As reported by The Hartford Courant, January 4, 2010.

Medicare to Help with Screening for HIV in Older Americans

By Arielle Levin Becker

Once a disease of the young, HIV has made its way into the lives of older Americans. People with the virus are living longer, while some are contracting it later in life.

There have been efforts to fight it: safe sex classes in senior housing, condom giveaways in community centers, AIDS education courses targeted at seniors.

But testing for the virus among those 65 and older lags far behind testing of other Americans, and experts say they worry that HIV cases in older adults go undiagnosed some because of the stigma that the disease still carries, some because patients might dismiss the symptoms of the virus as signs of other conditions more frequently associated with aging and some because doctors can be hesitant to talk to older patients about sex or link their symptoms with HIV.

A new federal policy could help. Last month, the federal Centers for Medicare and Medicaid Services announced that Medicare would cover HIV screenings for beneficiaries who are at increased risk for HIV, who are pregnant or who request it.

Although Medicare primarily covers people aged 65 and older, it also covers people under 65 with permanent disability, end-stage renal disease or Lou Gehrig's disease.

Medicare coverage removes a financial barrier to HIV testing for those covered under the program, and it could have even more far-reaching effects, said Judith Stein, executive director of the Center for Medicare Advocacy, a national group based in Mansfield.

"When Medicare covers something, it's also not just a signal to the population that this is something that's important and needs to be done, but it often becomes a standard that private insurance follows," Stein said.

AIDS advocates and people who work with the elderly welcomed the change, but some warned that it will probably take more than Medicare coverage to foster more widespread testing and awareness. Coverage isn't the only barrier to testing, they say. One problem is a lack of information.

Dr. George Kuchel, director of the UConn Center on Aging, noted that years ago, HIV and aging were two widely different fields.

"HIV was very much a disease of young individuals, particularly those who are homosexual or intravenous drug abusers, and as a geriatrician, it was a problem that we very, very rarely saw," he said. "But that has changed a great deal."

In part, that reflects advances in treatment that have helped HIV become more like a chronic disease, something people can age with, Kuchel said. Most older people with HIV got it when they were younger.

Less often, people contract HIV when they are older. But when it happens, it may not be as likely to be caught.

"In some ways, it's often misdiagnosed because people don't think about it," Kuchel said. "Clinicians will often think, 'Well, it's not a disease of older adults, we don't see it.' And it does happen."

There are other reasons, too, experts say: Older people might not be as knowledgeable about sexually transmitted diseases as those who came of age in the AIDS epidemic, and seniors might be less likely to identify themselves as at-risk. Public education campaigns are often not especially well targeted to the elderly, and doctors might not think that older patients are sexually active, said Kate McEvoy, deputy director of the Agency on Aging of South Central Connecticut, which has been running educational programs for older adults on HIV and AIDS in partnership with the Cornell Scott-Hill Health Center in New Haven.

"One of the issues that we're concerned about is there's still a lot of parochialism, misconceptions about the level of sexual activity in older adults," McEvoy said.

In its decision to cover HIV screening, the Centers for Medicare and Medicaid Services cited research suggesting that 53 percent of people aged 65 to 74 were sexually active, as were 26 percent of those aged 75 to 85.

In 2007, about a quarter of the HIV-infected adults in the U.S. were 50 or older a figure that could rise to half by 2015, according to federal estimates.

But testing rates among people over 65 still fall far behind younger people. A 2009 survey by the Kaiser Family Foundation found that only 16 percent of Americans 65 and older had ever been tested for HIV, compared with 40 percent of those aged 50 to 64, 61 percent of those aged 30 to 49 and 54 percent of people 18 to 29.

In part, that might reflect federal guidelines, which recommend that anyone between 13 and 64 be screened for HIV, regardless of risk factors, but do not recommend such broad screening for people over 64.

Kuchel said he recommends HIV screening for anyone who engages in high-risk behavior, had unprotected sex, had a blood transfusion, or has symptoms that could be associated with HIV, such as major muscle loss, muscle wasting or unexplained infections.