Aging Clin Exp Res DOI 10.1007/s40520-014-0222-2
POINT OF VIEW
Enhancing awareness to mitigate the risk of HIV/AIDS in older adults Emine Meral Inelmen • Giuseppe Sergi Marina De Rui • Enzo Manzato
•
Received: 27 September 2013 / Accepted: 8 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract HIV is often assumed to only affect younger people, and many older people do not realize that they might risk acquiring the virus. Given that sexual transmission is by far the most common way to contract HIV around the world, health care professionals do not usually pay enough attention to the possibility of HIV/AIDS in older adults, based on the common conviction that they no longer have any sexual desires and that they are sexually inactive. Nevertheless, the sexual behavior of older people is likely to change over time, as aging baby boomers progress into their 60s and 70s, meeting the criteria for ‘‘successful aging’’, and not conforming to the stereotype of ‘‘sexless elderly’’. Hence the urgent need to awareness is that HIV remains as a major health threat even in advanced age. Prompt diagnosis and treatment are especially crucial in older adults because of their general frailty and high comorbidity levels. This article reviews recent literature concerning HIV/AIDS in older adults, as regard the related epidemiological, clinical and public health issues, with a view to suggesting how the rising rate of HIV transmission in this age group might be mitigated, and shows the main points that HCP should tackle to identify older people at risk of HIV infection. In summary, there is a pressing need to develop effective prevention schemes and to adapt clinical and programmatic approaches to improve the survival of older people with HIV.
E. M. Inelmen G. Sergi M. De Rui E. Manzato Geriatric Section, Department of Medicine-DIMED, University of Padova, Padua, Italy G. Sergi (&) Clinica Geriatrica, Ospedale Giustinianeo (2° piano), via Giustiniani 2, 35128 Padua, Italy e-mail: [email protected]
Keywords HIV prevention Epidemiology HIV/AIDS Risk behavior Education
Introduction The perception that HIV is a problem only for young people and not for older adults needs to be dispelled, given that in the next 5 years more than half of all HIVinfected patients will be aged over 50 years [1]. HIV burden is even wider in developing countries, in which the number of HIV infections in the older adults is expected to increase by about 50 % in the next 15 years [2]. Thus, the number of older people with HIV will have a considerable impact on the future course of the epidemic [2, 3], with a resulting increase in the economic costs for the health care. Given that sexual transmission is by far the most common mode of HIV transmission globally [4], usually health care providers (HCP) do not pay sufficient attention to the possibility of HIV/AIDS in older adults, being a common opinion that they are sexually inactive [5]. On the contrary, older adults remain sexual beings with desires, fantasies and active sex lives, and the majority of even the ‘‘oldest old’’ (people over 85 years old) still engage in a spousal or other intimate relationship [5]. Furthermore, in older adults comorbidities can confound the clinical scenario and make it difficult to diagnose HIV infection. Undiagnosed HIV infection thus contribute to its transmission [6]. Hence, there is an urgent need to acknowledge that HIV remains a major health threat even in advanced age also because thanks to antiretroviral therapy, a person diagnosed HIV-positive and aged 20 years can expect to be alive well into their 60s [7].
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Aging Clin Exp Res Table 1 Main causes of HIV/AIDS in older adults Patients infected with HIV/ AIDS in earlier age
Increasing number of HIV survivors due to effective treatments
The increase will be particularly pronounced among men:\1 in 12 HIV-infected people is aged over 50 in 2010 but in 2040 this will be one in four [2].
Long incubation period from HIV infection to AIDS diagnosis Underestimation of the risk of acquiring HIV
Misbelief that HIV affects mostly young people Unawareness of the possibility of older men acquiring HIV Low health literacy Health care providers’ failure to provide information on HIV/AIDS
Behavior facilitating HIV transmission
Cultural reluctance to use condoms Purchasing the services of sexual workers Multiple partners and homosexual behavior Use of phosphodiesterase type 5 inhibitors
This article reviews recent literature concerning HIV/ AIDS in older adults with regard to epidemiologic, clinical and public health issues with a view to suggesting how the increase in the rate of HIV transmission in this age group may be mitigated.
