By 2015, according to the Centers for Disease Control and Prevention, half of HIV-positive Americans will be 50 or older.
As better drugs keep HIV patients alive longer, patients and healthcare providers must juggle treating the virus and the host of other chronic illnesses that come with aging.
Living long with HIV
As Michael Palumbaro whipped up a banana smoothie in his small Northeast Philadelphia kitchen on a recent morning, the tall man easily filled the space.
In his quest to eat right, he spends a decent amount of time there, moving in his characteristic slow but deliberate manner.
"If you had a Rolls Royce, you wouldn't put Coca-Cola and Twinkies in the gas tank and expect it to run," Palumbaro said. "So how much more important is it to put nutritious things in your body if you want your immune system to run properly?"
Palumbaro was diagnosed with HIV in 1987, when the virus was seen as a death sentence.
"My reaction was that I'd better hurry up and get my affairs in order because in those days, most people died within like 18 months," Palumbaro said. "And then I kept noticing that, oh, it's two years now, oh, it's five years. So the urgency kind of leaves after a while."
Shortly after diagnosis, Palumbaro vowed to start taking excellent care of himself: getting eight hours of sleep a night, eating well, and biking and swimming regularly. He credits his healthy lifestyle with keeping him alive for 26 years when many of his closest friends, and partner, died in the early days of the AIDS epidemic.
Still, as he nears his 70th birthday this spring, the afflictions that often come in old age are creeping up on Palumbaro.
He suffers from hypertension, arthritis, an irregular heartbeat, a case of vertigo that's led to some nasty falls, and peripheral neuropathy; numbness and tingling in his legs.
Palumbaro takes ten medications a day with the handy help of his cell phone alarm as a reminder, but he is not complaining.
"When I was diagnosed, one never thought that you'd live long enough to have any of these problems. So it's wonderful, actually, to start having these problems," Palumbaro said.
Managing multiple chronic illnesses a juggling act
Palumbaro is far from alone: 40 percent of HIV positive Philadelphians are 50 or older.
As better drugs allow for AIDS patients to live into old age, treating and studying the virus in an aging population has become something of a medical sub-specialty.
"It's clearly obvious that people are healthier, at least physically healthier, people are living longer," said nurse practitioner Catherine Holdsworth, who runs Albert Einstein Medical Center's immunodeficiency center in North Philadelphia. "So they are getting to an age that they are getting other chronic illnesses that they would likely have gotten regardless of their HIV infection."
Still, Holdsworth said HIV can elevate risks for a host of health problems, in ways that are only partly understood. For example: when the virus is replicating, the immune system creates an inflammatory response in a person's body, which can lead to faster than usual aging.
"That inflammatory response from the virus can make a person more likely to have bone mineral density problems, be more likely to develop heart disease, to be more likely to have high blood pressure," Holdsworth said.
For a healthcare provider, managing drugs that treat those disorders can be a juggling act of parsing side effects and risk factors.
"HIV medications have interactions with some of the cholesterol-lowering medications, or... blood thinners," Holdsworth said. "There are a lot of drug-to-drug interactions that occur with the medications, and so managing them can be complex."
A lack of prevention efforts
Much of the growth in HIV infection among older adults is from infected people aging, but some is from new infections later in life.
In Philadelphia, 16 percent of new infections in 2011 were in adults 50 and older.
ActionAIDS prevention coordinator Terri Clark said that population is largely overlooked in prevention efforts, which are targeted toward young people and gay men.
In phone calls to nine of Philadelphia's largest HIV service and outreach organizations, only one had any HIV testing or educational efforts targeted specifically at older adults.
Clark has an idea why. "I think it's that senior and sex thing," she said. "Folks are not comfortable even in their college years and their middle life years (talking about sex and sexuality), let alone their senior years."
Perhaps more importantly, limited prevention funds are earmarked for reaching out to the highest-risk groups.
"The messages are very youth-focused, and they don't relate to seniors," Clark said.
The new infection rate among Philadelphians 50 and older has held relatively steady for the past five years, which is part of the reason prevention efforts haven't been targeted to that age group. But Clark is worried infection rates may soon start to inch upward.
"Our baby boomers are living longer, and we will be sexual, so I think it may just be a matter of time before we start to see an increase of HIV or sexually transmitted infections," Clark said.
Michael Palumbaro hopes that is not the case, though he worries that medications making HIV a chronic illness have led some people to be less vigilant about safe sex.
As for him? He's one man who actually welcomes the aches and pains of old age.
"My new motto is any day above ground is a good day," Palumbaro said.
Carolyn Beeler produced this story through the MetLife Foundation Journalists in Aging Fellows program, a collaboration of New America Media and the Gerontological Society of America.