**5. Older adults**

Persons 50 and older comprise approximately 10-15% of all AIDS cases in the U.S. (CDC, 2002; Goodroad, 2003; Inelmen et al., 2005; Jacobs & Kane, 2009; Manfredi, 2002; Ory, et al., 1998; Radda, et al., 2003; Williams & Donnelly, 2002; Zelenetz & Epstein, 1998). However, these numbers may be subject to underreporting bias because they do not include those persons over 50 who are HIV-seropositive but have not developed AIDS (Altschuler et al., 2004; Heckman et al., 2006) or adults diagnosed with AIDS prior to 50 (Altschuler et al., 2004). More recent data indicates that older adults may account for a much higher percentage of people with HIV/AIDS. From 2001-2004 the percentage of all HIV cases in the U.S. for adults age 50 and older increased from 17% to 23% (CDC, 2004; Emlet et al., 2009; Gebo, 2006; Kirk, & Goetz, 2009; Orel et al., 2010). Moreover, the CDC forecasts that by the year 2015 half of all cases of HIV/AIDS will be in persons age 50 and older (Heckman et al., 2006). In creating the definition of "older adult", the CDC assumed a bell-shaped demographic distribution of people with HIV/AIDS infection. Using this approach, a person aged ≥ 50 meets the definition of older adult (CDC, 1992; Luther & Wilkin, 2007 Manfredi, 2002; Orel et al., 2005). The increases in incidence and prevalence of HIV diagnoses within this population are particularly important in lieu of the phenomenon of age transition6 (UN, 2007). This factor is heightened by the efficacy of Highly Active Antiretroviral Therapy (HAART) rendering HIV/AIDS a chronic disease with declining mortality and fewer AIDS- related opportunistic infections (Manfredi, 2002; Stark, 2006). Consequently, the net effect is a growing, vulnerable, graying HIV-positive population. Older adults experience specific health challenges (Siegel et al., 1999), HAART treatment issues (Grabar et al., 2006; Nogueras et al., 2006; Silverburg et al., 2007), and social stigma associated with the infection (Emlet, 2006; Goodroad, 2003; Stark, 2006). These health

challenges are unique to this subpopulation and create barriers to the receipt of care, and

 6The age transition refers to a predictable shift from a predominantly younger population when fertility is high to a predominantly older population when fertility is low.

Weeks et al., 1996; Zambrana et al., 2004). Moreover, this lack of knowledge limits coalition building, which is critical to HIV/AIDS prevention in women, among women in communities of color (Weeks, et al., 1996). To address these gaps in the research literature, limited enrollment in HIV clinical trials and limited treatment access, in 2003 the Center for Disease Control (CDC) created the Minority HIV/AIDS Research Initiative (Fitzpatrick et al., 2006). This program is designed to provide junior investigators assistance to conduct gap research in communities of color. The rationale for this program highlights the need to; (1) research HIV/AIDS in Black and Latino communities, (2); addressing evident research gaps can only be accomplished by understanding culture-specific nuances ascribed to Blacks and Latinos, and (3); the similarity between researcher and community would remove barriers to conducting effective research (Fitzpatrick et al., 2006). Weeks et al., highlight the need for indigenous female educators and organizers with an understanding of cultural issues to educate women of color about their risk potential (1996). Similarly, these women can also serve as principle investigators and direct research questions to build greater understanding of the social context within which Black and Latino women can make decisions and