Methods This literature review was conducted on available electronic journals, abstracts, reports, and any other relevant sources. Publications in English, German, French or Dutch on the topic of interest, dating from 1980 to 2013, were identified by means of an exhaustive search strategy in the Medline, Medscape and Embase, using the following terms: ‘‘HIV/AIDS’’, ‘‘epidemiology’’, ‘‘transmission’’, ‘‘awareness’’, ‘‘aging’’, ‘‘sexual behavior’’, ‘‘prevention’’, ‘‘homosexuality’’.
Epidemiology Relatively little attention has been paid to older patients with HIV infection in the past, thus few studies have documented HIV infection among older persons [8]. Estimates from the Centers for Disease Control (CDC) show a high rate of HIV infection: in 2008 about 29 % of the entire population living with HIV was aged over 50 years [9]. Furthermore, recent estimates for Sub-Saharan Africa predict that HIV prevalence in patients aged 50 and older will nearly double in the next 30 years from 9 % in 2010 to 17 % in 2040, whereas the fraction of HIV-infected patients aged 50 and over will triple in the same period [3].
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Risk-taking behavior and HIV transmission Risk-taking behaviors which are main causes of increasing rates of HIV/AIDS in older age are reported below and summarized in Table 1. Patients infected with HIV/AIDS at an earlier age With effective treatments now more widely available, the number of people surviving for years after testing positive for HIV has increased [10]. In addition, the frequently long incubation period before HIV infection develops into AIDS contributing to the rising incidence of the disease among older adults. Underestimation of the risk of contracting HIV in older old Older people’s generally low health literacy makes them unlikely to be informed about HIV/AIDS risk [11]. One of the main causes of the increasing rate of HIV/AIDS in older adults is failure to use condoms. Some older men are reluctant to take preventive measures even after they have been diagnosed with HIV or when purchasing the services of sex workers [12]. The use of phosphodiesterase type 5 inhibitors also complicates this issue because the availability of such medication has meant that some older adults who would otherwise have become sexually inactive turn to extramarital sexual activity. Homosexual behavior With the increasing age of the general population, the proportion of older homosexual adult has raised [2], and nearly 1 million homosexuals have been estimated to be over 65 [13]. For homosexuals unprotected anal sex is one of the greatest risk factors identified for HIV transmission [14] with obvious implications for spread. Besides, most older homosexuals lack a permanent partner; and partly for fear of being stigmatized, they may avoid medical examinations or provide false information [15]. Undiagnosed cases A delay in the diagnosis enhances HIV transmission. HCP often do not associate AIDS with older adults, and cases of HIV infection are not diagnosed until AIDS develops [12]. It is sometimes difficult to collect information on older
Aging Clin Exp Res
people’s sex lives because they may be reluctant to report ‘‘socially censured’’ behavior or refuse to be tested for HIV for fear of their family’s reactions [12].
AIDS [13] may be overlooked in older adults, so that they undergo the workup for other diseases but not for HIV.
Awareness and prevention Survival comorbidity and mortality Survival and comorbidity In older adults, seroconversion is followed by higher viral loads compared to the young, and being older at this time is strongly associated faster disease progression and shorter survival [6], particularly in males [16]. Besides, patients aging with HIV are more likely to develop comorbidities and at an earlier age than those who are HIV-uninfected [3]. These conditions include coronary artery disease, dyslipidemia, some cancers, metabolic syndrome and dementia [3]. In addition, these conditions as well as malnutrition and disability worsen overall survival among older adults living with HIV [3]. Delayed diagnosis in elderly people may affect antiretroviral therapy response [6] that can cause severe adverse effects due to the frailty of this group of patients [6]. Mortality In developing countries, as Kenya, AIDS in people aged 50 and older is the most frequent cause of death, causing 18.3 % of deaths in males and 15.8 % in females [17]. Immune senescence may contribute to the gap in survival between older and younger people [6]. In particular, older persons, who tend to have lower CD4? lymphocyte counts, are more likely than younger ones to die within the same month of diagnosis of such infection [18].
