HIV as You Get Older

Many people think of HIV as a young person's disease, but it's not. "By 2015, half of all people with HIV will be 50 or older," says Brad Hare, MD, director of the HIV/AIDS clinic at San Francisco General Hospital. This greying of the HIV population shows how well today’s HIV treatments can work.

HIV makes aging itself more complicated. But plenty of people have had HIV for years, even decades, and are doing well.  "These days, we fully expect that someone with HIV will live a long, healthy life," says Christine A. Wanke, MD, professor of medicine and director of the nutrition and infection unit at Tufts University School of Medicine. "But that means they have to plan ahead and adopt the healthy habits to stay that way, just like anyone without HIV."

HIV and Aging: 5 Common Challenges

As you get older with HIV, you may face issues including:

1. Other conditions. Just like anybody, getting older means you're more likely to have health problems, and HIV seems to bump up the risk even more. "HIV accelerates the aging process and magnifies its effects," says John G. Bartlett, MD, professor at the Johns Hopkins School of Medicine and director of its AIDS service. So HIV may make you more likely to get heart disease, diabetes, cancer, osteoporosis, kidney problems, and other conditions.

2. Drug interactions. Since you’re already taking medicines for HIV, additional drugs for other conditions can increase the chance of interactions.

3. Loss of support. Some people become more isolated as they age. That happens more often to people with HIV, who may also be dealing with embarrassment about the condition or strained family relationships. If you're alone and disconnected, you're more likely to get depressed.

4. Changing roles. Like many people without HIV, you may be caring for your aging parents. That can add emotional and financial pressures.

5. Difficulty adjusting. "I talk to people with HIV who say, 'I didn't expect to live to middle age,'" says Hare. "'But now I'm middle-aged and I'm probably going to live another 30 years.'" Many people who got HIV long ago didn't plan for a long life, and adjusting can be a challenge. For instance, you might not have saved for a longer life.

7 Steps to Take

1. See an HIV expert. The more your health is complicated by age and other conditions, the more crucial it is to have an expert overseeing your HIV care.

2. Get good routine medical care. Specialty HIV care is not enough. Because your risks of other medical problems are higher, keep on top of your general health, says Hare. Get your annual physicals, keep tabs on your blood pressure, cholesterol, and other tests your doctor recommends.

3. Avoid drug interactions. Make certain every doctor you see knows about every medication and supplement you take, including prescription drugs, over-the-counter products, vitamins, and natural products. Doctors may adjust your medicines, dosages, or schedules to prevent interactions.

4. Improve your lifestyle. To enjoy life as you age, stay fit. Exercise regularly, and if you smoke, stop.

5. Eat a healthy diet. Go for lots of fruits and vegetables, lean proteins, whole grains, and healthy fats. "Eating a heart-healthy diet makes sense for everyone," says Bartlett. "But because people with HIV have higher risks of heart disease, it makes even more sense for them."

6. Seek support. Having a support system of family and friends is key. Make an effort to stay connected. If close friends or family have died or moved away, work on making new friends. You might also connect through a support group.

7. Get help. Call your local health department to learn about local resources for people with HIV, says Hare. Your local Council on Aging is a good place to start; it can point you toward programs and services that could help. A financial planner may also help you work on savings and expenses.

Plant-Based Compound May Inhibit HIV

A compound found in soybeans may become an effective HIV treatment without the drug resistance issues faced by current therapies

It's in the early stages, but genistein, derived from soybeans and other plants, shows promise in inhibiting the HIV infection, says Yuntao Wu, a professor with the George Mason-based National Center for Biodefense and Infectious Diseases and the Department of Molecular and Microbiology.

Still, that doesn't mean people should begin eating large amounts of soy products. "Although genistein is rich in several plants such as soybeans, it is still uncertain whether the amount of genistein we consume from eating soy is sufficient to inhibit HIV," Wu says.

