AIDS drugs a mixed blessing for older patients

By CANDACE RONDEAUX, Times Staff Writer
© St. Petersburg Times
published November 27, 2002

ST. PETERSBURG -- When AIDS drug therapies were first introduced nearly a decade ago, they almost doubled the life expectancy of people diagnosed with HIV and AIDS overnight. But now some medical experts say there's a downside: older people are suffering serious health complications caused by the wonder drugs themselves.

For some of Dr. Jeffrey Levenson's patients, the medicines that revolutionized AIDS treatment a few years ago have been miracles, prolonging lives for months or years. But for the dozens of middle-aged and elderly AIDS patients that Levenson treats, the drugs have been anything but a quick fix.

"With older patients, they may have been sick for other reasons, and HIV compounds the problem. And if they're on some of these new medications, it might be more complicated," said Levenson, an infectious disease specialist in St. Petersburg.

"I've seen increased rates of kidney failure, increased rates of blood disorders and special types of cancers," he said.

In 1999, 13.4 percent of all AIDS cases occurred in people over 50, according to the Centers for Disease Control and Prevention, which was up from about 10 percent a little under a decade ago. And many health experts say that number may increase as millions of baby boomers enter their retirement years.

People 50 and older account for 8 percent of Pinellas County HIV cases to date. But twenty-two percent of the county's HIV cases involve people in their 40s. In Hillsborough County, 9 percent of HIV cases fall in the 50-plus group, while 24 percent of people with HIV are in their 40s. This next generation of middle-aged people with HIV/AIDS could create a crisis of care for nursing homes and geriatric specialists.

Doctors like Levenson are especially worried about the trend. With drug treatments now creating a new class of patients who can sometimes survive as long as 15 years with the virus, more research needs to be done on how the new drugs affect older people, he said.

When Shaun, one of Levenson's older patients, tested positive for HIV in 1985, survival was the last thing on his mind.

"I thought I was going to be dead in a couple of years," Shaun said. He asked to be identified by only his first name for fear of reprisals from his neighbors who don't know he has AIDS.

About 40 when he tested positive for HIV, Shaun, of St. Petersburg, is now 58. And now he is coping with full-blown AIDS, diabetes and hypertension.

Shaun, like many HIV patients, had been taking a "cocktail" of several drugs, including protease inhibitors, which block the growth of the enzyme that enables the virus to multiply.

A few months ago, however, he was forced to eliminate the AIDS cocktail from his 52-pill daily arsenal after he began having severe gastrointestinal problems. He is convinced the protease inhibitors caused his diabetes and other health problems.

"At my age, it gets so your system just can't take the protease inhibitors anymore," he said.

Dr. Amy Justice, an associate professor at the University of Pittsburgh's School of Medicine, is concerned about the broader consequences of long-term exposure to highly toxic treatments for middle-aged AIDS patients like Shaun.

"I believe that reflects the future wave of HIV. People are going to be aging, and more and more people are going to be taking" the powerful medications, known as anti-retrovirals, Justice said.

Although Justice believes the combination drug therapy used to retard growth of the virus is necessary for many HIV-positive people and AIDS patients, she said the severe side effects for older patients need to be studied.

"The meds cause diabetes. Similarly, the meds are known to cause hypertension. If you have HIV and Hepatitis B, we have no reason to think that Hepatitis B is caused by HIV but it is exacerbated by the treatment. How susceptible you are to the toxicity depends on how old you are," Justice said.

That's why she is leading one of the first major studies on HIV-positive people 50 years and older. Last year, Justice, a staff physician at the VA Medical Center of Pittsburgh, received $11-million in grants from the National Institute on Alcohol and Alcohol Abuse and the National Institute of Mental Health to conduct a five-year study. That seven-city study on the effects of aging, anti-retroviral drug therapies and alcohol use on HIV-positive patients, will survey 6,000 people over 50 at Veterans Affairs hospitals.

Justice said alcohol, the sedative of choice for many older HIV-positive patients, is an especially important factor to look at because it could exacerbate liver damage caused in part by anti-retroviral HIV drugs.

Along with growing concern about treatment hazards, health care specialists and AIDS educators worry that many middle-age and elderly people are still in denial about their risk of infection. People who lose their partners to death or divorce find themselves back in a dating mainstream that has changed drastically.

Jim Campbell, president of the National Association of HIV Over Fifty, said he frequently encounters people his age who don't realize that in most cases the only thing that stands between them and infection is a condom.

"In people 65 and up, we have a population of people who always thought about condoms as birth control and nothing more than that," Campbell said.

Colette Vallee, a project coordinator at the University of South Florida's Senior HIV/AIDS Prevention and Education program, or SHAPE, counsels health care providers and individuals about HIV in middle-age and elderly people. She said many doctors do not ask older patients for their sexual history because they assume they are not as sexually active. For many doctors, the face of HIV and AIDS is still considerably younger.

"We don't like to think about our grandparents having sex," Vallee said."But if the equipment is working, we're going to use it."

Vallee, whose program will soon be shut down because of cuts in state funding for health care programs, said the trend of infections in older adults is especially disturbing in a state like Florida, where thousands of older vacationers arrive each winter season.

"Snowbirds are very active people and to think that they're celibate is not realistic," she said.

Tom Liberti, chief of the state health department's bureau of HIV/AIDS, said he hopes to keep helping winter residents and older Floridians despite the closing of the SHAPE program next year.

"We're in a state that's well known in the U.S. for having a large elderly population," Liberti said, "so I feel it's on our shoulders to take the lead in this respect."

-- Times researchers John Martin and Kitty Bennett contributed to this report.

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