Up to now, population aged 50 years and over has been largely excluded from HIV testing services [8], and few prevention programs have specifically focused on older adults [19]. The majority of this kind of interventions has been conceived for the African population, in which HIV/ AIDS is endemic but the proportion of older adults was very scarce [7]. HIV/AIDS prevention is a personal responsibility, and HCP play an important role in enhancing people’s awareness and education. Figure 1 is a roadmap which shows the main points that HCP should tackle to identify older people at risk of HIV infection. Interviews should include a comprehensive assessment, and a person’s sexual history should be collected preferably questioning both husband and wife separately to guarantee confidentiality and bring to light any discrepancies concerning their sexual behavior. The assessment should focus particularly on medication, sexual behavior, substance abuse and psychosocial aspects. Clinical assessments should make suspected signs and symptoms of HIV infection emerge. In cases with any risk factors for HIV infection, HCP should inform patients about HIV/AIDS and the importance of being tested. If patients refuse to be tested, their awareness should be enhanced and HIV testing should be recommended periodically during their follow-up. If they test positive, they should be referred to the infectious diseases clinic.
Conclusion Diagnostic issues AIDS is frequently described as ‘‘the great imitator’’, with the spectrum of HIV disease in older adults ranging from nonspecific symptoms to AIDS-defining illnesses. Many symptoms such as fatigue, weight loss, night sweats and diminished appetite masquerade as part of the normal process of aging and may be dismissed as such by HCP. There have been several case reports of HIV presenting ‘‘atypically’’ in older patients with AIDS; in each case, the diagnosis of HIV infection was significantly delayed because care providers thought that HIV infection was very unlikely [13]. Also new-onset and rapidly progressing dementia, solid tumors, dermatologic manifestations and opportunistic infections that in a younger patient would suggest HIV/
At present, the health care infrastructure is ill-equipped to handle the care needs of HIV-positive older adults, although the aging people are growing worldwide and they are at the same risk of HIV/AIDS as their younger counterparts. There is, therefore, a pressing need to develop effective prevention interventions and to adapt clinical and programmatic approaches to improve survival among older people. Moreover, political will is needed to mobilize governments worldwide, and thus improving access to health care services for HIV/AIDS infected older people. As the difficulties in diagnosing HIV infection is particularly challenging in patients [50 years of age, HCP need to discuss sexual behavior with them, in order to be able to recognize as early as possible the symptoms of HIV/AIDS, given also the expanded availability of antiretroviral therapies.
123
Aging Clin Exp Res Fig. 1 How health care providers could approach older adults at risk of HIV/AIDS
Key policy changes could greatly improve health outcomes for HIV-positive older persons by increasing access to treatment and support. Acknowledgments Inelmen.
Our sincerest gratitude goes to Prof. Erol
Conflict of interest
None to declare.
