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Staying Positive

Jon Reinfurt

Staying Positive (continued)

Still, certain conditions related to the infection are beginning to concern Burnett. The neuropathy long in her feet, a common drug side effect, is now affecting her legs as well. But most worrying is her memory, which was always razor sharp. Cognitive impairment has long been observed in some HIV-positive patients; Burnett, a self-admitted fanatic about taking her medication on schedule, says, “After 20 years of being very adherent, I’m [now] forgetting to take my medication. And they’re right beside my bed. [But] some days it’s not even on the radar screen,” she says. “A few months ago my pharmacist called me to say, ‘Ms. Burnett, isn’t it time to refill your medication?’ And it hit me, because I had forgotten so often that I had so many pills left in all the bottles that it didn’t occur to me that it was time to call in my renewal. That made my blood turn cold.”

With so many potential co-morbidities to observe and quantify, public health officials are being conservative when it comes to making hard and fast clinical recommendations specifically related to aging HIV patients (though it should be noted that numerous Hopkins clinicians who treat HIV-infected patients say they’re relatively aggressive when it comes to screening for suspected linked conditions, including bone loss, metabolic syndromes, liver disease and kidney function).

Still, researchers have some strong opinions regarding areas of potential therapeutic value to HIV patients. “Smoking has such a high prevalence among populations living with HIV. Depending upon which cohort we look at here, prevalence runs between 60 and 80 percent,” says David Holtgrave, PhD, chair of Health, Behavior and Society. “We’re trying to convince funders to support work that examines the best way to do smoking cessation interventions among persons living with HIV.”

Lisa Jacobson says she’d like to see more clinical emphasis on anal cancer screening.  “A lot of literature coming out, including our own, is showing the incidence of anal cancer is much higher in HIV-infected gay men than uninfected men.” Jacobson especially points to screening for co-infections common to certain HIV-positive populations. In addition to doing anal pap smears looking for HPV that can lead to anal cancer, she notes the high vulnerability of HIV-infected IV drug users to HCV (hepatitis C virus) that can lead to liver cancer and other serious hepatic issues.

“It’s clear that HIV fuels the fire of hepatitis C,” agrees Gregory Lucas, MD, PhD,  an associate professor in Infectious Diseases at Johns Hopkins School of Medicine.  “Having HIV and hepatitis C  causes liver disease progression that’s on the order of sevenfold faster than in HIV-uninfected people with hepatitis C.”

A few months ago, Marilyn Burnett’s pharmacist called to remind her to refill her medications. “I had forgotten so often that I had so many pills left. It didn’t occur to me to call in my renewal,” she says. “That made my blood turn cold.”

Lucas adds that keeping a close eye on kidney disease, his prime area of study, is equally important. “There’s no question chronic kidney disease is increased with HIV infection and, potentially, its treatments. The order of magnitude in what I’d call well-characterized HIV-positive and HIV-negative populations is threefold to fivefold higher risk, what I’d call unequivocal. In African-Americans in particular, the risk of end-stage kidney disease is increased at least 10-fold with HIV infection.”

But perhaps the strongest recommendations for screening have to do with finding those estimated 21 percent of infected Americans who don’t know they are already HIV-positive, as well as people who don’t perceive themselves to be at risk, notably sexually active elders. The over-50 population is the fastest growing group of those newly infected with HIV. And while drug toxicities have greatly dropped, there’s evidence that the infection is harder to combat in older populations, perhaps because their immune systems have been compromised by age. While the CDC recommends HIV testing up to age 64, John Bartlett, MD, professor of Infectious Diseases at Hopkins Medicine, notes the American College of Physicians suggests upping the age of testing to 75.

One thing is clear: Many sexually active elders are surprised that HIV could possibly affect their lives. Bloomberg School epidemiologist and physician Kelly Gebo says, “I’ve been to several senior centers and [asked], ‘How many people here have had a high-risk HIV behavior?’ and they’ve had no idea. Then I ask, ‘How many people here have had unprotected sex?’ and many of them raise their hand. I then say, ‘Well, all of you have been at risk.’ And they look at me like ‘what, are you crazy? Only reckless young people or drug users get that. Not people who go to my church!’”

Gebo, MD, MPH, an associate professor in Medicine and in Epidemiology, adds that “getting people diagnosed at an older age is often hard because providers and geriatricians may feel less comfortable asking about high-risk behaviors. There’s often a ‘don’t ask, don’t tell’ principle. I ask everyone between 12 and 112, ‘Are you having sex? Anal, vaginal, or oral? With protection? With men, women, or both?’ When you ask [older] patients this, without judgment, they answer you.”

While the risks for premature aging and certain diseases are still being assessed and debated, graying patients, meanwhile, are doing their best to make life with the infection both long and vital.

“I’m extremely vigilant, and unless an asteroid drops on my head, I think I’ll be around here a long time,” laughs Chris Camp.

“And if I live to be 85, would they say I died of AIDS?”

Comments

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  • SnO-FlAkE

    leland ms 09/18/2012 11:49:30 AM

    very very gd info

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