Genistein is a "tyrosine kinase inhibitor" that works by blocking the communication from a cell's surface sensors to its interior. Found on a cell's surface, these sensors tell the cell about its environment and also communicate with other cells. HIV uses some of these surface sensors to trick the cell to send signals inside. These signals change cell structure so that the virus can get inside and spread infection.

But genistein blocks the signal and stops HIV from finding a way inside the cell. It takes a different approach than the standard antiretroviral drug used to inhibit HIV. "Instead of directly acting on the virus, genistein interferes with the cellular processes that are necessary for the virus to infect cells," Wu says. "Thus, it makes the virus more difficult to become resistant to the drug. Our study is currently it its early stage. If clinically proven effective, genistein may be used as a complement treatment for HIV infection."

Wu sees possibilities in this plant-based approach, which may address drug toxicity issues as well. Because genistein is plant-derived, it may be able to sidestep drug toxicity, a common byproduct of the daily and lifelong pharmaceutical regimen faced by patients with HIV to keep the disease at bay, Wu says. Typically, patients take a combination of multiple drugs to inhibit the virus. The frequency can lead to drug toxicity. Plus, HIV mutates and becomes drug-resistant.

Wu and his team are working at finding out how much genistein is needed to inhibit HIV. It's possible that plants may not have high enough levels, so drugs would need to be developed, Wu says.

HIV/AIDS Vaccines: Defining What Works

Designing an effective HIV/AIDS vaccine is something of a paradox: a good vaccine would be safe and look enough like HIV to kick-start the immune system into neutralizing the virus -- but the problem is that this is exactly what the human immune system has trouble doing even when it's exposed to the real thing.

Now a team of researchers led by scientists at The Scripps Research Institute in La Jolla, CA has developed a strategy for inducing a key part of an effective immune response to HIV. By tracing the evolution of HIV-recognizing molecules called antibodies taken from the blood of rare individuals whose immune systems are naturally able to target and neutralize the virus, they may have found a way to replicate this for everybody.
At a talk next week at the American Crystallographic Association meeting in Hawaii, the team will present multiple crystal structures, which like detailed architectural blueprints show how the virus interacts with components of the immune system. Examining these structures has allowed them to reverse engineer molecules that specifically activate the precursors of effective, neutralizing antibodies against the virus -- molecules that may be components of a future vaccine against HIV.
"What we tried to do was to learn how those [effective] antibodies developed over the course of natural infection and attempt to guide the immune response in the direction of what we know works in certain HIV-infected individuals," said structural biologist Jean-Philippe Julien, who is presenting the work in Hawaii.
He conducted the research under the direction of Professors Ian Wilson and William Schief of The Scripps Research Institute. The work was funded by the International AIDS Vaccine Initiative Neutralizing Antibody Center, the Scripps Center for HIV/AIDS Vaccine Immunology and Immunogen Discovery and the National Institute of Allergy and Infectious Diseases (one of the National Institutes of Health). Additional support was provided through a Canadian Institutes of Health Research fellowship.
Julien cautioned that the work might not, by itself, be the final answer that shows how to make an effective HIV/AIDS vaccine -- but it is a step in the right direction. Most likely, Julien said, any future HIV/AIDS vaccine would combine multiple biological components in order to give the broadest possible protection against the virus.
He added that their candidate molecule was able to achieve the desired immune reactions in the test tube, and they are currently testing it in animals to see if it is able to kick start the desired immune response. If those experiments go well, he said, further studies will examine whether it can protect animals against infection, and human trials for safety and vaccine efficacy would be next -- though it may be years before those results are known.
While designing a vaccine against any pathogen is a long, hard process, HIV has been particularly difficult, and despite decades of efforts and hundreds of millions of dollars spent in the process, we still do not yet have an effective vaccine that can prevent infection.