References 1. Effros RB, Fletcher CV, Gebo K et al (2008) Workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 47:542–553 2. Hontelez JAC, Lurie MN, Newell ML et al (2011) Ageing with HIV in South Africa. AIDS 25:1665–1673
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3. Negin J, Martiniuk A, Cumming RG et al (2012) Prevalence of HIV and chronic comorbidities among older adults. AIDS 26(Suppl 1):S55–S63 4. Scharnhorst S (1992) AIDS dementia complex in the elderly. Diagn Manag Nurse Pract 37:41–43 5. Inelmen EM, Sergi G, Girardi A et al (2012) The importance of sexual health in the elderly: breaking down barriers and taboos. Aging Clin Exp Res 24(3 Suppl):31–34 6. Justice AC, Weissman S (1998) The survival experience of older and younger adults with AIDS: is there a growing gap in survival? Res Aging 20:665–685 7. Mills EJ, Rammahan A, Awafeso N (2010) Ageing faster with AIDS in Africa. Lancet 377:1131–1133 8. Negin J, Cumming RG (2010) HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data. Bull World Health Organ 88:847–853 9. CDC (2010) HIV/AIDS Surveillance Report, 2008, vol 20. Centers for Disease Control and Prevention, Atlanta. http://www. cdc.gov/hiv/surveillance/resources/ reports/2008/index.html
Aging Clin Exp Res 10. Padian NS, Isbell MT, Russell ES, Essex M (2012) The future of HIV prevention. J Acquir Immune Defic Syndr 60:S22–S26 11. Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D (2000) Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med 18(4):325–331 12. Inelmen EM, Gasparini G, Enzi G (2005) HIV/AIDS in older adults: a case report and literature review. Geriatrics 60:26–30 13. Chiao EY, Ries KM, Sande MA (1999) AIDS and the elderly. CID 28:740–745 14. Johnson WD, Diaz RM, Flanders WD et al (2008) Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database Syst Rev (3):CD001230. doi:10.1002/14651858.CD001230.pub2 15. Tokarski Z, Florkowski A, Talarowska M et al (2012) Assessment of psychosocial attitudes among homosexual men. Pol Merkur Lekarski 189:167–169
16. Negin J, van Lettow M, Semba M, Martiniuk A, Chan A, Cunning RG (2011) Anti-retroviral treatment outcomes among older adults in Zomba District, Malawi. Plos One 6(10):e26546. doi:10. 1371/journal.pone.0026546 17. Negin J, Wariero J, Cumming RG, Mutuo P, Promyk PM (2010) High rates of AIDS-related mortality among older adults in rural Kenya. J Acquir Immune Defic Syndr 55:239–244 18. Mills EJ, Bakanda C, Birungi J et al (2011) Life expectancy of persons receiving combination antiretroviral therapy in lowincome countries: a cohort analysis from Uganda. Ann Intern Med 155:209–216 19. (2009) AIDS epidemic update: December 2009. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). http://data.unaids.org/pub/report/2009/ jc1700_epi_update_2009_en.pdf
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POINT OF VIEW
Enhancing awareness to mitigate the risk of HIV/AIDS in older adults Emine Meral Inelmen • Giuseppe Sergi Marina De Rui • Enzo Manzato
•
Received: 27 September 2013 / Accepted: 8 April 2014 Ó Springer International Publishing Switzerland 2014
Abstract HIV is often assumed to only affect younger people, and many older people do not realize that they might risk acquiring the virus. Given that sexual transmission is by far the most common way to contract HIV around the world, health care professionals do not usually pay enough attention to the possibility of HIV/AIDS in older adults, based on the common conviction that they no longer have any sexual desires and that they are sexually inactive. Nevertheless, the sexual behavior of older people is likely to change over time, as aging baby boomers progress into their 60s and 70s, meeting the criteria for ‘‘successful aging’’, and not conforming to the stereotype of ‘‘sexless elderly’’. Hence the urgent need to awareness is that HIV remains as a major health threat even in advanced age. Prompt diagnosis and treatment are especially crucial in older adults because of their general frailty and high comorbidity levels. This article reviews recent literature concerning HIV/AIDS in older adults, as regard the related epidemiological, clinical and public health issues, with a view to suggesting how the rising rate of HIV transmission in this age group might be mitigated, and shows the main points that HCP should tackle to identify older people at risk of HIV infection. In summary, there is a pressing need to develop effective prevention schemes and to adapt clinical and programmatic approaches to improve the survival of older people with HIV.
