Gray wave of AIDS puzzles Hawai'i

By Beverly Creamer
Advertiser Education Writer

New state health data shows that Hawai'i has almost double the national percentage of newly reported cases of AIDS in people older than 50, leaving health experts puzzled and concerned.

Why is the state's incidence of new AIDS cases in people older than 50 higher than the national average? Dr. Victor Valcour checks Vickie Cabaltera-Rowland of Hilo as part of a UH medical school investigation centered at Leahi Hospital. Bruce Asato • The Honolulu Advertiser

"When we started looking into this we didn't expect this many older individuals with AIDS," said Dr. Cecilia Shikuma, an infectious disease specialist and associate professor of medicine at the University of Hawai'i.

Health experts don't know exactly why the numbers are up. Some believe that of the rising number of older people coming to live in Hawai'i, some may have been living with the virus for years and have never known it until now. Others blame unprotected sex among people who may be divorced or widowed and new to the dating scene but don't think of themselves as vulnerable.

National AIDS research-er Dr. Karl Goodkin, of the University of Miami School of Medicine, said that those over 50 who engage in drug use or risky sexual behavior are one-sixth as likely to use condoms as those under 50 and one-fifth as likely to have been tested for HIV antibodies.

Goodkin also said some of his own study data show more rapid disease progression in older people because of the suppression of their immune systems by the virus itself.

With the leading edge of the Baby Boomers well into their 50s, the new statistics may mean that this age group may be looking at relearning what it means to have "safer sex."

"With Viagra (you could have) the Don Juans of the geriatric set," said Peter Whiticar, chief of the Sexually Transmitted Diseases/AIDS branch of the State Department of Health. "And there are often a lot of older women, so there are a lot of people looking for companionship and affection. With everyone trying to be younger, they may be rediscovering sexual activity without knowing about prevention."

For 51-year-old Vickie Cabaltera-Rowland, part of a UH study about cognitive changes — those affecting memory and reasoning — in people over 50 with AIDS, the disease progressed from HIV to AIDS in only two years when she was in her late 40s.

The percentages of newly diagnosed AIDS cases for those over 50 have been rising steadily here for several years, from 13 percent of the overall cases in 1998 to 19 percent in 2000 and then 20 percent last year.

While the raw numbers themselves are tiny, reflecting the still-low numbers of infection in Hawai'i, the high percentage of new cases implies a disturbing trend that could mean higher healthcare costs down the road, and new challenges to protect and treat an aging population that doesn't see itself at risk.

"It will definitely impact healthcare costs," said the UH's Shikuma, who is also director for the specialized neuroscience research program. "Being older you may not respond as well as you should, even to being treated for HIV."

Drugs alone can cost around $17,000 a year to treat an individual with HIV, and that doesn't include physician and lab costs. It also doesn't include additional costs arising from side effects of HIV/AIDS medications, including diabetes, high cholesterol and lipid levels in the blood that increase the risk of heart problems and stroke, and the effects of lowered immune system function.

"When you don't die of AIDS you get the other things older people get and the AIDS drugs cause many," said 71-year old Beth, who was infected with HIV at age 55. She asked that her last name not be used because of the stigma still associated with those with HIV and AIDS.

Beth, who had a stroke last year that may have been stimulated by her AIDS medication, needed hospitalization and now spends all her time resting. "AIDS and age are something else," she said.

"The older crowd seems to have been infected for a longer period of time," he said. "They've had HIV as early as the early 1980s." But he also knows of people who are part of his study who were infected recently, in their 60s. Cognitive impairment could be a costly major medical issue in this group, he said.

Bob Zimmer, a case manager for the Life Foundation, Hawai'i's largest HIV/AIDS service organization, said people can harbor the infection for 14 or 15 years without treatment before their health becomes compromised. "Usually it's some chronic symptom that doesn't seem to go away and the doctor says, 'Well, maybe we should try an HIV test.' "

Dr. Drew Kovach, AIDS treatment specialist for Kaiser Permanente who, with 400 patients, handles the largest HIV/AIDS practice in the state, said doctors are beginning to realize they need to ask for HIV testing if patients show up with unusual ailments that don't fit their past medical picture.

"Our index of suspicion is getting higher," he said, "and more physicians are testing for it."

CDC spokeswoman Jessica Frickey said that the rising statistics could also be reflecting a slower progression of HIV to AIDS in longtime patients because of the effectiveness of multidrug "cocktails," as well as the positive sign of a decrease in infection among younger people.

"As therapies become more effective, people are living longer with HIV before being diagnosed with AIDS," she said. "Some who are diagnosed (with AIDS) at 50 may have been infected in their 30s."

Within the next few months the state should have its first data on HIV infection numbers in Hawai'i, and experts expect some of these questions to have better answers. To better track the HIV/AIDS epidemic, the state began collecting HIV statistics late last year as a majority of other states have done.

But regardless of the numbers, the CDC's Frickey said the rising percentage of AIDS in an older population is signalling that more needs to be done for this group, in both prevention and care. "There are significant challenges in conducting HIV prevention in older Americans," she said. "There's discomfort in discussing prevention topics and doctors might not ask older patients about their risk for HIV."

But there is some good news. Whiticar believes that older patients with AIDS may have a more stable lifestyle and may be willing to mentor younger patients. "All people really want to give something back," he said. "Maybe we need to find ways to engage them in a positive way."

Reach Beverly Creamer at bcreamer@honoluluadvertiser.com or 525-8013.