Marital Status Reduces Risk of Death

At the height of the AIDS epidemic in the 1980s men who were married were significantly less likely to die of HIV/AIDS than their divorced or otherwise single counterparts

 For women, marital status had little impact on who was more likely to die of the disease. But race proved to be a significant risk factor, with African-American women nine times more likely to die of HIV/AIDS and Latinas seven times more likely to die of the disease than white women. Those mortality rates were considerably higher than those for men of color compared to white men.
The study by UCR sociology professor Augustine Kposowa -- "Marital status and HIV/AIDS mortality: evidence from the U.S. National Longitudinal Mortality Study" -- is the first to examine the effects of marital status on deaths of individuals with HIV/AIDS.

Using data from a recent release of the U.S. National Longitudinal Mortality Study and the National Death Index, Kposowa tracked nearly 763,000 individuals age 15 and older between 1983 and 1994. A total of 410 of those individuals died of HIV/AIDS in that period of time.

"These data capture when HIV/AIDS was approaching pandemic level," Kposowa explained. "People were very afraid. The perception was that only men who had sex with men were getting infected, so no one was looking at risk factors for people who were married, widowed or separated."

Kposowa's analysis of 11 years of mortality data found that marital status was a significant risk factor for men, but not women. Divorced and separated men were more than six times more likely to die of AIDS than married men, and those who had never married were 13.5 times more likely to die of the disease than those who were married. African-American men were 2.7 times as likely to die of HIV/AIDS as white men, and Hispanic men were more than twice as likely to die of the disease as white men.

"It turns out that the big story for women is race, particularly for African-Americans and Latinos," Kposowa said. "The question is, why would Latino and African-American women have been more at risk of HIV?"
The most logical explanation, Kposowa believes, relates to how little was known in the 1980s about how the HIV virus was transmitted, and a health care system that historically disadvantages the poor.

"Those without care are more likely to be minority women," he said. "It's really a function of the health care system, who has access, and how soon people seek care. So in the 1980s, poor people and minorities, who often lack information about health care, were at greater risk of death from HIV/AIDS. By the time they presented themselves for health care, the disease would have progressed."

Kposowa said his assertion is supported by other studies showing that women of color typically receive less aggressive treatment for diseases such as cancer, and that African-Americans and Hispanics are less likely to be prescribed narcotic pain medications for back pain than whites even when one takes into account pain severity. He noted that in the US, post diagnosis cancer survival rates are much lower for people of color than whites.

"The elephant in the room is the health care system and the value we put on different people because of their color and background," the sociologist added. "We don't say that consciously, but it is why the Obama administration has put so much emphasis on reducing health disparities in this country."

Pregnancy and HIV Testing

HIV, or human immunodeficiency virus, is the virus that causes AIDS (acquired immune deficiency syndrome). HIV weakens a person's immune system reducing their ability to fight infections and cancers. A person can get HIV by coming into contact with an infected person's body fluids (blood, semen, vaginal fluids, breast milk), and HIV can be spread through:

• Vaginal, oral, or anal sex
• Sharing unclean needles to take drugs
• Pregnancy (from an infected mother to baby)
• Blood transfusions (since 1985, blood donations have been routinely tested for HIV, so infection from blood transfusions is rare)

You cannot get HIV from:

• Touching or hugging someone who has HIV or AIDS
• Public bathrooms or swimming pools
• Sharing cups, utensils, telephones, or other personal items
• Bug bites

Doctors recommend all pregnant women get tested for HIV. Medications are available to prevent the spread of the virus to your unborn baby. In addition, steps can be taken during delivery to prevent spreading the infection. Some studies show a woman can further reduce the risk of spreading the virus to her baby by having a cesarean section before her water breaks. Moreover, your health care provider can take steps to help you stay healthy longer.

HIV testing is voluntary. Anyone is free to decline testing. Your decision to not get tested, or the test result itself, will not prevent you from getting health care during pregnancy.

What Do the HIV Test Results Mean?