Persons 50 and older comprise approximately 10-15% of all AIDS cases in the U.S. (CDC, 2002; Goodroad, 2003; Inelmen et al., 2005; Jacobs & Kane, 2009; Manfredi, 2002; Ory, et al., 1998; Radda, et al., 2003; Williams & Donnelly, 2002; Zelenetz & Epstein, 1998). However, these numbers may be subject to underreporting bias because they do not include those persons over 50 who are HIV-seropositive but have not developed AIDS (Altschuler et al., 2004; Heckman et al., 2006) or adults diagnosed with AIDS prior to 50 (Altschuler et al., 2004). More recent data indicates that older adults may account for a much higher percentage of people with HIV/AIDS. From 2001-2004 the percentage of all HIV cases in the U.S. for adults age 50 and older increased from 17% to 23% (CDC, 2004; Emlet et al., 2009; Gebo, 2006; Kirk, & Goetz, 2009; Orel et al., 2010). Moreover, the CDC forecasts that by the year 2015 half of all cases of HIV/AIDS will be in persons age 50 and older (Heckman et al., 2006). In creating the definition of "older adult", the CDC assumed a bell-shaped demographic distribution of people with HIV/AIDS infection. Using this approach, a person aged ≥ 50 meets the definition of older adult (CDC, 1992; Luther & Wilkin, 2007 Manfredi, 2002; Orel et al., 2005). The increases in incidence and prevalence of HIV diagnoses within this population are particularly important in lieu of the phenomenon of age transition6 (UN, 2007). This factor is heightened by the efficacy of Highly Active Antiretroviral Therapy (HAART) rendering HIV/AIDS a chronic disease with declining mortality and fewer AIDS- related opportunistic infections (Manfredi, 2002; Stark, 2006). Consequently, the net effect is a growing, vulnerable, graying HIV-positive population. Older adults experience specific health challenges (Siegel et al., 1999), HAART treatment issues (Grabar et al., 2006; Nogueras et al., 2006; Silverburg et al., 2007), and social stigma associated with the infection (Emlet, 2006; Goodroad, 2003; Stark, 2006). These health challenges are unique to this subpopulation and create barriers to the receipt of care, and

6The age transition refers to a predictable shift from a predominantly younger population when fertility

is high to a predominantly older population when fertility is low.

influence their sexual partners.

**5. Older adults** 

mediate the rising trend of a geriatric HIV positive population. Symptom ambiguity between HIV/AIDS infection and diseases associated with aging (such as diabetes mellitus, decreased renal function, and cardiac disease) often leading to misdiagnosis (Siegel et al., 1999; Zelentz & Epstein, 1998) and delays in diagnosing HIV. Moreover, due to physiologic changes associated with aging, there is a more rapid rate of progression of HIV to AIDS, and increased susceptibility to opportunistic illnesses in older adults (Gebo, 2006; Goodroad, 2003; Mack & Bland, 1999; Manfredi, 2002) (See figure 5). Other health challenges faced by older adults who are diagnosed with HIV include treatment complications due to comorbidities and polypharmacy (Grabar et al., 2006; Luther & Wilkin, 2007; McLennon, 2003).

Fig. 5. Concurrent HIV/AIDS among Persons Diagnosed With HIV in 2006, By Age Group in The United States.

In addition to the issues associated with diagnosis of HIV, not too many advances have been made in the provision of effective HAART therapy, amongst older populations. Late diagnosis, impaired immune response, toxicities associated with HAART therapy and lack of knowledge about efficacy of HAART treatment among older adults contribute to high rates of mortality soon after diagnosis (Goetz et al., 2001; Mack & Bland, 1999; Manfredi & Chiodo, 2000; Nokes et al., 2000). Advanced age at seroconversion have always been important prognostic factors in the progression of HIV infection and survival mediated only by the widespread introduction of HAART therapy (Grabar et al., 2006; Manfredi, 2002). However, older patients are often excluded from clinical trials, and studies evaluating efficacy of HAART therapy in older adults are characterized by small numbers and short follow up (Grabar et al., 2006).

Social issues surrounding HIV/AIDS in the older adult are just as important as the biomedical and pharmacotherapeutic aspects. Adults aged ≥50 experience a multidimensional form of HIV-related social stigma. Initially, ageist ideologies among many health care workers contribute to the general lack of understanding and recognition of HIV

Impact of Socio-Medical Factors on the

for youth to adhere to HAART (Garvie et al., 2010).

