Vol. 13 Issue 2
HIV and Other STDs in Older Adults
Greater Awareness Leads to Better Prevention
Since the HIV epidemic began in the 1980s, our understanding of the disease, its pathology and its treatment has grown significantly. Epidemiologists and health care experts have identified populations at risk and provided timely education, early detection, appropriate treatments and prevention strategies. However, the scientific community in general has ignored older people with HIV.
Sexual desire and activity do not necessarily decrease with age. In fact, 40% to 65% of older adults between ages 60 and 71 report being sexually active.1 Older people who are sexually active are at risk for infection with HIV and other sexually transmitted diseases (STDs). In people older than 50, about 58% report that sexual contact is their sole risk factor for HIV and STD infection.2 People 50 and older may not seek prompt testing for HIV, however, because they tend not to perceive themselves at risk for it.3 Older people at risk are less likely to adopt AIDS prevention strategies, including regular condom use and HIV testing, than younger at-risk people.4 A 1994 study conducted in 12 state and local health department clinics found that older women with heterosexually-acquired AIDS were less likely than younger women to have used a condom before their HIV diagnosis and were less likely to have been tested for HIV before being hospitalized with an AIDS-related opportunistic infection.5
With the number of elders growing steadily in the United States, the potential for HIV and other STDs will proportionately increase. Because of the frequently long incubation period from HIV infection to AIDS diagnosis, many people who have been diagnosed with AIDS at age 50 or later engaged in high-risk sexual and drug use behaviors.
Myths and Misconceptions
Many myths and misconceptions exist about sexual interest and activity among older people. These include:
• Older people are not interested in sex.
• If they are interested in sex, no one is interested in them.
• If older people do have sex, it is within monogamous, heterosexual relationships.
• Older people do not use illicit drugs.
• If they ever used drugs, the use occurred so long ago it doesn't matter.
The facts are:
• Between 11% and 15% of U.S. AIDS cases occur in people older than 50.6
• The number of AIDS cases in this age group is expected to increase as people of all ages survive longer due to triple-combination drug therapy and other HIV treatment advances.
• Older people with HIV infection or AIDS are often isolated and generally ignored.1
• Despite myths and stereotypes, many seniors are sexually active, and some are drug users; therefore, their behaviors can put them at risk for HIV infection.
• Older adults are at the same risk for STDs as other age populations.2
• Health care providers often are reluctant to discuss or question matters of sexuality with aging patients.2
• Rates of HIV infection in seniors are especially difficult to determine because older people are not routinely tested.3
• Many older patients are first diagnosed with HIV at a late stage of infection. They often become ill with AIDS-related complications and die sooner than their younger counterparts. These deaths can often be attributed to a series of misdiagnoses as the immune system naturally weakens with age.7
• Seniors are unlikely to consistently use condoms during sex because of a generational mindset and unfamiliarity with HIV and STD prevention methods.4
Older people with HIV/AIDS face a double stigma: ageism and infection with a disease that is transmitted sexually or by IV drug use. While men who have sex with men constitute the largest group of AIDS cases in the over-50 population, the number of cases among women infected heterosexually has been rising at a higher rate and comprises a greater percentage as age increases into the 60s and beyond.8 Because of the stigma, it can be extremely difficult for seniors and women in particular to disclose their HIV status to family, friends and their community. Older women have special considerations. After menopause, condom use for birth control becomes unimportant. In addition, normal age-related changes such as decreased vaginal lubrication and thinning of the vaginal walls put women at higher risk during unprotected sexual intercourse.8
HIV symptoms can be and are often similar to those associated with aging. Fatigue, weight loss, dementia, skin rashes and lymphadenopathy are common and not always a trigger to investigate further. Thus, diagnosis and education are often delayed.
Due to the general lack of awareness about HIV/AIDS in older adults, this segment of the population has for the most part been omitted from research, clinical drug trials, prevention programs and intervention efforts.
During the early years of the AIDS epidemic, the care of HIV-infected patients in the United States was relegated to relatively restricted groups of providers and hospitals. These were predominantly located in urban areas, particularly on the northeastern and western seaboards. Today, it is clear that every health care provider must have a degree of familiarity with the work-up, diagnosis, management and specific treatment of HIV-infected patients.
