National Plan on Aging Comments

1. What do you like about the Strategic Framework for a National Plan on Aging?

The framework addresses aging in a comprehensive way, focusing on critical areas like age-friendly communities, access to long-term services, and coordinated housing. It also emphasizes the importance of aligning health care with supportive services, which is crucial for older adults, especially those living with HIV. The framework’s attention to diverse aging populations is also a positive step toward inclusivity and equity.

2. What is missing from the Strategic Framework for a National Plan on Aging?

The Strategic Framework should recognize the urgent need for advocacy on behalf of those aging with HIV—a group that continues to face significant challenges due to stigma and the long-term medical impacts of their diagnosis. According to the latest CDC data, over 53% of the nearly 1.1 million people living with diagnosed HIV in the U.S. in 2021 were aged 50 and older.

The framework must emphasize those who lived through the HIV epidemic of the 1980s and now face the long-term effects of earlier, more toxic treatments, particularly those over 65. This includes long-term survivors, many of whom have been on antiretroviral therapy (ART) since before the introduction of single-tablet regimens in 2006, which offer fewer side effects. Additionally, long-term survivors who acquired HIV through vertical transmission, often referred to as “Dandelions,” must be recognized.

This is especially urgent given the critical need for new antiretroviral drugs and tailored research, as many in this population are running out of viable treatment options. As their immune systems become more fragile due to both aging and the lasting effects of HIV and earlier treatments, they face increased risks for comorbidities like cardiovascular disease, cognitive decline, and frailty. Without immediate advancements in drug development and clinical trials, this population is likely to experience declining health outcomes and diminished Quality of Life (QoL). For these survivors, QoL—including the ability to maintain independence and social connections—must be a critical outcome in both therapeutic development and clinical trials.

Biomedical Innovation Gaps and Exclusion: Biomedical innovation is notably absent from the current strategic framework, failing to address the needs of older adults with HIV. The aging body metabolizes medications differently, and there is an urgent need for new antiretroviral drugs designed for this population. Adjustments in treatment are necessary to avoid interactions with medications for other age-related conditions while minimizing side effects. Long-acting therapies should be studied for their long-term impacts on older adults, including dosage adjustments.

Additionally, clinical trials must focus on older adults living with HIV, who face challenges like bone density loss, neurocognitive decline, and frailty. Studies should evaluate how treatments, including long-acting injectables, perform in older populations, ensuring they remain both safe and effective.

Resource Gaps: Resources from key programs like the Ryan White Program—including ADAP, which faces reduced rebates from manufacturers as people transition into Medicare—must be reassessed to ensure continuous care retention. Reduced resources mean flat funding for the growing “silver tsunami” of aging adults with HIV, now comprising 53% of the U.S. HIV population. This places significant strain on healthcare systems and demands additional support in medical and supportive services.

Other critical resources include Title XIX-targeted Medicaid case management, Veterans Administration benefits, and marketplace or basic health benefit plans, which should be better integrated to provide a continuum of care for older adults with HIV. This integration will help ensure consistent care that addresses both medical and social service needs.

Support for LGBTQ+ Seniors: The framework must also address the unique needs of LGBTQ+ seniors, especially those aging with HIV. Many lack traditional family support and rely heavily on non-medical case management and social services. A more integrated approach is necessary to ensure access to a continuum of care that supports both medical and social needs.

Geriatric and HIV Care Models: Both Comprehensive Geriatric Care Models and Comprehensive Geriatric HIV Care Models must be expanded—and explicitly outlined in any strategic plan. Geriatric care should integrate with HIV treatment to address age-specific health issues like bone density loss, cardiovascular problems, and neurocognitive decline. As long-acting HIV therapies gain prominence, research should prioritize their accessibility and efficacy, with an emphasis on the long-term effects and dosage adjustments for aging bodies.

Mental Health and Social Support: Mental health and social support are essential for aging adults, particularly those with HIV and LGBTQ+ seniors, who face heightened risks of isolation, depression, and cognitive decline. Tailored support, including improved access to mental health services via technology, home-based care, and specialized programs, is critical to addressing the unique challenges of these populations.

Comorbidities: Addressing comorbidities is equally important, as older adults with HIV often manage multiple chronic conditions like diabetes, hypertension, and kidney disease. Biomedical innovations must ensure that HIV treatments do not exacerbate these conditions, allowing for integrated care that tackles both HIV and other age-related health issues.

Finally, the framework must tackle stigma and systemic discrimination against LGBTQ+ seniors, particularly those living with HIV, to ensure equitable access to treatment and promote social acceptance. This is crucial to improving overall Quality of Life.

3. What could be added or changed to the Age-Friendly Communities domain in the Strategic Framework for a National Plan on Aging?

The Age-Friendly Communities domain could benefit from incorporating a specific focus on social inclusion for older people with HIV and LGBTQ+ individuals. Communities need to be equipped with resources to combat the stigma associated with both aging and HIV. Interventions that support intergenerational connections, mental health resources, and the reduction of ageism should be more prominent, ensuring that older persons with HIV feel welcomed and valued within their communities.

4. What could be added or changed to the Coordinated Housing and Supportive Services domain in the Strategic Framework for a National Plan on Aging?

Housing services must prioritize addressing the disproportionate levels of housing insecurity faced by older individuals living with HIV. The plan should emphasize affordable housing options situated near healthcare services, as long-term survivors often have complex medical needs. Integration with supportive services—such as medical case management, mental health care, and peer support—will be crucial for improving the quality of life for these individuals. Additionally, there should be a focus on including LGBTQ+ seniors, particularly to support their ability to age in place. Many face chronic conditions and comorbidities, compounded by social determinants of health, making accessibility and comprehensive care even more essential.

5. What could be added or changed to the Increased Access to Long-Term Services and Supports domain in the Strategic Framework for a National Plan on Aging?

There should be a stronger emphasis on access to long-term services tailored to the aging HIV population. Many older individuals with HIV have experienced years of toxic treatments and deal with a multitude of comorbidities, requiring specialized, long-term care. The framework could address this by advocating for more comprehensive insurance coverage and government-supported programs that recognize the exceptional medical and social needs of this group.

6. What could be added or changed to the Aligned Health Care and Supportive Services domain in the Strategic Framework for a National Plan on Aging?

This domain should emphasize a holistic approach to healthcare that includes mental health, social support, and peer-based programs, especially for people aging with HIV. The integration of HIV-specific care with general geriatric services can ensure that individuals do not fall through the cracks. Aligning healthcare with supportive services should also prioritize reducing barriers such as discrimination and provider bias that older LGBTQ+ individuals and those with HIV often encounter in healthcare settings.

7. Is there anything else you would like to add?

The Strategic Framework should recognize the urgent need for advocacy on behalf of those aging with HIV, a group that continues to face significant challenges due to the stigma and medical impacts of their diagnosis. By explicitly addressing this population, the plan can make meaningful strides toward health equity. Additionally, leveraging intergenerational programs to bridge the gap between younger and older generations can foster greater understanding and resilience across age groups.                                                                                

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