During the summer of 2022, Jim Malatchi returned to Boise, Idaho for his 60th high school reunion. As he remarked, a surprising number of his classmates were still around to attend. The biggest surprise may have been that Malatchi himself was an attendee.
On an afternoon 30 years before the reunion, Malatchi visited a Denver-area dermatologist’s office seeking care for a patch of foot fungus. Malatchi agreed to routine blood work before treatment as well as a test for the human immunodeficiency virus (HIV), which can cause acquired immune deficiency syndrome (AIDS).
He was stunned when the HIV test came back positive. Malatchi was 49, straight, married and didn’t use drugs. His life was stable. He had forged a successful early career as a musician and later as a builder and designer of sound equipment for music venues in the Denver area and lighting systems he distributed around the country.
“I couldn’t quite process the diagnosis,” Malatchi recalled.
The shock deepened when he met with an infectious disease specialist whose first words were, “There is no cure.” It was 1992, and the only HIV medication available was AZT, which had shown some success in preventing the virus from replicating, but also carried difficult side effects. Malatchi started taking AZT, the start of a grueling fight that included a diagnosis of AIDS. Three different times, specialists told him he had six months to live.
Malatchi defied those predictions. Thanks to his own determination and remarkable medical advances in HIV treatments, he has not merely survived; he has thrived.
Not so long ago, that would have made him part of a vanishingly small group. No longer. Today, Malatchi is part of a rapidly growing community: HIV-positive individuals 50 years of age and older. They now account for more than half of all people living with HIV. The gift of life, however, comes with the common challenges of advancing age – creaky joints, frailty, fading vision and the like – as well as heightened risks linked to the virus.
Care for a growing HIV community
The recently launched Positive Aging Clinic at UCHealth University of Colorado Hospital aims to help older people with HIV address their varied and often complex health concerns. The clinic, which opened in late 2022, is an extension of a collaboration that began in 2019 between the UCHealth Seniors Clinic and UCHealth Infectious Disease Clinic to care for older adults with HIV through joint consultations. The new clinic is one of only a handful in the country that offers geriatric and HIV care at one site.
“We address the advanced care needs of older adults in this unique population,” said clinic director Dr. Jacob Walker, a dually trained geriatrician and HIV specialist and assistant professor of Medicine-Geriatrics at the University of Colorado School of Medicine. “Being an HIV specialist [as well as] a geriatrician, I can further consolidate their care into one unit and integrate it as much as possible.”
Jim Malatchi, who recently had his first clinic appointment with Walker, understands that approach. He said he has been satisfied with the care he’s received separately in the UCHealth Seniors Clinic and in the UCHealth Infectious Disease Clinic. However, at 79, health issues are a regular presence. For example, he recently had his gallbladder removed and endured a painful recovery. His knees are balky. He manages multiple medications for his HIV, heart disease and other conditions. He looks forward to Walker helping him stay on top of it all.
“I’ve had nobody to take a look at the big picture and manage all the specialists I’m seeing,” Malatchi said.
Bridging the geriatric-HIV gap
As a geriatrician, Walker can help older people with HIV manage common aging concerns. The issues include frailty, fall risk, osteoporosis, cognitive decline, dental problems and hearing and vision loss.
“For a lot of patients, their only primary care has been through their HIV clinic,” Walker said. “There is a lot they haven’t had a chance to talk with their physicians about or thought to. We can hit a lot of low-hanging fruit, such as just getting them to an eye doctor or the dentist.”
At the same time, older adults with HIV have “particular problems” related to their HIV that “put an extra layer on top of the unique medical features that a lot of older adults experience,” he said.
Walker divides that layer into three categories. First, many people with HIV have earlier onset of common age-related illnesses, such as osteoporosis. Second, these patients also deal with higher rates of some conditions, such as heart disease and depression, than those without HIV. Finally, Walker addresses HIV-specific problems that include certain types of cancer, such as lymphoma; social stigma; and cognitive impairment that is “specifically associated with HIV.”
The health care system itself adds another worrisome wrinkle for older HIV patients, Walker added. These include barriers to insurance and advanced care planning. All of the issues may be exacerbated by social isolation, which can worsen people’s medical and mental health.
A thorough health review for older adults with HIV
Given the range of issues his patients may face, it’s not surprising that Walker spends at least one hour with them on the initial visit. He gathers information in key areas that include:
- Social history (living circumstances, family and support system)
- Function (activities of daily living, independence and fall risk)
- Frailty (strength, gait, and fatigue)
- Review of systems (vision, hearing, sleep, dental, bowel and bladder)
- Full medication review
The medication review sometimes takes most of the time, Walker said, noting that he works with the clinic’s specialty pharmacist to review the lists of what patients are taking and modifying them to ensure their safety.
“It’s a real blessing to have help from a specialty pharmacist with tricky medication situations,” he said.
