As HIV population grows older, diseases of aging a new dilemma

Old age doesn't creep slowly on Lou Grosso like it does on other 57-year-olds. Signs of aging bombard him.

Grosso has high cholesterol and plaque in his arteries, his joints hurt and his memory is not as sharp as it used to be. But the aches of aging don't deter the San Francisco native from enjoying his life, which includes building web sites and white-water rafting.

After all, when he was diagnosed with AIDS in 1986, doctors didn't think he'd live past age 35.

Thanks to better treatments and powerful medicines, HIV is now often manageable and not the killer it was two decades ago. People infected with HIV are living longer, but doctors are finding that many in this group are showing signs of premature or accelerated aging.

"I know I'm getting older," said Grosso, who also copes with blindness not related to HIV infection. "So is that why I have the aches and pains and memory issues? Or is it because I have been taking all those antiretroviral drug cocktails that have been keeping me alive all these years? I never thought I would live this long to ask these questions."

Scientists are trying to determine if these ailments are a result of HIV ravaging body organs and the immune system over the long haul, side effects of the potent therapies or a combination of both.

"Conditions that you might normally see in patients in their 60s or 70s are showing up in HIV patients who are only in their 40s and 50s," said Dr. Brad Hare, Grosso's doctor and medical director of the UCSF Positive Health Program at San Francisco General Hospital.

The longer life expectancy of those infected with HIV presents a new challenge for patients and health care providers: keeping the AIDS-causing virus in check and at the same time battling high blood pressure, heart disease, diabetes, cancer, bone loss, arthritis and cognitive decline.

A grant the California HIV/AIDS Research Program of the University of California awarded in December will provide funds to develop and evaluate programs that integrate HIV and geriatric services for HIV/AIDS patients who are 50 and older. Researchers at the San Francisco Department of Public Health and UCSF received a three-year grant to study new models of care and offer best-practice guidelines for treating HIV and aging throughout California.

The efforts are timely and urgent. In the U.S., more than 1 million people today are living with HIV, and that number is growing. The AIDS Community Research Initiative of America, which presented study findings at a White House meeting on HIV and aging last fall, projects that half of all people living with HIV will be over age 50 by 2015. It also surveyed 1,000 HIV-positive men and women and found that 91 percent are also battling chronic medical conditions associated with aging.

At his clinic, which serves 3,000 people with HIV, the average age of patients is 46, said Hare, a co-investigator in the new research project. "We're seeing from other UC research — at the clinical and molecular level — that the immune systems of people with HIV look older than non-infected people of the same age."

Dr. Malcolm John, director of 360: The Positive Care Center at UCSF, began noticing trends of accelerated aging, especially cardiovascular diseases, among his older HIV patients a few years ago. "We've had patients with mild hypertension or lipid abnormalities — nothing ragingly bad — who develop angina and heart problems quickly," said John, who also is an investigator in the new UC study aimed at finding the best ways to treat older HIV patients.

And it's not just heart disease. John tells of a patient who was diagnosed with a massive lung tumor even though his previous visits and tests showed that the cancer was tiny and confined. Clinicians are seeing diseases in multiple body organs, osteoporosis and even early signs of Alzheimer's in people with HIV. When John noticed the phenomena, he gathered physicians and researchers to study the link between HIV and aging, and 360-UCSF started a program for people over 50 with HIV.

The new project funded by the California HIV/AIDS Research Program could speed solutions for health care systems that soon may be burdened by a growing and aging population of HIV patients with special needs. The study will build and assess programs based on the "Patient-Centered Medical Home" model of care, which is a community-based system of coordinated care, treatment, prevention and support services.

The new research project, said John, will integrate geriatric specialists who offer a different perspective than infectious disease experts, identify which and when screenings tests should be conducted to monitor for diseases of aging, and bring in nutritionists and pharmacists as essential members of the care team.

Patients are prescribed a variety of drugs to combat HIV, and with many now taking more medicines for other chronic conditions, adherence to drug regimens and watching for side effects are critical. Grosso, for example, takes 10 pills in the morning and another three at night for HIV, high cholesterol and pain in his joints.

UCSF's Hare adds that services in the new programs will address more than the physical aspects of HIV disease and aging, with plans to include psychologists and social support staff.

"Just on the psychology side, a lot of patients suffer from depression," he said. "Many have seen friends and peers die over the years. The majority of people with HIV live alone and many are poor. Adding the troubles that go with aging can be tough."

UC programs, such as those directed by Hare and John, already are touted as models for comprehensive care for HIV/AIDS patients in general, and they hope those developed for older people with HIV will, too, set standards in the state and the nation.

"It's our legacy and responsibility at UC to be leaders in research and caring for people with HIV," said Hare.