Between 10 percent and l5 percent of all AIDS cases throughout the United States have been reported in people ages 50 and over. However, older adults often have been overlooked in research on HIV/AIDS. The study discussed in this article examined 571 individuals ages 30 to 81 who had been diagnosed with symptomatic HIV or AIDS. A cross-sectional analysis found that those in older age groups were more likely to be female, to live alone, to have private health insurance, and to have died during the study. The results of the study suggest that social workers need to be aware of and sensitive to the role of sociodemographic factors in the lives of older HIV-infected individuals.
HIV/AIDS has been a growing area of concern for social workers and other health care professionals since the early 1980s; HIV/AIDS has become a disease common in later life. More cases of AIDS have been diagnosed in the geriatric population than in younger children (Ory & Mack, 1998). As of June 2000,22,014 cases of AIDS had been reported in people ages 60 and over compared with 12,669 cases in children and adolescents ages 0 to 19 years (Centers for Disease Control and Prevention [CDC], 2000). New cases of AIDS have risen twice as fast in people ages 50 and over compared with the younger population (CDC, 1998). One physician recently described the increasing HIV-positive rate among elderly men as spreading like a "forest fire" (Palmer, 2000).
The primary transmission route for HIV in older adults is sexual exposure, and the highest risk behavior associated with HIV transmission is older men having sex with an infected male partner (Puleo, 1996). Exposure to HIV among older people, however, is changing substantially (Emlet, 1997). In the past 10 years, there has been a significant increase in the numbers of older people infected through heterosexual contact (Gordon & Thompson, 1995; Ory & Mack, 1998; Puelo, 1996), injection drug use (Gordon & Thompson; Ory & Mack), and undetermined or unidentified exposure (CDC, 1998; Ory & Mack), whereas the proportion of older people infected through blood transfusions has declined significantly (Gordon & Thompson; Ory & Mack). Improved health and increased levels of interest in sexual activity as well as pharmaceutical assistance from Viagra have given rise to concerns about the transmission of HIV in older people (Palmer, 2000). The increase in sexual transmission rates, both same sex and heterosexual, have imp lications for prevention and treatment initiatives with the elderly population.
Older women are especially disadvantaged because of the simultaneous exclusion of both women and older people from HIV/AIDS research and intervention (Zablotsky, 1998). Clinicians do not expect older women to be infected with HIY so symptoms often go undiagnosed, misdiagnosed, or diagnosed late in the disease process (AIDS Alert, 1995; American Association of Retired Persons [AARP], 1994; El-Sadr & Gettler, 1995; Schable, Chu, & Diaz, 1996). Because most prevention activities for women focus on women of childbearing age, older women are neither targeted nor reached by current prevention strategies (AARP; Zablotsky). Older women themselves may not see the need to practice safe sex because they may not see themselves as at risk of pregnancy, HIV/AIDS, or other sexually transmitted diseases. Older women may not have the knowledge or skills that allow them to insist on or initiate safe sex behaviors.
Little has been written on the similarities and differences between elderly HIV/AIDS populations and their younger counterparts. This article describes the characteristics of people participating in California's system of HIV/AIDS case management programs and compares selected characteristics across age groups. The analysis provides information on the similarities and differences of the HIV/AIDS groups ages 50 and older and gives direction to prevention and interventions strategies with elderly people.
SERVICE DELIVERY SYSTEMS IN CALIFORNIA
California has maintained a significant portion of the AIDS cases diagnosed nationally. By the end of 1998, 17 percent of all AIDS cases diagnosed in the United States were in California (California Department of Health Services [CDHS], 1998).
In 1986 California initiated case management services for people with symptomatic HIV (then referred to as AIDS-related complex or ARC) and AIDS. These services were made available to local jurisdictions (primarily counties) through a competitive grant process. Although grant funds initially came exclusively from state government, funding from the Health Resources and Services Administration later augmented these grants.
The case management programs' services included an interdisciplinary team consisting of a social worker and a nurse case manager, the client or his or her representative, and the attending physician; initial and ongoing client assessments, development of a service plan, and coordination of services; attendant care, homemaker services, skilled nursing, nutritional counseling, benefit and psychosocial counseling, transportation, and food and housing subsidies (CDHS, 1998). To be eligible for these services, an individual must have a diagnosis of symptomatic HIV or AIDS certified by a physician, reside in a participating county, and be under the care of a primary care physician.
As funds became available, additional case management programs were funded, with the goal of expanding services statewide. By 1996 the Office of AIDS had contracts with 43 local health department and community-based agencies administering services in 53 of California's 58 counties (CDHS, 1996). The few counties without these services were very rural counties with few or no diagnosed cases of AIDS. Because these programs were initially pilot programs, contractors were required to collect service utilization data on each client as part of the contractual agreement with the Office of AIDS. Data collected by case managers were uniform across all programs including the data fields, …