E. M. Inelmen G. Sergi M. De Rui E. Manzato Geriatric Section, Department of Medicine-DIMED, University of Padova, Padua, Italy G. Sergi (&) Clinica Geriatrica, Ospedale Giustinianeo (2° piano), via Giustiniani 2, 35128 Padua, Italy e-mail: [email protected]
Keywords HIV prevention Epidemiology HIV/AIDS Risk behavior Education
Introduction The perception that HIV is a problem only for young people and not for older adults needs to be dispelled, given that in the next 5 years more than half of all HIVinfected patients will be aged over 50 years [1]. HIV burden is even wider in developing countries, in which the number of HIV infections in the older adults is expected to increase by about 50 % in the next 15 years [2]. Thus, the number of older people with HIV will have a considerable impact on the future course of the epidemic [2, 3], with a resulting increase in the economic costs for the health care. Given that sexual transmission is by far the most common mode of HIV transmission globally [4], usually health care providers (HCP) do not pay sufficient attention to the possibility of HIV/AIDS in older adults, being a common opinion that they are sexually inactive [5]. On the contrary, older adults remain sexual beings with desires, fantasies and active sex lives, and the majority of even the ‘‘oldest old’’ (people over 85 years old) still engage in a spousal or other intimate relationship [5]. Furthermore, in older adults comorbidities can confound the clinical scenario and make it difficult to diagnose HIV infection. Undiagnosed HIV infection thus contribute to its transmission [6]. Hence, there is an urgent need to acknowledge that HIV remains a major health threat even in advanced age also because thanks to antiretroviral therapy, a person diagnosed HIV-positive and aged 20 years can expect to be alive well into their 60s [7].
123
Aging Clin Exp Res Table 1 Main causes of HIV/AIDS in older adults Patients infected with HIV/ AIDS in earlier age
Increasing number of HIV survivors due to effective treatments
The increase will be particularly pronounced among men:\1 in 12 HIV-infected people is aged over 50 in 2010 but in 2040 this will be one in four [2].
Long incubation period from HIV infection to AIDS diagnosis Underestimation of the risk of acquiring HIV
Misbelief that HIV affects mostly young people Unawareness of the possibility of older men acquiring HIV Low health literacy Health care providers’ failure to provide information on HIV/AIDS
Behavior facilitating HIV transmission
Cultural reluctance to use condoms Purchasing the services of sexual workers Multiple partners and homosexual behavior Use of phosphodiesterase type 5 inhibitors
This article reviews recent literature concerning HIV/ AIDS in older adults with regard to epidemiologic, clinical and public health issues with a view to suggesting how the increase in the rate of HIV transmission in this age group may be mitigated.
Methods This literature review was conducted on available electronic journals, abstracts, reports, and any other relevant sources. Publications in English, German, French or Dutch on the topic of interest, dating from 1980 to 2013, were identified by means of an exhaustive search strategy in the Medline, Medscape and Embase, using the following terms: ‘‘HIV/AIDS’’, ‘‘epidemiology’’, ‘‘transmission’’, ‘‘awareness’’, ‘‘aging’’, ‘‘sexual behavior’’, ‘‘prevention’’, ‘‘homosexuality’’.
Epidemiology Relatively little attention has been paid to older patients with HIV infection in the past, thus few studies have documented HIV infection among older persons [8]. Estimates from the Centers for Disease Control (CDC) show a high rate of HIV infection: in 2008 about 29 % of the entire population living with HIV was aged over 50 years [9]. Furthermore, recent estimates for Sub-Saharan Africa predict that HIV prevalence in patients aged 50 and older will nearly double in the next 30 years from 9 % in 2010 to 17 % in 2040, whereas the fraction of HIV-infected patients aged 50 and over will triple in the same period [3].
