Testimony

Statement by
Robert S. Janssen, M.D.
Director,
Division of HIV/AIDS Prevention
National Center for Infectious Diseases
Coordinating Center for Infectious Diseases
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services
on
HIV/AIDS In Persons 50 Years of Age and Older
before
The Special Committee on Aging
United States Senate

May 12, 2005

Introduction
Good afternoon Mr. Chairman and Members of the Committee. My name is Robert Janssen and I am the Director of the Divisions of HIV/AIDS Prevention of the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC). Thank you for the opportunity to discuss U.S. HIV/AIDS trends, specifically among persons 50 years and older, and CDC prevention efforts for people in this age group who are at high risk for acquiring and transmitting HIV.

We are now in the third decade of the HIV/AIDS epidemic. HIV has claimed the lives of more than 22 million people worldwide. In our nation alone, more than 500,000 people have died of AIDS. At the same time, countless Americans have been spared from infection through prevention efforts, and the lives of thousands of HIV-infected people have been extended because of advances in treatment.

The HIV/AIDS epidemic has changed significantly over the past two decades. Initially it primarily affected whites, but today the majority of those affected are people of color. Racial and ethnic minorities are now disproportionately at risk for and affected by the HIV/AIDS epidemic. In the United States, there are an estimated 850,000-950,000 people living with HIV. Twenty-five percent or 180,000 to 280,000 people do not know they are infected with HIV. It has been estimated that infections transmitted from this group account for more than half of new HIV infections each year. It is critically important that we get these individuals diagnosed and into medical treatment and HIV prevention services.

HIV/AIDS Trends
Today, the good news is that people are living longer and living healthier lives with HIV, as a result of effective treatments.

I am aware of the media and interest groups reporting increasing rates of HIV among people aged 50 years and older. To address the Committee’s concerns related to such reports, I would like to share with you data on the total number of people living with HIV/AIDS and on rates of newly diagnosed cases of HIV for persons aged 50 plus and for persons younger than age 50. These data have been collected in 32 states with confidential name-based HIV reporting.

The total number of people living with HIV/AIDS is increasing. This is true for both those under 50 and those over 50. For instance, in the 32 states with name-based HIV reporting in 2000, almost 40,000 people who were over 50 were living with HIV/AIDS (see figure 1 in appendix). This number increased to almost 67,000 by 2003. Similarly, the number of people living with HIV/AIDS who are under 50 is also increasing. The most likely explanation for these trends is that with newly available treatments, people who are infected are living longer, healthier lives. We do not believe the increase in people living with HIV or AIDS is caused by an increase in new infections.

Data on newly diagnosed cases are a surrogate for new infections and serve as our best source of data on trends in infection. When you look at the rates of newly diagnosed persons who are under 50 and those who are over 50, you can see the lines are flat (see figure 2 in appendix). Neither line shows a significant change in rates for these age groups. However, the rate of newly diagnosed HIV infection is three to four times higher among those younger than 50 years than among persons aged 50 and older. In 2003, in 32 states with confidential name-based HIV reporting, there were 27,524 HIV/AIDS cases among persons under 50 and 4,308 HIV/AIDS cases among persons 50 years of age and older. Thus, fourteen percent of new HIV/AIDS cases occurred in persons age 50 years and older.

The HIV/AIDS epidemic in our nation affects African Americans and Hispanics disproportionately. This is true for those aged 50 and older as well as for younger persons. When you look at rates of newly diagnosed cases of HIV/AIDS among persons age 50 and older by race, rates are 10 to 15 times higher among African Americans than among whites, and 5 times higher among Hispanics than among whites. The numbers of cases among American Indians, Alaska Natives, and Asian and Pacific Islanders are too small to calculate rates among those groups.