To identify patients infected with HIV at an early stage and to provide life-extending treatment and reduce the transmission of HIV, we need to identify people who are at risk. Once someone is identified as HIV-positive, a complete evaluation is needed. The goals of this evaluation are to
• stage HIV disease for prognostic and treatment purposes
• identify active HIV-related opportunistic infections and tumors
• identify medical conditions associated with specific risk behaviors, such as sexually transmitted diseases and infections associated with drug use
• develop strategies to prevent transmission of HIV and delay progression of HIV and its associated immune system dysfunction
• prevent the onset of HIV-related infections
• assist the patient in making informed health choices.
Components of the medical history are listed in Table 1, and elements of the physical examination are listed in Table 2. Suggested laboratory tests are listed in Table 3.
Therapies for HIV infection have evolved rapidly since the first antiviral drug, zidovudine, was cleared for marketing in 1987. At least 20 antiretroviral compounds are available today. Experts estimate that these can be combined in roughly 25 different ways when attempting to design an optimal regimen for a particular patient.
Due to the complex nature of the management and treatment of HIV infection, many primary care providers refer newly diagnosed elderly patients to an infectious disease specialist. The complexity of current treatment protocols, combined with the multiple medications and comorbid conditions common among the elderly, make referral judicious. Once the patient has been seen by an infectious disease specialist and treatment protocols have been developed, the primary care provider can manage or co-manage the older patient infected with HIV.
The growth of the HIV pandemic has been matched by an explosion of information in HIV virology, pathogenesis and treatment, and prophylaxis of the opportunistic diseases associated with HIV. This section reviews some of the most common HIV-associated infections.
Pneumocystis carinii remains one of the most common causes of infection in patients with HIV.7 Pneumocystis carinii pneumonia (PCP) is the initial AIDS-defining illness in close to 20% of patients, and approximately 50% of patients with HIV experience at least one bout of PCP during the course of their disease.7 As a result of increased awareness, improved diagnosis and better treatment, the death rates from a single episode of PCP have decreased from a high of 50% to 2%.7
Presenting symptoms can include fever, a nonproductive cough and retrosternal chest pain. On exam, breath sounds are usually clear or diminished. While occasional rhonchi or wheeze can be elicited in patients with underlying lung disease, findings of consolidation are often absent.
Diagnosis can be made based on chest x-ray. While x-rays can reveal a variety of patterns, a common finding is a normal chest x-ray or an x-ray with a faint bilateral interstitial infiltrate.
The gold standard for treatment of PCP is trimethoprim-sulfamethoxazole (Bactrim DS, Septra), which is available in oral and intravenous preparations. In addition, Bactrim DS can be used as prophylaxis at a dose of one double-strength tablet three times/week.
Toxoplasmosis is the most common cause of secondary central nervous system (CNS) infection in patients with AIDS. It accounts for 50% to 60% of all mass lesions in patients with HIV infection.7 Toxoplasmosis is generally a late complication of HIV infection and represents a reactivation of a previously acquired infection due to advancing immunodeficiency. Approximately 30% of AIDS patients with antibodies to T. gondii develop CNS infection at some time during the course of their disease.7
Patients with HIV should be screened for IgG antibody to toxoplasma as part of their initial workup. Patients who are seronegative require counseling about ways to avoid infection, including avoiding undercooked meat and performing careful hand washing after contact with soil or changing a cat litter box. The standard combination treatment for CNS toxoplasmosis is pyrimethamine (Daraprim) and sulfadiazine.
Mycobacterium avium complex (MAC) is the most common opportunistic bacterial infection in the United States.7 While a variety of clinical syndromes have been attributed to MAC infections, the most common presentation is fever, weight loss and night sweats, presumably due to disseminated infection. Liver involvement is common. Chest x-rays are abnormal in about 25% of all patients with MAC. The most common radiographic finding is bilateral lower lobe infiltrates frequently associated with mediastinal or hilar adenopathy.
Treatment with clarithromycin (Biaxin) and ethambutol (Myambutol) is the treatment of choice for MAC infection. Today, many providers add a third drug to the regime, such as rifabutin (Mycobutin), rifampin (Rifadin), clofazimine (Lamprene), ciprofloxacin (Cipro) or amikacin (Amikin).7 MAC infection may be prevented with a dose of azithromycin (Zithromax) 1,200 mg once/week.