**6.1 Interventions** 

Prevention and Treatment of HIV/AIDS Among Specific Subpopulations 301

The identification of adolescents with HIV proves difficult because of medicolegal difficulties regarding consent and testing of adolescents, and procurement of this at risk group (Earl, 1993). Historically, these rates of HIV infection have been viewed as a function of adolescent risky sexual and drug use behavior (Di Clemente, 1997; Di Clemente & Wingood, 2000). Initiation of sexual activity often begins in mid adolescences (13-17) (Earl, 1993). Additionally, rates of STD infections are highest for sexually active persons between the ages of 15-24 (Balassone et al., 1993). Findings indicate that a majority of sexually active adolescents do not consistently take precautions to avoid contracting HIV/AIDS and other STDs (Balassone et al., 1993). Adolescence represents a developmental period characterized by risk taking behaviors prefaced on denial, invulnerability, and succumbing to peer influence (Garvie et al., 2009). Yet other risk factors unique to this group, such as, childhood sexual abuse and homelessness contribute to this sub-populations rate of HIV infections. Several studies report incest and sexual abuse survivors may engage in HIV-risky sexual behavior, including sexual compulsivity (Whitmire et al., 1999). In one study, college aged women who reported childhood sexual abuse reported less assertiveness in refusing unwanted sexual activity and less assertiveness about the use of condoms (Whitmire et al., 1999). Many adolescents who experience childhood abuse resort to escapism often becoming homeless runaways (Di Clemente, 1992; National Commission on AIDS, 1994). Consequently, this group may practice survival strategies such as prostitution or pornography that contribute to increased risk for HIV infection (Di Clemente, 1992; Lyon & D' Angelo, 2006; Whitmire et al., 1999). The residential instability of this group of adolescents, dysfunctional family history, lack of perceived life chances, and mental and physical deterioration and may not only contribute to HIV infection, but to rapid progression from HIV to AIDS, compared to their non homeless counterparts (Di Clemente, 1992; Lyon & D' Angelo, 2006; Whitmire et al., 1999). Interesting additional risk factors that influence the contraction of HIV by youths include many of the aforementioned populations in this chapter. These include adolescents who may be; (1) young MSMs; (2) IDUs; (3) racial and ethnic minorities; (4) and heterosexual females; (Kalichman, 2005). The diversity among this group and overlapping needs makes developing effective intervention programs challenging. However, regardless of risk factor experienced adolescents are less likely than adults to adhere to HAART therapy (Belzer, et al., 1999; Lyons & D'Angelo, 2006; Williams et al., 2006). Psychosocial, mental health and substance use problems often make it difficult

Adolescents as a group need sensitive and appropriate anticipatory guidance as they transition into adulthood. Adolescents with HIV need considerably more support. Most interventions are designed with an individualistic perspective and are sexual behavior modification interventions, aimed at reducing adolescent vulnerability to HIV by enhancing intrapersonal and interpersonal mediators of preventive behavior (Di Clemente, 1997; Di Clemente & Wingood, 2000). Appropriately tailored interventions addressing; (1) maintaining good physical health; (2) reducing transmission risk behavior and; (3) and promoting and maintaining positive mental health (Kalichman, 2005; Murphy et al., 2000) have been developed. Numerous avenues of dissemination are currently employed in intervention/education efforts and include telephone, internet (Noia et al., 2004) focus group, and individual delivery mechanisms. Current interventions stress the importance of

in the older adult (Goodroad, 2003; Stark, 2006). Research indicates relatively high sexual activity and some risk taking behavior among older adults (Gott, C.M., 2001; Inelman et al., 2005; Jacobs & Thomlison, 2009; Neundorfer et al., 2005; Steinke, 1994). However, ageism and myths concerning elderly populations and infrequent sexual activity, drug use, and other risk taking behavior have made routine screening less common, HIV/AIDS cases more often ignored, and diagnosis of disease delayed (Grabar et al., 2006; Mack & Bland, 1999; Orel et al., 2005). After diagnosis many older adults refrain from disclosing their HIV status to family and friends. Emlet found that older adults were less likely to disclose HIV to relatives, partners, mental health workers, neighbors, and church members than those 20-39 years of age (2006). Limiting the disclosure of HIV status controls the possibility of being stigmatized and facing discrimination (Emlet, 2006; Goodroad, 2003). A latent consequence of such behavior is the forgoing of much needed social support during this health crisis.