HIV Prevention Programs
It is critical for CDC, along with state and local health departments and community-based organizations to prevent the most infections possible with the resources that are available. For this reason, we focus services on those populations who are at the highest risk. To ensure that publicly funded HIV prevention programs reflect local needs and priorities, CDC began in 1993 to require that all health department grantees follow a community planning approach to HIV prevention. The community planning process requires formation of planning groups composed of health department, community, and scientific representatives. These planning groups determine local priorities for HIV prevention resources; priorities are based on data about the local epidemic, existing community resources, and science about the most effective interventions available. Community planning is about using public resources in a way that will have the greatest public health impact.

Although persons aged 50 and older account for fewer than one-fifth of new HIV diagnoses, HIV transmission remains a concern among this age group. Thus, it is important that they get information and prevention services to help protect them from acquiring and transmitting HIV. Among 141 community-based organizations across the country funded directly by CDC, 112 or nearly 80 percent include this age group as one of their target populations. They provide prevention services to them, such as: targeted outreach, voluntary counseling and testing, partner counseling and referral, and health education and risk reduction.

One of the challenges of prevention among persons 50 and older is the mistaken belief that they are not at risk for HIV or other STDs. Studies have noted that physicians do not always address sexual health with their older patients and that their patients often have only limited knowledge about risk factors for HIV transmission. This lack of awareness on the part of health care providers is a barrier to educating older adults about the risk of HIV. CDC recommends that physicians take a sexual history from their older patients and discuss their risk for HIV and other STDs.

Another important strategy to prevent HIV is to increase the number of people in this country who get tested for HIV. As I stated earlier, one of the reasons this is so important is because research suggests more than half of new infections are transmitted by individuals who do not know they are infected. In addition, when people become aware of their infection, they usually take steps to protect their partners.

CDC strives to increase the number of people getting tested for HIV in medical settings such as publicly funded clinics, clinics run by community-based organizations, private doctor’s offices, or in hospitals. To increase voluntary HIV testing in medical care settings, CDC strongly encourages all health care providers to include HIV testing, when indicated, as part of routine medical care and on the same voluntary basis as other diagnostic and screening tests. In addition, CDC encourages wider availability of testing services outside of medical settings, in community settings such as homeless shelters and mobile testing sites. We believe that widening options for and increasing the availability of testing will help more people learn their HIV status. By increasing the availability of testing in non-traditional venues and encouraging health care providers to offer testing more routinely in medical settings, more people will have the opportunity to get tested, have access to medical care, have access to ongoing prevention services to prevent transmission to partners, and decrease new infections. This is especially true for older adults, as they more frequently must seek medical care for other conditions.

HIV/AIDS Research
CDC is also working closely with our colleagues in the National Institutes of Health (NIH) to better understand the relationship between age and HIV disease progression and how this impacts HIV prevention efforts. NIH supports the Multicenter AIDS Cohort Study (MACS) and Women’s Interagency HIV Study (WIHS), which are the largest observational cohort studies of HIV infection in the United States. In August 2004, the National Institute of Allergy and Infectious Diseases (NIAID), held an expert panel on aging and HIV to develop specific aging-related hypotheses in need of future study. As a result of the panel, NIH has implemented a number of studies to assess diseases affecting those who are now over 50 which may accelerate HIV progression or become more severe with HIV infection. Examples of these studies include a study of the increased risk of cardiovascular disease among aging persons on HIV therapy; and a study to evaluate the increased risk of diabetes, bone mass depletion, and stroke in aging, HIV-positive persons. In addition, the National Institute on Aging (NIA) supports survey research on HIV/AIDS and aging, in both the US and in developing nations, primarily through its Centers on the Demography of Aging. Finally, several projects are ongoing that focus on improving the overall well-being of the older AIDS population, including preventive behaviors and information dissemination among the elderly.

In summary, HIV/AIDS affects Americans from all age groups. All Americans need to know how to avoid infection, and if infected, should be aware of their infection and know how to avoid transmitting the disease to others. CDC and our federal, state, and community partners are working to this end to reduce new infections as much as possible and link those infected into prevention and care services.

Thank you again for this opportunity. I will be pleased to answer any questions.

Last Revised: May 17, 2005