Tuberculosis (TB), once thought to be on its way to extinction in the United States, has resurged in association with HIV disease. Tuberculosis is a particularly important problem in patients with HIV, since HIV disease progresses more rapidly in patients with TB. Most cases of tuberculosis in the HIV-infected population are thought to be reactivations, especially in older patients. However, acute infections and re-infections are increasing, especially in the context of outbreaks of multidrug-resistant (MDR) tuberculosis.9
Patients with TB usually present with fever, cough, dyspnea on exertion, weight loss and night sweats. The chest x-ray can reveal cavitary apical disease of the upper lobes. However, HIV-infected patients with sputum culture-positive and AFB-positive tuberculosis may present with a normal chest x-ray. Thus, in patients with HIV infection, a normal chest x-ray does not rule out the diagnosis of pulmonary tuberculosis.1
Purified protein derivative skin testing is the most widely used screening test for M. tuberculosis infection. However, keep in mind that false negative reactions are common in immunosuppressed patients.10
Tuberculosis is one of the curable conditions in patients with HIV infection. However, given the potential for MDR, the gold standard is to initiate therapy with four drugs: isoniazid (Nydrazid), rifampin, ethambutol and pyrazinamide (Tebrazid).
Candidiasis infection is the most common fungal infection in patients with HIV disease.1 Virtually all patients with HIV who are immunocompromised experience some type of candida infection over the course of their illness.7
Superficial infection of the oral cavity with Candida (thrush) generally presents as white, cheesy exudates on the posterior oropharynx. The exudates are usually easy to scrape and readily detectable on KOH preparations. In women, recurrent vaginal yeast infections are an early sign of immunodeficiency.11
Oral and vaginal candida infections can be treated with topical nystatin (Mycostatin) or clotrimazole (Mycelex) troches. In severe cases, many providers find it more convenient to prescribe systemic therapy with fluconazole (Diflucan).
Cytomegalovirus (CMV) causes an acute infection, generally early in life, after which it exists in a latent state. More than 95% of patients with HIV infection are seropositive for CMV.12
Clinical manifestations of CMV generally occur late in the course of HIV infection. Among the most devastating manifestations of CVM is retinitis, occurring in 25% to 30% of patients. CMV retinitis usually presents as a painless, progressive loss of vision. The characteristic retinal appearance is that of perivascular hemorrhage and exudates. CMV infection of the retina results in a necrotic inflammatory process, and the visual loss that develops is irreversible.
Four drugs are available to systemically treat CVM infection: ganciclovir (Cytovene), foscarnet (Foscavir) and cidofovir (Vistide).
Other STDs in the Elderly
Any unprotected sexual exposure puts a person at risk for sexually transmitted disease. No single STD can be considered an isolated problem because multiple infections are common and because the presence of one STD denotes high-risk sexual behavior that is often associated with other infections.
An overall approach to the management of a patient with an STD begins with risk and clinical assessments. There is no difference in STD symptom presentation between young and old patients. However, there are special considerations for older women. As a result of postmenopausal changes in the vagina, older women are at higher risk for heterosexually-acquired STDs and HIV infection.13 In fact, older women are at higher risk than their male counterparts.13
Vaginal discharge that is not associated with yeast or cervical infection is usually due to bacterial vaginosis. This syndrome is characterized by vaginal malodor and a slight to moderate increase in white discharge that is homogeneous, low in viscosity, and smoothly coats the vaginal mucosa.
The syndrome is associated with STD risk factors such as multiple sexual partners and recent intercourse with a new partner, but no single sexually transmitted pathogen has been clearly implicated as the cause.
Microscopic examination may identify clue cells. Alternately, the laboratory diagnosis of bacterial vaginosis can be based on the detection of clue cells in a Gram-stained smear of vaginal discharge.
The treatment regimen for bacterial vaginosis is as follows: metronidazole (Flagyl) 500 mg orally 2 times/daily for 7 days OR clindamycin cream 2% (Cleocin) one 5 g applicator intravaginally for 7 days at bedtime.
Genital infection caused by Chlamydia trachomatis represents the most common bacterial STD in the United States.13 Chlamydial infections have been associated with urethritis, proctitis and conjunctivitis in both sexes. In general, chlamydial infections produce few signs and symptoms and are often asymptomatic.13
Although many women with C. trachomatis infection of the cervix have no symptoms or signs, a careful speculum examination reveals a yellow, mucopurulent discharge from the endocervical columnar epithelium.
