Roosevelt Institute | Cornell University

Increased Life, Increased Costs: The Policy Implications of an Aging Demographic with HIV

By Frank SunPublished April 25, 2014

HIV treatments have lengthened the lives of many patients, but as life expectancy increases so do the cases of chronic medical problems associated with old-age. What are the new challenges this presents to policy makers, patients, and healthcare providers?

By Frank Sun, 04/25/2014

           Since the 1980s, scientific research and medicines have increasingly extended the life expectancies of HIV/AIDS patients. Increased use of early combination antiretroviral therapy (cART) and an emphasis on prevention over treatment between the years of 1996 and 2009 has saved approximately $128 billion in avoided losses in life expectancy when compared to patients of the past. As a result, many more patients have been reaching old age while carrying HIV, and because of the overall emphasis on prevention over treatment, the United States is finally able to look at the prospect of an AIDS free generation in the future. Although much advancement has been made in the fight against AIDS, the negative stigma associated with the disease persists and as people with the disease are living longer, more problems have arisen. 

            In the past, AIDS patients seldom lived to old age and did not have to worry about the issues that came with growing old.  As aforementioned, cART is a promising strategy to combat HIV and prevent it from spreading. However, it is extremely resource intensive — health providers and policy makers now need to support a rapidly aging group of AIDS patients who must utilize these costly treatments for longer periods of time, thus increasing the amount that needs to be spent per patient throughout their lifetimes. HIV service providers have also realized the need to shift their focus from the community level to the national level as AIDS continues to extend into the older-age demographic.

            Also, as the AIDS population ages, the focus shifts from simply suppressing HIV to balancing other illnesses. The older population faces many problems of their own such as multiple chronic illnesses (cardiovascular disease, diabetes, cancers, osteoporosis, etc.), with HIV increasing rates of hypertension because of its inflammatory response in the human body. Therefore, these patients not only need to be treated for AIDS, but other health problems as well, which will continue to drive up healthcare costs. A large proportion of AIDS patients are low-income so it is more difficult for them to obtain the care they need. Many also suffer from housing instability, which leads to disruptions in treatment — this can be extremely fatal to the patients.

            This has implications for nationally funded systems like Medicare and Medicaid as well as the pharmaceutical sector and other programs such as the Ryan White program, which has served as a last resort for many AIDS patients. Ultimately, the Affordable Care Act should help to cover individuals who are aging and afflicted with HIV/AIDS. However, the court's ruling on Medicaid expansion may hinder the delivery process of care. Over 60,000 low-income elderly people with HIV are living in states that chose not to expand Medicaid. Thus, many of these individuals are left without insurance to help them pay for their treatments not only for AIDS, but for their other chronic illnesses as well. This also works the other way around. If more people do get covered under Medicaid, the help from other programs may decrease. An example of this is perceptible in California. Medi-Cal is the state's Medicaid program and California is one of the states that are expanding Medicaid. This has implications for programs such as the Ryan White program, which is restricted to serving as a payer of last resort. Therefore, if Medicaid is expanded to cover more services and individuals, the Ryan White program can no longer interfere and cover those services, disrupting the continuity of care for many patients living with HIV/AIDS.

             The spread of AIDS to the older generation also has implications for prevention programs, public health, and activist attention. The older population is a demographic that has never received much focus from the AIDS activist community because the people never used to live long enough with the disease. Attention now needs to be placed on prevention, treatment, and education in the older population to help stop the spread of HIV. Humans will continue to be sexually active past their young adult years and can still suffer from drug addictions so it is imperative that the older demographic understands the risks of spreading HIV and that they are educated about the disease. 

             After acquiring HIV, the patient is basically put on a lifelong treatment plan. As the AIDS population ages, this lifelong treatment plan is extended compared to the past. It is wonderful news to know that so many patients can live to old age even with HIV, but everything comes with a cost. Patients, policy makers, and healthcare providers all need to face the new challenges posed by HIV/AIDS. Policy and health decisions involving HIV/AIDS now must take into account the older demographic if we wish to continue moving towards an AIDS-free generation of people.