When Malcolm Coley was diagnosed with HIV, he began preparing to die.
The Baltimore man, a former heroin user who suspects he contracted the virus by sharing needles, packed his bags and moved to Washington to live his last days closer to family.
"I figured the end was near," he says.
That was 1988. More than two decades later, Coley, 54, is, in his words, "still hanging around." He traded drugs long ago for a healthful diet, owns his own home, works for a Baltimore nonprofit and volunteers as an AIDS educator, talking to students and adults about living with HIV.
As advances in treatment have turned what was once a virtual death sentence into a livable condition, the HIV/AIDS population is aging.
Nationwide, people older than 50 are the fastest-growing segment of that population. By 2015, the Centers for Disease Control and Prevention estimates, they will make up more than half of the total number of people who are infected.
In the Baltimore area, the numbers are even more striking: Two-thirds of the region's HIV/AIDS population is between ages 45 and 64, according to a recent survey by the Greater Baltimore HIV Health Services Planning Council. Seven years ago, when the council conducted its last survey, the majority was between the ages of 25 and 44.
"It's become like a chronic disease," said Dorcas Baker, nurse site director for a Johns Hopkins AIDS education and training center. "People are living long and healthier lives with HIV."
While their survival amounts to a public health victory, it's also posing new medical and social challenges.
There are signs that the disease might cause premature aging and depression. Older patients might not have the support network to cope with the disease.
And some seniors who remain sexually active, but have no more need for birth control, are having unprotected sex, risking the further spread of the disease. People older than age 50 accounted for 17 percent of new diagnoses in 2009, according to the CDC.
"We definitely have to prepare ourselves for people living with HIV who are getting older and living longer," said Angela Wakhweya, deputy director of the Maryland Infectious Disease and Environmental Health Administration. "There is a need for us to prepare for the baby boomers who have HIV."
As understanding of HIV/AIDS has evolved, treatments have become more effective.
Patients once were required to take several pills a day on a complicated schedule; the treatment caused side effects that included violent nausea.
Those who couldn't or wouldn't keep up with the regime stopped treatment, health officials say, endangering their lives.
Now patients can take as few as one pill a day, they say, and the side effects are comparatively mild.
"It is much easier to take," said Lori Fantry, medical director of the Evelyn Jordan Center, the University of Maryland's main cancer center.
"The side effects are not as bad." Fantry added. "We can treat people without harming the rest of the body."
But as treatment allows people to live longer with the disease, it also opens the door for them to pass it along to others.
Older people might not think they are at risk of HIV/AIDS, and it doesn't always occur to doctors to raise the subject.
But in fact, low estrogen levels might put post-menopausal women at greater risk of contracting the virus, according to Eva Hersh, chief medical officer at Chase Brexton Health Services in Baltimore. The low levels can cause vaginal dryness that can result in tears through which the virus can enter.
After seeing diagnoses in people they never would have suspected, doctors at Chase Brexton began screening all patients for HIV two years ago, even if they didn't have risk factors.
Anna Fowlkes was diagnosed with HIV in 2006 after she had unprotected sex with an old friend from high school she was romantically involved with.
The 64-year-old Baltimore woman says her friend knew that he was HIV-positive but didn't want to tell her for fear that she would break up with him.
She says now that she was too trusting.
"[I] didn't think about HIV, even though I knew better," Fowlkes said.
Fowlkes says the disease makes parts of her life, such as dating, complicated. But she doesn't look at it as a catastrophe.
"You can stay healthy for a long time, as long as you're compliant, if you take your medicine every day," Fowlkes said. "I take my medicine and live my life."
When Gregory Scott received his diagnosis in 1985, doctors told him he had three months to live. He says he dealt with the news by burying himself in his job as a marketing executive.
"My fear was that when you died of AIDS you broke out in festering scabs and became disgusting," the Towson man said. "I didn't want to be disgusting."
At 64, Scott is grateful to be alive. He has seen many people — including his partner in the 1980s — die of AIDS.
"I can still enjoy life," Scott said.
But he also says that his body has been worn down by the disease.
When his employer moved to Canada eight years later, Scott stayed in Baltimore with his doctors. His will to live seemed to disappear.
Scott was diagnosed with renal failure, diabetes and non-Hodgkin's lymphoma. Even today, he feels the disease is destroying his body.
Health officials are watching how HIV/AIDS affects the body as it ages.
Those who have had the disease for many years seem to have a greater chance of developing inflammation-induced conditions such as kidney, bone, liver or lung disease. Some are also more prone to certain cancers.
There are also signs of premature aging in older patients. They are three to four times more likely to develop osteoporosis, according to medical studies, which increases their risk of fractures.
Mental health also can be affected. The stigma of the disease can prevent older patients from getting tested. They can risk isolating themselves, and might not have adequate support networks.
Public health officials have increased their focus on older HIV/AIDS patients. Age-specific support groups have sprouted up. Baltimore health officials have offered free HIV tests at the city's senior centers.
HIV/AIDS patients are also playing a role in speaking out about the issue.
Coley, the former heroin user, is one of them.
With his own home, his job and a healthful lifestyle, Coley is in many respects living a better life with HIV than before he contracted the virus. He says he hasn't taken drugs in 16 years.
He sees many more years of good living in his future. His grandmother died three years ago at age 98. Her sister is still alive at 106.
"Longevity runs in my family, " Coley said. "I suspect another good 20 or 30 years."
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