123
Risk-taking behavior and HIV transmission Risk-taking behaviors which are main causes of increasing rates of HIV/AIDS in older age are reported below and summarized in Table 1. Patients infected with HIV/AIDS at an earlier age With effective treatments now more widely available, the number of people surviving for years after testing positive for HIV has increased [10]. In addition, the frequently long incubation period before HIV infection develops into AIDS contributing to the rising incidence of the disease among older adults. Underestimation of the risk of contracting HIV in older old Older people’s generally low health literacy makes them unlikely to be informed about HIV/AIDS risk [11]. One of the main causes of the increasing rate of HIV/AIDS in older adults is failure to use condoms. Some older men are reluctant to take preventive measures even after they have been diagnosed with HIV or when purchasing the services of sex workers [12]. The use of phosphodiesterase type 5 inhibitors also complicates this issue because the availability of such medication has meant that some older adults who would otherwise have become sexually inactive turn to extramarital sexual activity. Homosexual behavior With the increasing age of the general population, the proportion of older homosexual adult has raised [2], and nearly 1 million homosexuals have been estimated to be over 65 [13]. For homosexuals unprotected anal sex is one of the greatest risk factors identified for HIV transmission [14] with obvious implications for spread. Besides, most older homosexuals lack a permanent partner; and partly for fear of being stigmatized, they may avoid medical examinations or provide false information [15]. Undiagnosed cases A delay in the diagnosis enhances HIV transmission. HCP often do not associate AIDS with older adults, and cases of HIV infection are not diagnosed until AIDS develops [12]. It is sometimes difficult to collect information on older
Aging Clin Exp Res
people’s sex lives because they may be reluctant to report ‘‘socially censured’’ behavior or refuse to be tested for HIV for fear of their family’s reactions [12].
AIDS [13] may be overlooked in older adults, so that they undergo the workup for other diseases but not for HIV.
Awareness and prevention Survival comorbidity and mortality Survival and comorbidity In older adults, seroconversion is followed by higher viral loads compared to the young, and being older at this time is strongly associated faster disease progression and shorter survival [6], particularly in males [16]. Besides, patients aging with HIV are more likely to develop comorbidities and at an earlier age than those who are HIV-uninfected [3]. These conditions include coronary artery disease, dyslipidemia, some cancers, metabolic syndrome and dementia [3]. In addition, these conditions as well as malnutrition and disability worsen overall survival among older adults living with HIV [3]. Delayed diagnosis in elderly people may affect antiretroviral therapy response [6] that can cause severe adverse effects due to the frailty of this group of patients [6]. Mortality In developing countries, as Kenya, AIDS in people aged 50 and older is the most frequent cause of death, causing 18.3 % of deaths in males and 15.8 % in females [17]. Immune senescence may contribute to the gap in survival between older and younger people [6]. In particular, older persons, who tend to have lower CD4? lymphocyte counts, are more likely than younger ones to die within the same month of diagnosis of such infection [18].
Up to now, population aged 50 years and over has been largely excluded from HIV testing services [8], and few prevention programs have specifically focused on older adults [19]. The majority of this kind of interventions has been conceived for the African population, in which HIV/ AIDS is endemic but the proportion of older adults was very scarce [7]. HIV/AIDS prevention is a personal responsibility, and HCP play an important role in enhancing people’s awareness and education. Figure 1 is a roadmap which shows the main points that HCP should tackle to identify older people at risk of HIV infection. Interviews should include a comprehensive assessment, and a person’s sexual history should be collected preferably questioning both husband and wife separately to guarantee confidentiality and bring to light any discrepancies concerning their sexual behavior. The assessment should focus particularly on medication, sexual behavior, substance abuse and psychosocial aspects. Clinical assessments should make suspected signs and symptoms of HIV infection emerge. In cases with any risk factors for HIV infection, HCP should inform patients about HIV/AIDS and the importance of being tested. If patients refuse to be tested, their awareness should be enhanced and HIV testing should be recommended periodically during their follow-up. If they test positive, they should be referred to the infectious diseases clinic.
Conclusion Diagnostic issues AIDS is frequently described as ‘‘the great imitator’’, with the spectrum of HIV disease in older adults ranging from nonspecific symptoms to AIDS-defining illnesses. Many symptoms such as fatigue, weight loss, night sweats and diminished appetite masquerade as part of the normal process of aging and may be dismissed as such by HCP. There have been several case reports of HIV presenting ‘‘atypically’’ in older patients with AIDS; in each case, the diagnosis of HIV infection was significantly delayed because care providers thought that HIV infection was very unlikely [13]. Also new-onset and rapidly progressing dementia, solid tumors, dermatologic manifestations and opportunistic infections that in a younger patient would suggest HIV/
At present, the health care infrastructure is ill-equipped to handle the care needs of HIV-positive older adults, although the aging people are growing worldwide and they are at the same risk of HIV/AIDS as their younger counterparts. There is, therefore, a pressing need to develop effective prevention interventions and to adapt clinical and programmatic approaches to improve survival among older people. Moreover, political will is needed to mobilize governments worldwide, and thus improving access to health care services for HIV/AIDS infected older people. As the difficulties in diagnosing HIV infection is particularly challenging in patients [50 years of age, HCP need to discuss sexual behavior with them, in order to be able to recognize as early as possible the symptoms of HIV/AIDS, given also the expanded availability of antiretroviral therapies.