A confirmed, positive test result means you have been infected with HIV. Being infected with HIV does not necessarily mean that you have AIDS. It can take many years for people with HIV to develop AIDS.

A negative test result means that no signs of HIV infection were found in your blood. A negative test does not always mean that you do not have HIV. Signs of HIV may not show up in the blood for several months after infection. For this reason, you should be tested again if you could have been exposed to HIV or are at risk for HIV infection.

Though HIV tests performed at most doctors offices become part of the patient's medical record, there are places you can go that provide confidential HIV testing. These places will perform HIV tests without even taking your name (anonymous testing). An anonymous HIV test does not become part of your medical record.

Should you discover that you have HIV, inform you medical providers so that you can receive proper care.

When AIDS Viruses Are Transmitted Despite Treatment

While antiretroviral drugs offer an efficient means of preventing the replication of HIV in the blood, shedding of HIV may occur in semen, so that other persons can become infected during unprotected sexual intercourse. This occurs in particular if the male genital tract also has other viral infections.

That is the conclusion reached by a scientist who is supported by the Swiss National Science Foundation (SNSF).
In principle, modern combination therapies are very effective at keeping AIDS causative agents in check. The treatment usually leads to a situation in which there is no longer any evidence of Human-Immunodeficiency Viruses (HIV) in the body. In this way, the drugs can also reduce the disease transmission rate to just one tenth. So why do new infections occur despite treatment?

Sperm containing a cocktail of viruses

The answer, according to findings recently published by the Swiss researcher Sara Gianella Weibel and her American colleagues, is that other viruses also play a role. Working at the University of California in San Diego, the SNSF-funded scientist studied the semen of 114 HIV-infected men undergoing treatment who have sex with men. She found that the seminal fluid of 11 of the men contained a considerable quantity of HI viruses, even though the viral load of the blood of all of the men was very low. In eight of these 11 cases, Gianella Weibel also found evidence of various forms of herpes.

Locally activated immune system

Some of these herpes viruses, such as cytomegalovirus, often remain unnoticed. However, if the viruses infect the male genital tract, they locally activate the immune system. As a result, there is a build-up of immune cells, including those in which HIV replicate, in the genital area. "Our data suggests that we must also direct our focus towards other viruses, if we really want to interrupt the transmission of AIDS," explains Gianella Weibel.

Myths and Facts about HIV/AIDS

Having HIV Means You Have AIDS?

Myth. Human immunodeficiency virus (HIV) is a virus that destroys the body's CD4 immune cells, which help fight disease. With the right medications, you can have HIV for years or decades without HIV progressing to AIDS. AIDS (acquired immunodeficiency syndrome) is diagnosed when you have HIV as well as certain opportunistic infections or your CD4 cell count drops below 200.

It's Difficult to Get HIV From Casual Contact?

Fact. You can't catch or spread HIV from hugging someone, using the same towel, or sharing the same glass. It's very rare to get HIV from a blood transfusion -- the U.S. blood supply is carefully tested. However, you can spread the disease from having unprotected sex, sharing needles, or getting a tattoo from unsterilized equipment.

You Have Just a Few Years to Live?

Myth. Everyone with HIV experiences it differently. Some people may develop AIDS within a few months as the virus quickly weakens their immune system. Many others can live for decades with HIV and have a normal life expectancy. You can help prevent HIV from progressing to AIDS by seeing your doctor regularly and following your doctor's recommendations.

You'll Know You Have HIV Because of Your Symptoms?

Myth. Some people don't show any signs of HIV for years after being infected. Many can have some symptoms within 10 days to a few weeks after infection. These first symptoms are similar to the flu or mononucleosis and may include fever, fatigue, rash, and sore throat. They usually disappear after a few weeks and you may not have symptoms again for several years. The only way to tell you have HIV is to get tested.

HIV Can Be Cured?