#### **5.1 Interventions**

Despite being one of the fastest growing segments of the HIV/AIDS caseload, persons age 50 and older have been largely neglected in both education and intervention efforts. While many public health campaigns are designed to target at risk populations and youth in the 13-24 age range, older adults are being ignored in terms of age-specific epidemiology, prevention, intervention and treatment programs (Mack & Ory, 2003; Ory et al., 1998). Hence older adults with HIV/AIDS have been coined in the literature as "the invisible ten percent" and the "hidden population" (Orel et al., 2005). Efforts to understand the rationale behind the unmet need for educational and intervention programs among older adults highlighted the role of state departments of public health in the distribution of current HIV/AIDS health- related information (Orel et al., 2004; Orel et al., 2005). However, findings indicate that only 15 of the 50 state health departments (30%) reported providing HIV/AIDS publications that were specifically intended for older adults (Orel et al., 2004). Successful intervention strategies include embedding and personalizing HIV/AIDS education for older adults with other provided health information. Emlet and colleagues advocate for national collaboration between aging network organizations and AIDS service organizations (ASOs), thereby providing seamless access to services /programs for AIDS and aging service providers (2009). Additionally, the use of HIV peer educators for older adults has been explored by the Senior Intervention Project (SHIP) in south Florida and proven successful not only in education, but also in linking and referring HIV positive patients to care and treatment services (Agate et al., 2003).

#### **6. Adolescents**

Adolescents and young adults represent one of the at risk groups for contracting HIV infections in the United States (Belzer et al., 1999). Approximately one quarter of new infections occur among adolescents and young adult (ages 13-29) (CDC, 2008). The definition for adolescence varies depending on the organization and the type of report being produced. The CDC often refers to adolescence between the ages 10-19 and young adults between the ages 20-24 (Wilson et al., 2010). Conversely, the World Health Organization often refers to young people and includes individuals between the ages of 10 to 24 years of age. Due to this variance both adolescents and young adults up till the age of 25 will be discussed in this chapter.

The identification of adolescents with HIV proves difficult because of medicolegal difficulties regarding consent and testing of adolescents, and procurement of this at risk group (Earl, 1993). Historically, these rates of HIV infection have been viewed as a function of adolescent risky sexual and drug use behavior (Di Clemente, 1997; Di Clemente & Wingood, 2000). Initiation of sexual activity often begins in mid adolescences (13-17) (Earl, 1993). Additionally, rates of STD infections are highest for sexually active persons between the ages of 15-24 (Balassone et al., 1993). Findings indicate that a majority of sexually active adolescents do not consistently take precautions to avoid contracting HIV/AIDS and other STDs (Balassone et al., 1993). Adolescence represents a developmental period characterized by risk taking behaviors prefaced on denial, invulnerability, and succumbing to peer influence (Garvie et al., 2009). Yet other risk factors unique to this group, such as, childhood sexual abuse and homelessness contribute to this sub-populations rate of HIV infections. Several studies report incest and sexual abuse survivors may engage in HIV-risky sexual behavior, including sexual compulsivity (Whitmire et al., 1999). In one study, college aged women who reported childhood sexual abuse reported less assertiveness in refusing unwanted sexual activity and less assertiveness about the use of condoms (Whitmire et al., 1999). Many adolescents who experience childhood abuse resort to escapism often becoming homeless runaways (Di Clemente, 1992; National Commission on AIDS, 1994). Consequently, this group may practice survival strategies such as prostitution or pornography that contribute to increased risk for HIV infection (Di Clemente, 1992; Lyon & D' Angelo, 2006; Whitmire et al., 1999). The residential instability of this group of adolescents, dysfunctional family history, lack of perceived life chances, and mental and physical deterioration and may not only contribute to HIV infection, but to rapid progression from HIV to AIDS, compared to their non homeless counterparts (Di Clemente, 1992; Lyon & D' Angelo, 2006; Whitmire et al., 1999). Interesting additional risk factors that influence the contraction of HIV by youths include many of the aforementioned populations in this chapter. These include adolescents who may be; (1) young MSMs; (2) IDUs; (3) racial and ethnic minorities; (4) and heterosexual females; (Kalichman, 2005). The diversity among this group and overlapping needs makes developing effective intervention programs challenging. However, regardless of risk factor experienced adolescents are less likely than adults to adhere to HAART therapy (Belzer, et al., 1999; Lyons & D'Angelo, 2006; Williams et al., 2006). Psychosocial, mental health and substance use problems often make it difficult for youth to adhere to HAART (Garvie et al., 2010).