123
Aging Clin Exp Res Fig. 1 How health care providers could approach older adults at risk of HIV/AIDS
Key policy changes could greatly improve health outcomes for HIV-positive older persons by increasing access to treatment and support. Acknowledgments Inelmen.
Our sincerest gratitude goes to Prof. Erol
Conflict of interest
None to declare.
References 1. Effros RB, Fletcher CV, Gebo K et al (2008) Workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 47:542–553 2. Hontelez JAC, Lurie MN, Newell ML et al (2011) Ageing with HIV in South Africa. AIDS 25:1665–1673
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3. Negin J, Martiniuk A, Cumming RG et al (2012) Prevalence of HIV and chronic comorbidities among older adults. AIDS 26(Suppl 1):S55–S63 4. Scharnhorst S (1992) AIDS dementia complex in the elderly. Diagn Manag Nurse Pract 37:41–43 5. Inelmen EM, Sergi G, Girardi A et al (2012) The importance of sexual health in the elderly: breaking down barriers and taboos. Aging Clin Exp Res 24(3 Suppl):31–34 6. Justice AC, Weissman S (1998) The survival experience of older and younger adults with AIDS: is there a growing gap in survival? Res Aging 20:665–685 7. Mills EJ, Rammahan A, Awafeso N (2010) Ageing faster with AIDS in Africa. Lancet 377:1131–1133 8. Negin J, Cumming RG (2010) HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data. Bull World Health Organ 88:847–853 9. CDC (2010) HIV/AIDS Surveillance Report, 2008, vol 20. Centers for Disease Control and Prevention, Atlanta. http://www. cdc.gov/hiv/surveillance/resources/ reports/2008/index.html
Aging Clin Exp Res 10. Padian NS, Isbell MT, Russell ES, Essex M (2012) The future of HIV prevention. J Acquir Immune Defic Syndr 60:S22–S26 11. Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D (2000) Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med 18(4):325–331 12. Inelmen EM, Gasparini G, Enzi G (2005) HIV/AIDS in older adults: a case report and literature review. Geriatrics 60:26–30 13. Chiao EY, Ries KM, Sande MA (1999) AIDS and the elderly. CID 28:740–745 14. Johnson WD, Diaz RM, Flanders WD et al (2008) Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database Syst Rev (3):CD001230. doi:10.1002/14651858.CD001230.pub2 15. Tokarski Z, Florkowski A, Talarowska M et al (2012) Assessment of psychosocial attitudes among homosexual men. Pol Merkur Lekarski 189:167–169
16. Negin J, van Lettow M, Semba M, Martiniuk A, Chan A, Cunning RG (2011) Anti-retroviral treatment outcomes among older adults in Zomba District, Malawi. Plos One 6(10):e26546. doi:10. 1371/journal.pone.0026546 17. Negin J, Wariero J, Cumming RG, Mutuo P, Promyk PM (2010) High rates of AIDS-related mortality among older adults in rural Kenya. J Acquir Immune Defic Syndr 55:239–244 18. Mills EJ, Bakanda C, Birungi J et al (2011) Life expectancy of persons receiving combination antiretroviral therapy in lowincome countries: a cohort analysis from Uganda. Ann Intern Med 155:209–216 19. (2009) AIDS epidemic update: December 2009. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). http://data.unaids.org/pub/report/2009/ jc1700_epi_update_2009_en.pdf
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