Myth. There is no cure for HIV, but treatment can keep virus levels low and help maintain your immune system. Some drugs interfere with proteins HIV needs to copy itself; others block the virus from entering or inserting its genetic material into your immune cells. Your doctor will consider your general health, the health of your immune system, and the amount of virus in your body to decide when to start treatment.

Anyone Can Get HIV?

Fact. About 56,000 people in the U.S. get HIV each year, and 18,000 people with AIDS die each year. Anyone can get HIV -- men, women, and children, people who are gay or straight. Men who have sex with men make up more than half (53%) of new HIV infections each year. Women account for 27% of new infections, and children 13%. African-Americans make up almost half of all new HIV infections each year.

Sex Is Safe When Both Partners Have HIV?

Myth. Just because you and your partner both have HIV, doesn't mean you should forget about protection when you have sex. Using a condom or other latex barrier can help protect you from other sexually transmitted diseases as well as other strains of HIV, which may be resistant to anti-HIV medication. Even if you are being treated and feel well you can still infect others.

You Can Have a Baby if You Are HIV-Positive?

Fact. Infected mothers can indeed pass HIV to their babies during pregnancy or delivery. However, you can lower the risk by working with your doctor and getting the appropriate care and medication. Pregnant women with HIV can take medications to treat their infection and to protect their babies against the virus.

You Can’t Avoid Other HIV-Related Infections?

Myth. Due to weakened immune systems, people with HIV can be vulnerable to infections like pneumocystis pneumonia, tuberculosis, candidiasis, cytomegalovirus, and toxoplasmosis. The best way to reduce your risk is to take your HIV medications. Some infections can be prevented with drugs. You can lessen your exposure to some germs by avoiding undercooked meat, litter boxes, and water that may be contaminated.

Without Insurance You Can't Get Lifesaving Drugs?

Myth. There are government programs, nonprofit groups, and some pharmaceutical companies that may help cover of the cost of HIV/AIDS drugs. But be aware: These drug "cocktails" can cost $15,000 a year. Talk to your local HIV/AIDS service organization to learn about financial help.

HIV No Barrier to Getting Liver Transplant

Liver transplants to treat a common type of liver cancer are a viable option for people infected with HIV.
 The Italian study found that the AIDS-causing virus doesn't affect survival rates and cancer recurrence after transplants among HIV patients with this particular type of liver cancer, called hepatocellular carcinoma (HCC). The study's authors noted, however, that HCC is more aggressive in people with HIV and it is becoming a major cause of death among these patients as antiretroviral treatment prolongs their lives.

The key message of this study is that liver transplantation is a valid option for HCC treatment in HIV-infected patients.
The study involved 30 HIV-positive patients and 125 patients not infected with HIV who received a liver transplant to treat HCC at three different hospitals in northern Italy between 2004 and 2009.

During a follow-up period of roughly 32 months, the researchers found a recurrence of HCC in 6.7 percent of the patients with HIV and 14.4 percent of the patients who were not HIV positive.

The study also revealed that survival was similar for all of the patients one year after surgery and three years post-surgery.

The researchers, led by Dr. Fabrizio Di Benedetto, associate professor of surgery at the University of Modena, said the HIV-positive patients were treated with antiretroviral therapy until they underwent the transplant. The therapy was not resumed until their liver function stabilized after surgery.

None of the HIV-positive patients developed AIDS during the post-surgery follow-up period. The study's authors suggested that this may be due to timely resumption of HIV therapy following the liver transplant.

New options in antiviral therapy for people with HIV could improve control of the HIV virus as well as outcomes following liver transplant for HCC, the researchers said.

Patients with HIV undergoing liver transplant for HCC would benefit most from a multidisciplinary approach to care, the study authors said, which would involve collaboration among oncologists, radiologists, gastroenterologists, liver surgeons and infectious disease specialists.

How HIV Kills Immune Cells

Untreated HIV infection destroys a person's immune system by killing infection-fighting cells, but precisely when and how HIV wreaks this destruction has been a mystery until now.

