Human Immunodeficiency Virus

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Human immunodeficiency virus (HIV) is the cause of a worldwide pandemic with estimates that 50-100 million individuals will be infected by the year 2000. (See also Chapter 25.) Although acquired immunodeficiency syndrome (AIDS) is primarily a disease of young persons, elderly persons are also affected and diagnosis is frequently unrecognized (81-83). As of June 1996, 10% of the AIDS cases in the United States were in persons older than age 50 (81). Of these, 28% were over age 60 and 13% were 65 yr and older. Until recently, the primary source of HIV in the elderly was blood transfusion during the period between 1978 and 1985. Currently, the most common risk factor among AIDS patients over age 50 is homosexuality. It is estimated that in the United States, one million homosexuals persons are aged 65 and older (82). Intravenous drug use ranks second and a history of blood transfusion now ranks third as the most common HIV risk factors in older persons (82). In addition, older adults have a greater probability of having no identifiable risk factors that may reflect heterosexual transmission from at-risk partners (81,82). Finally, older at-risk Americans are much less likely to have adopted AIDS-preventing strategies than persons in their twenties (84). Persons over age 50 are one-sixth as likely to use condoms during sex and one-fifth as likely to have ever been HIV tested.

HIV infection appears to progress more rapidly in older persons. Age over 40 yr is an independent risk factor for poor survival among patients with transfusion-related AIDS (85). Older AIDS patients who develop an AIDS-defining opportunistic infection are also more likely to progress quickly and die. Approx 37% of persons over age 80 die within the same month as they have AIDS diagnosed compared with 12% in young adults (82). The decreased survival time is likely due to a combination of comorbid disease, immunosenescence, and most importantly, delayed diagnosis (81,83). In general, the most frequent illness in older persons with HIV infection is bacterial pneumonia, although opportunistic infections do occur and are similar to those in younger AIDS patients. A significant problem in the elderly is AIDS dementia, as it may be mistaken for Alzheimer's disease or Parkinson's disease. If unrecognized, the opportunity for a trial of antiretroviral medication is lost. Regardless of age, all patients with clinical syndromes compatible with AIDS should be evaluated for HIV infection.

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