#### **6.1 Interventions**

300 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

in the older adult (Goodroad, 2003; Stark, 2006). Research indicates relatively high sexual activity and some risk taking behavior among older adults (Gott, C.M., 2001; Inelman et al., 2005; Jacobs & Thomlison, 2009; Neundorfer et al., 2005; Steinke, 1994). However, ageism and myths concerning elderly populations and infrequent sexual activity, drug use, and other risk taking behavior have made routine screening less common, HIV/AIDS cases more often ignored, and diagnosis of disease delayed (Grabar et al., 2006; Mack & Bland, 1999; Orel et al., 2005). After diagnosis many older adults refrain from disclosing their HIV status to family and friends. Emlet found that older adults were less likely to disclose HIV to relatives, partners, mental health workers, neighbors, and church members than those 20-39 years of age (2006). Limiting the disclosure of HIV status controls the possibility of being stigmatized and facing discrimination (Emlet, 2006; Goodroad, 2003). A latent consequence of such behavior is the forgoing of much needed social support during this health crisis.

Despite being one of the fastest growing segments of the HIV/AIDS caseload, persons age 50 and older have been largely neglected in both education and intervention efforts. While many public health campaigns are designed to target at risk populations and youth in the 13-24 age range, older adults are being ignored in terms of age-specific epidemiology, prevention, intervention and treatment programs (Mack & Ory, 2003; Ory et al., 1998). Hence older adults with HIV/AIDS have been coined in the literature as "the invisible ten percent" and the "hidden population" (Orel et al., 2005). Efforts to understand the rationale behind the unmet need for educational and intervention programs among older adults highlighted the role of state departments of public health in the distribution of current HIV/AIDS health- related information (Orel et al., 2004; Orel et al., 2005). However, findings indicate that only 15 of the 50 state health departments (30%) reported providing HIV/AIDS publications that were specifically intended for older adults (Orel et al., 2004). Successful intervention strategies include embedding and personalizing HIV/AIDS education for older adults with other provided health information. Emlet and colleagues advocate for national collaboration between aging network organizations and AIDS service organizations (ASOs), thereby providing seamless access to services /programs for AIDS and aging service providers (2009). Additionally, the use of HIV peer educators for older adults has been explored by the Senior Intervention Project (SHIP) in south Florida and proven successful not only in education, but also in linking and referring HIV positive patients to care and

Adolescents and young adults represent one of the at risk groups for contracting HIV infections in the United States (Belzer et al., 1999). Approximately one quarter of new infections occur among adolescents and young adult (ages 13-29) (CDC, 2008). The definition for adolescence varies depending on the organization and the type of report being produced. The CDC often refers to adolescence between the ages 10-19 and young adults between the ages 20-24 (Wilson et al., 2010). Conversely, the World Health Organization often refers to young people and includes individuals between the ages of 10 to 24 years of age. Due to this variance both adolescents and young adults up till the age of 25 will be

**5.1 Interventions** 

treatment services (Agate et al., 2003).

**6. Adolescents** 

discussed in this chapter.

Adolescents as a group need sensitive and appropriate anticipatory guidance as they transition into adulthood. Adolescents with HIV need considerably more support. Most interventions are designed with an individualistic perspective and are sexual behavior modification interventions, aimed at reducing adolescent vulnerability to HIV by enhancing intrapersonal and interpersonal mediators of preventive behavior (Di Clemente, 1997; Di Clemente & Wingood, 2000). Appropriately tailored interventions addressing; (1) maintaining good physical health; (2) reducing transmission risk behavior and; (3) and promoting and maintaining positive mental health (Kalichman, 2005; Murphy et al., 2000) have been developed. Numerous avenues of dissemination are currently employed in intervention/education efforts and include telephone, internet (Noia et al., 2004) focus group, and individual delivery mechanisms. Current interventions stress the importance of

Impact of Socio-Medical Factors on the

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