The treatment regimen for chlamydial infection is as follows: azithromycin 1 g orally in a single dose OR doxycycline (Vibramycin) 100 mg orally 2 times/daily for 7 days OR erythromycin (Ery-Tab) 500 mg orally 4 times/daily for 7 days.
The prevalence of gonorrhea in the United States is quite low. During the past decade, the incidence of gonococcal urethritis has fallen precipitously in nearly all industrialized countries. Unlike chlamydial infection, gonorrhea is frequently symptomatic, especially in men, and commonly requires medical care. Urethritis is the most commonly recognized syndrome associated with gonorrhea in men. In women, N. gonorrhoeae urethritis is characterized by pyuria, acute dysuria and frequency, costovertebral pain and tenderness or fever. In all cases, bacterial urinary tract infection needs to be ruled out.
Gonorrhea infection should be evaluated by culture with a cervical or penile swab.
Treatment is as follows: cefixime (Suprax) 400 mg orally in a single dose OR ciprofloxacin (Cipro) 500 mg by mouth in a single dose or ceftriaxone (Rocephin) 125 mg intramuscularly in a single dose PLUS azithromycin 1 g orally in a single dose OR doxycycline 100 mg orally 2 times/daily for 7 days.
The primary route of acquisition for herpes simplex virus (HSV) infection is through genital-to-genital sexual contact with an infected partner who is shedding virus. The risk of infection correlates with the number of lifetime sexual partners.14
The first episode of primary genital herpes is characterized by fever, headache, malaise and myalgias. Pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal lymphadenopathy are the predominant local symptoms.14
The cervix and urethra are involved in more than 80% of women with first-episode infections. In men, lesions of the external genitalia are characteristic. Lesions may be present in varying stages, including vesicles, pustules or painful erythematous ulcers.
Acyclovir (Zovirax) is the best-studied and most frequently used agent for the treatment of HSV infections.
Syphilis, a chronic systemic infection, is usually sexually transmitted and is acquired by sexual contact with infectious lesions (e.g., chancre, mucous patch, skin rash or condyloma latum). The disease course is characterized by episodes of active disease interrupted by periods of latency. After an incubation period averaging 3 weeks, a primary lesion appears, often associated with regional lymphadenopathy.
Diagnosis can be made with the RPR and VDRL tests. The tests are equally sensitive and may be used for initial screening or for quantization of serum antibody.
Treatment options for primary syphilis include benzathine penicillin G (Bicillin), given at 2.4 million units intramuscularly in a single dose. Alternatives include doxycycline 100 mg twice/day for 14 days or tetracycline (Sumycin) 500 mg orally 4 times/day for 14 days.
All nurse practitioners need to recognize that elderly patients may be sexually active and can be at risk for HIV and other STDs.
Precise and thorough questioning about safe sexual practices and questions about IV drug use must not be confined to any age group. The mortality rate among older patients who contract HIV is high.14 Older people at risk for HIV and other STDs are those who have had unprotected sex, shared needles when using drugs, received blood transfusions prior to 1986, and men who engage in homosexual activities.
I practice in the veterans health care system. Many of my older male patients readily admit they are sexually active and enjoying dating. In contrast, women are much less likely to offer any information about their sexual practices. Men often ask for prescriptions to improve erectile function, and this presents an opportune time for explicit behavioral questioning and education about safe sexual practices. We cannot assume that because a patient is over 50, he or she is not sexually active and thus not at risk for HIV and other sexually transmitted diseases.
1. Johnson BK. Older adults and sexuality; a multidimensional perspective. Journal of Gerontological Nursing. 1996;22:6-15.
2. Centers for Disease Control and Prevention. AIDS Among Persons Aged 50+ Years. United States, 1991-1996. Atlanta, Ga: CDC; 1999.
3. Stall R, Catania J. AIDS behaviors among late, middle-aged and older Americans. The national AIDS behavioral surveys. Archives of Internal Medicine. 1994;154:57-63.
4. Mack KA, Bland SD. HIV testing behaviors and attitudes regarding HIV/AIDS of adults ages 50-61. The Gerontologist. 1999;39:687-694.
