherent to ART. The proportion of such PLWH who do not get annual viral load testing in the calendar year and are still adherent and virally suppressed is unknown.
It is vital the support services are provided to improve the health of aging PLWH, so that they remain healthy and engaged in care. 4,5 In the RWSP, many elders living with HIV share similar concerns to aging as the general population. How do I pay for healthy food and nutritional supplements on a fixed income? How do I pay for uncovered medical expenses and car repairs? And while these concerns are similar, they can be amplified because of concerns about the costs of HIV medications. In addition, the RWSP has been asked about assistance with burial costs, medications not covered by insurance programs, items which are not eligible Ryan white Program expenses. Elder clients also seek assistance with getting reinstated on Medicare or Medicaid.
Clinicians and care providers should be aware of common comorbidities among aging PLWH. Researchers estimate that 50% of PLWH have HIV-Associated Neurocognitive Disorders (HAND). 3 Many people with HAND experience depression and psychological distress. There is also an increased risk among older PLWH of cardiovascular disease, bone loss, certain cancers, and chronic inflammation. 5,6 Special considerations include depression due to illness, or loss of family and friends. 5
HIV-related discrimination can also occur in untrained assisted living facilities. Particularly, stigma from nursing home/long term care staff and other residents can affect the mental health of aging PLWH. 7
Oftentimes, people feel the need to hide their sexual orientation from nursing home staff or other residents to avoid discrimination, abuse or neglect. Training of elder care providers on the unique needs of older PLWH is vital to resolve misbeliefs among staff members and residents who may hold inaccurate beliefs on HIV transmission. It is also vital that elderly care providers be trained on LGBT issues in order to provide nondiscriminatory, culturally competent care. 7 Furthermore, social networking websites may also be used to reduce social isolation that aging PLWH may feel, and social marketing campaigns targeting the general public, health care providers, and long term care facilities to reduce stigma toward aging PLWH should be considered. 7
1. January 31, C. S. H. govDate last updated: & 2017. National HIV/AIDS Strategy: Updated to 2020. HIV.gov https://www.hiv.gov/federal-response/national-hiv-aids-strategy/nhas-update (2017).
2. Life expectancy for people living with HIV. aidsmap.com http://www.aidsmap.com/about-hiv/life-expectancy-people-living-hiv.
3. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data—United States and 6 Dependent Areas, 2017. 24, 74.
4. September 13, C. S. H. govDate last updated: & 2019. Aging with HIV. HIV.gov https://www.hiv.gov/hiv-basics/living-well-with-hiv/taking-care-of-yourself/aging-with-hiv (2019).
5. HIV Among People Aged 50 and Over | Age | HIV by Group | HIV/AIDS | CDC. https://www.cdc.gov/hiv/group/age/olderamericans/index.html (2019).
6. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. AIDSinfo https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/37/whats-new-in-the-guidelines-.
7. Cahill, S. & Valadéz, R. Growing Older With HIV/AIDS: New Public Health Challenges. Am. J. Public Health 103, e7–e15 (2013).