For many years, people with HIV required handfuls of pills simply to treat their infection. With advances in antiretroviral medications, patients often need no more than a daily pill or bimonthly shot. Today, like many older patients, those with HIV take many medications, but that is often because they suffer higher rates of high blood pressure and cholesterol, diabetes and heart disease. With referrals to multiple specialists, their medication lists can become unwieldy and riddled with potential interactions, Walker said.
“The primary problem now is managing the non-HIV medications,” Walker said.
Another issue, he added, is that HIV drugs “remain fairly interactive with other common medications,” such as statins, an important class of cholesterol-lowering medications; antacids, which can decrease absorption of HIV medications; and anticoagulants.
Walker’s worries as a provider are familiar to Jim Malatchi as a patient. With his HIV well under control, he now deals with keeping his heart healthy, overcoming knee pain, monitoring multiple medications and other realities of aging. He’s grateful he has the chance.
“I never thought I’d reach 80,” Malatchi said.
An arduous struggle with HIV
That he has is a story in itself and a testament to his commitment to fighting the HIV infection that most considered a death sentence.
Shortly after his diagnosis in 1992, Malatchi went to University of Colorado Hospital, on the old Ninth and Colorado site, where he talked to nurses and met infectious disease specialist Dr. Steven Johnson, who provides his primary HIV care to this day.
The campus, Malatchi soon learned, was a focal point of research aimed at attacking the HIV/AIDS scourge. Two years before, the University of Colorado School of Medicine had recruited infectious disease specialist Dr. Robert “Chip” Schooley, a key figure in the effort to advance HIV care.
Schooley had formed CU’s AIDS Clinical Trial Unit as part of the national AIDS Clinical Trial Group (ACTG), a network of institutions conducting research to treat AIDS and its complications. Malatchi began attending monthly meetings of the group. He not only learned about the latest potential therapies but also met important drivers of the research, including Johnson and Schooley, Dr. David Ho and an infectious disease specialist named Anthony Fauci (or “Dr. Tony,” as Malatchi and other patients came to call him).
Malatchi joined the ACTG as a patient advocate. He and his colleagues read proposed trials from an ethical point of view, making sure that they were conducted fairly and with the greatest possible commitment to patient safety. More personally, Malatchi wanted to enroll in the growing number of trials of HIV medications.
His participation in those trials was a mixed blessing. Each new drug helped a little more, Malatchi recalled, but there was a catch. He took one medication at a time, which made it easier for the virus to mutate and grow drug resistant. By 1994, his CD4 (helper T cell) count had fallen below 200, the measure for an AIDS diagnosis. With that, he applied for and went on disability.
Deliverance from disease
However, research for new treatments marched on. The FDA began fast-tracking HIV drug trials, which enabled Malatchi and other patients to accept the risk of taking cutting-edge medications.
“That’s what saved me,” he said. His deliverance came in the form of a drug called Crixivan. It was one of the first protease inhibitors, which work by disrupting the virus’s ability to replicate. Malatchi’s viral load had soared as high as 500,000 (100,000 is considered high), sending him to the hospital for regular treatments to clear his lungs.
“Everything was shutting down,” he said. But once he began treatments, his viral load plummeted, and his health began to improve. With that, he reclaimed pieces of his life that the HIV ordeal had taken from him.
After graduating from Colorado State University in 1965 with an electrical engineering degree, Malatchi took a job with aerospace company McDonnell Douglas in St. Louis. He was part of the company’s deep involvement in the NASA space program, including the launch of Apollo 11, better known as the mission landed men on the moon on July 20, 1969.
That triumph was a turning point for Malatchi – away from engineering. “I’d had enough,” he said. He’d learned to play guitar and collaborated with his then wife as one-half of a successful folk singing duo. A few months after the moon landing, they packed up their belongings and their newborn son, left St. Louis, headed to Houston and then hit the road to perform as much as they could.
Malatchi later put his skills into building sound systems, so successfully that he contracted for a time with Feyline Productions, then a dominant presence on the Denver music scene. His systems were used for dozens of shows at venues that included Red Rocks Amphitheater and the Denver Coliseum, he said.
Keeping the music playing
His HIV diagnosis took all of it away from him. He couldn’t work and he says his guitar went into storage for years. But well over a decade after his health struggles began, Malatchi started strumming again. He ventured back to public performance with a few songs at a Lakewood coffee shop, then connected and played with a bass player who had been a classmate at CSU.
Over time, others joined his musical orbit and became part of an informal roster of players who rehearsed and played behind a group he formed with two female vocalists. They performed fall shows for six years. He’s now collaborating with a new group.
His comeback didn’t stop with picking and singing. Malatchi also made movement a big part of his recovery. He competed in 10 national U.S. Open Swing Dance Competitions in California and said he’d been dancing regularly to stay in shape before the COVID-19 pandemic shut things down.
“Dancing is what really saved my life,” he said. “That and music has given a real purpose, and it’s stuff I love to do.”
Malatchi’s example illustrates Walker’s observation that “older people are not a monolith.” That also applies to those diagnosed with HIV. Age does not necessarily define their experiences with their diagnoses.
“We have to be systematic about how we treat everyone, no matter their age,” Walker concluded.