5. Schable B, Chu SY, Diaz T. Characteristics of women 50 years of age or older with heterosexually acquired AIDS. American Journal of Public Health. 1996;86:1616-1618.
6. Centers for Disease Control and Prevention. U.S. HIV and AIDS cases reported through June 2001. HIV/AIDS Surveillance Report: Midyear Edition. 2002;13(1):14.
7. Fauci A, Lane HC. Human immunodeficiency virus (HIV) disease: AIDS and related disorders. In: Harrison's Principals of Internal Medicine. 1998;308(14):1791-1855.
8. Tabnak F, Sun R. Need for HIV/AIDS early identification and preventive measures among middle-aged and elderly women. American Journal of Public Health. 2000;90(2):287-288.
9. Riley MG, Ory D, Ablotsky. AIDS in an Aging Society: What We Need To Know. New York: Springer; 1989: 52-76.
10. Wooten-Bielski K. HIV and AIDS in older adults. Geriatric Nursing. 1999;20(5):268-272.
11. Cantwell MF. Epidemiology of tuberculosis in the United States. JAMA. 1994;272:535.
12. Spector SA. Oral ganciclovir for the prevention of cytomegalovirus disease in persons with AIDS. New England Journal of Medicine. 1996;334:1491.
13. Centers for Disease Control and Prevention. Policy guidelines for the prevention and management of sexually transmitted diseases. MMWR. 2002;51(RR-6).
14. Stone KM, Whittington WL. Treatment of genital herpes. Review of Infectious Disease. 1990;12:S610.
Gail Fox-Seaman is a gerontologic and adult nurse practitioner who practices at the Veterans Affairs Medical Center in West Palm Beach, Fla. She is president of the South Florida Conference of Gerontological Nurse Practitioners, secretary of the Palm Beach Nurse Practitioner Association, and is a member of the board of directors for the Florida Nurses Association.
Table 1: Components of the Medical History for Older Patients Who Are HIV-Positive
SYMPTOMS: Any fever, weight loss, fatigue, night sweats?
ORAL HEALTH: Any dental or gingival problems, lesions, candida infections in the mouth?
Gastrointestinal: Any dysphagia, odynophagia, diarrhea?
PULMONARY: Any cough or shortness of breath?
NEUROLOGIC: Any headaches, seizures, visual disturbances, memory loss?
DERMATOLOGIC: Any skin rashes or other lesions?
INFECTIONS: Any sinusitis, pneumonia, viral hepatitis, tuberculosis exposure?
SEXUAL: Are you sexually active right now? Do you know about any risk behaviors of your sexual partners?
What is your sexual orientation? Do you have oral, vaginal or anal intercourse? Are you having problems with recurrent vaginal candida infections?
SUBSTANCE USE: Do you use alcohol, heroin, cocaine, amphetamines, tobacco or injectable drugs?
ALLERGIES: Do you have any allergies to seasonal allergens, food or medication?
PAST MEDICAL HISTORY: Do you have any history of significant illnesses, hospitalizations, infections?
Table 2: Components of the Physical Exam for Older Patients With HIV
GENERAL: Any weight change, evidence of muscle wasting or adenopathy?
SKIN: Any psoriasis, eczema, seborrheic dermatitis, molluscum contagiosum, dermatophytes or Kaposi's sarcoma?
EYE: Perform a dilated fundoscopic examination to look for exudates associated with cytomegalovirus retinitis, toxoplasmosis.
ORAL: Perform a soft tissue exam to look for evidence of candidiasis, herpes simplex, leukoplakia, apthous ulcers, Kaposi's sarcoma or gingivitis.
NEUROLOGIC: Determine mental status, sensory or motor deficits, abnormal sensation.
RECTAL: Check for anal or perirectal chancroid, syphilis, herpes simplex, molluscum contagiosum, condylomata.
PELVIC and GENITOURINARY: Check for genital, anal or perirectal chancroid, syphilis, herpes simplex, molluscum contagiosum, candidiasis, condylomata, annexal masses or evidence of pelvic inflammatory disease.
Table 3 Suggested Laboratory Testing
Complete blood count
Chemistry panel including liver function testing
Hepatitis B & C panels
Tuberculin skin test with anergy panel
Pap smear in women