New research by scientists at the National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, reveals how HIV triggers a signal telling an infected immune cell to die. This finding has implications for preserving the immune systems of HIV-infected individuals.

 HIV replicates inside infection-fighting human immune cells called CD4+ T cells through complex processes that include inserting its genes into cellular DNA. The scientists discovered that during this integration step, a cellular enzyme called DNA-dependent protein kinase (DNA-PK) becomes activated. DNA-PK normally coordinates the repair of simultaneous breaks in both strands of molecules that comprise DNA. As HIV integrates its genes into cellular DNA, single-stranded breaks occur where viral and cellular DNA meet. Nevertheless, the scientists discovered, the DNA breaks during HIV integration surprisingly activate DNA-PK, which then performs an unusually destructive role: eliciting a signal that causes the CD4+ T cell to die. 

The cells that succumb to this death signal are the very ones mobilized to fight the infection.

According to the scientists, these new findings suggest that treating HIV-infected individuals with drugs that block early steps of viral replication -- up to and including activation of DNA-PK and integration -- not only can prevent viral replication, but also may improve CD4+ T cell survival and immune function. The findings also may shed light on how reservoirs of resting HIV-infected cells develop and may aid efforts to eliminate these sites of persistent infection.

Strategy to Help Vaccines Outsmart HIV

A new discovery at Oregon Health & Science University highlights an ingenious method to ensure the body effectively reacts when infected with the highly evasive HIV virus that causes AIDS. 

The same team of researchers has been utilizing this unique approach to develop its own HIV vaccine candidate, which has so far shown promising results in animal studies.

A major challenge in developing an effective HIV vaccine is figuring out how to target this evasive virus," said Dr. Louis Picker, M.D., associate director of the OHSU Vaccine and Gene Therapy Institute, where the work was conducted.

CD8+ "cytotoxic" T cells are an important component of the immune system and are particularly important for pathogens, like HIV, that easily evade antibodies. They serve as sentries within the body that detect and destroy virus-infected cells, accomplishing this function by recognizing short viral peptides on the surface of infected cells. T-cells are designed to be quite frugal in the number of different viral peptides they recognize, typically responding to just a handful of such peptides. This is a problem for control of HIV, which is able to able change its peptides and thus escape T cells responses that do not target the relatively few functionally critical peptides that can't change without debilitating the virus. In the vast majority of HIV infections, the few viral peptides recognized by T cells are not the vulnerable ones, and the virus escapes.

Therefore, the strategy that Dr. Picker and his colleagues adopted was to try to develop a vaccine to increase the number of viral peptides that T cells would recognize, reasoning that increasing this "recognition breadth" would allow T cells to more effectively respond to HIV.

The researchers found that cytomegalovirus or CMV, a common virus already carried by a large percentage of the population, may hold the key. Their studies in the non-human primate model of HIV, called SIV, found that a modified version of CMV engineered to express SIV proteins generates SIV-specific T cells that recognize three-fold as many SIV peptides as T cell generated by conventional vaccines and SIV itself. 

Moreover, these responses were entirely different from conventional responses, such that even viruses that had previously escaped natural responses would still be vulnerable. In effect, the hunters of the body were provided with a much better targeting system to help them find and destroy an elusive enemy.

Picker and his colleagues believe an HIV vaccine equipped with a modified CMV vector might be able to both prevent infection (prophylactic vaccine) and effectively battle the virus even if applied post-infection in individuals with infections suppressed by anti-retroviral therapy. Moving forward, the research team hopes to utilize this new information to create customized CMV vectors with a broad ability to identify several components of HIV and then incorporate this component into an effective vaccine.

"We hope we can begin clinical trials in human patients within a few years," explained Dr. Picker. "This new information gives us a much clearer roadmap for effectively targeting the disease which to this point has found ways to evade the human immune system."