As we mark World AIDS Day 2011, it is important to recognise the success and progress that has been made in preventing the spread of HIV, as well as in treating and supporting those living with the condition. However, this day also provides opportunity to reflect on the work that is still needed, including raising awareness of the risk of HIV infection among those who are not traditionally targeted by HIV health promotion, such as those over the age of 50, and the challenge posed by caring and providing services for those living longer and getting older with HIV in light of impending health and social care reform.
In the UK, approximately one in five of all HIV infected adults accessing care were aged 50 and older, representing about 12,063 total cases of HIV infection, a threefold increase since 2000 . Some of these adults have been infected for years, while others have acquired the infection more recently. Adults who become infected later in life are far more likely to be diagnosed late and have worse survival rates and more illness . These occur earlier in HIV infected adults than in the general population and the nexus between age and HIV adds layers of complexity [3, 4, 5]. For many, HIV at older age can be isolating: ‘long term survivors’ may have outlived friends, family and partners. Both these individuals and those newly infected later in life, sometimes experience isolation due to the shame and stigma of being HIV positive, often inflicted by peers, family members as well as health and other service professionals [6, 7].
The complex health and social needs accompanying the ageing of the HIV epidemic in the UK are occurring within a rapidly and drastically changing health care system. Proposed changes will see decision-making for health and social care, including HIV care, primarily made at a local level, with GPs at the centre of this process . Simultaneously, there is an urge to move away, where possible, from providing HIV care in specialised and acute settings, particularly for those with uncomplicated HIV infection . With the Health and Social Care Bill still under debate in the House of Lords, it is not entirely certain what ‘localism’ and GP commissioning will mean for older people with HIV. However it is clear that further consideration needs to be given to the implications that impending changes will have on the day to day management as well as long term care options and pathways for this population.
In light of these changes in the provision and delivery of health and social care to older people with HIV, consideration must be given to:
1) assessing the cost, feasibility and suitability of the GP as the locus of control for providing and coordinating HIV and related care for a growing number of people,
2) the standardisation and quality of care for older people living with HIV within and across commissioning consortia,
3) patient preference and individualised need,
4) the training and ongoing support needs of largely generalist health and social care practitioners for providing care and support for those with specialised needs.
It is with these considerations in mind that those soon to be responsible for the provision of HIV services should first recognise that the needs of those living longer and getting older with HIV can be multiple and involve a number of service providers, requiring coordination across both HIV and non-HIV settings. It is also paramount to consult with HIV positive older people about their needs and preferences, as well as their worries and fears about the treatment they are likely to receive, as these are likely to go unheard and unaddressed if they are not on the radar of their local commissioning consortium. Likewise, those enacting further change should consider the implications of cost and the cost-savings associated with providing HIV care in fewer specialist or acute settings, but also whether or not a model of localised care is suitable, as it removes a layer of anonymity which is crucial for many people living with HIV still experiencing stigma and discrimination. Additionally, it is important to consider the training and support needs of those working with HIV positive older adults, perhaps for the first time, as both the knowledge, skill level and confidence of these individuals is likely to impact on the quality of care provided.
Dr Nena Foster
Senior Lecturer in Public Health and HIV and Ageing Researcher
 Health Protection Agency (2010) HIV in the United Kingdom: 2010 Report. Health Protection Report, 4(47). London: HPA.
 Smith, R., et al., (2010) ‘HIV transmission and high rates of late diagnoses among adults aged 50 years and over.’ AIDS, 24(13): p. 210-2115.
 Longo, B., et al. (2008) ‘Increasing proportion of AIDS diagnoses among older adults in Italy.’ AIDS Patient Care and STDS, 22(5): p. 365-71.
 Mothe, B., et al. (2009) ‘HIV-1 Infection in Subjects Older than 70: A Multicenter Cross-Sectional Assessment in Catalonia, Spain.’ Current HIV Research, 7(6): p. 597-600.
 Adeyemi, O., et al. (2008) ‘Metabolic Syndrome in Older HIV-Infected Patients: Data from the CORE50 Cohort.’ AIDS Patient Care & STDs, 22(12): p. 941-945.
 Emlet, C. (2006) ‘An examination of the social networks and social isolation in older and younger adults living with HIV/AIDS.’ Health and Social Work, 31(4): 299-308.
 Emlet, C. A. (2006) ‘A Comparison of HIV Stigma and Disclosure Patterns Between Older and Younger Adults Living with HIV/AIDS.’ AIDS Patient Care & STDs, 20(5): 350-358.
 Department of Health (2011) The Functions of GP Commissioning Consortia: A Working Document. London: Crown.
 Miller, R and Gubb, J (2011) Commissioning London’s HIV Services. London: CIVITAS.