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Addressing The Psychosocial & Behavioural Aspects of Aging With HIV and The Impact of

Long-term Treatment

Mark Brennan-Ing, PhD

Director for Research and Evaluation

ACRIA, Center on HIV & Aging

Adjunct Professor

New York University College of Nursing

New York, NY United States

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Psychosocial Issues: Aging & HIV

Depression

Care Needs

Social Resources

LonelinessStigma

Comorbid Conditions

Substance Use

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• New York City data obtained from Research on Older Adults with HIV (ROAH):

– Adults 50 and older living with HIV (N = 914)– Average age of 55.5 years– Approximately one-third are women– Fifty-percent African-American/Black, 33% Latino– Living with HIV 12.6 years on average– 85% on ART– 51% with AIDS diagnosis

• Uganda data obtained from ROAH Uganda :– Adults 50 and older living with HIV (N = 101)– Average age of 61.0 years– 58% percent are women– Living with HIV 9.0 years on average– 98% on ART– 59% with AIDS diagnosis

Data Sources

3

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Why Depression Among PWHA is Important

• Can suppress immune responses (e.g., Tiemeier, van Tuijl, Hofman, Kiliaan, & Breteler, 2003)

• Associated with an increased inflammatory response (Kiecolt-Glaser & Glaser, 2002)

• Contributes to neuropsychological impairment or exacerbates cognitive deterioration caused by normal aging in HIV-infected adults (Gibbie et al., 2006) :

– Decrements in functional ability

– Difficulty with adherence to HAART and other treatments

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• One of the most frequently self-reported comorbid conditions:

– 52% in ROAH NYC and 42% in ROAH Uganda

• Depression is often related to:– Prior history of depression

– Comorbidity (i.e., physical illness, psychiatric, substance use)

– Chronic stress

– History of trauma/abuse and PTSD

– HIV stigma, and concomitant loneliness and social Isolation

Depression

5

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CES-D Severe Depression (≥23)

ROAH Uganda

ROAH NYC

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

44%

43%

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Mean CES-D Score Comparison by Region and HIV Status

South African Adults (Age

20+)

ROAH Uganda* Older U.S. Adults

ROAH NYC0

5

10

15

20

25

18.8

24.6

7.2

20

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Significant Covariates of Severe Depression (CES-D ≥ 23):ROAH NYC

Grov, C., Golub, S. A., Parsons, J. T., Brennan, M., & Karpiak, S. E. (2010). Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care, 22(5), 630-639.

Covariate AOR Δ R2

Female (1=yes) 1.06

Gay/Bisexual/Lesbian 0.68

Age 0.96

White (1 = yes) 1.25

Latino (1 = yes) 1.06 .05

MOS-HIV Physical Function 1.00

MOS-HIV Social Function 1.00

MOS-HIV Cognitive Function 0.98

MOS-HIV Pain 0.99

MOS-HIV Energy/Fatigue 0.97 .29

Berger Stigma Scale 1.013

UCLA Loneliness Scale 1.06 .08

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Covariates of Depression :ROAH Uganda

CES-D Depressive Symptoms r

UCLA Loneliness .41***

Sowell Stigma Scale .41***

PANAS Positive Affect -.36***

Life Satisfaction -.35***

Number Comorbid Conditions .50***

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• Substance and alcohol use among persons living with HIV is associated with:– Behavioral health issues (Pence et al.)

– ART non-adherence (Chesney, 2000; Ware et al., 2005)

– Risk for HIV infection (Leigh & Stall, 1993; Semaan et al., 2002)

• Alcohol and substance use can DECREASE the efficacy of antiretroviral therapy (Michel, Carrieri, Fugon et al., 2010)

• In ROAH Uganda, 30% reported using alcohol; no one reported any other substance use

Substance Use Complicates HIV Care

10

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AlcoholMarijuana

Pain KillersCocaine

CrackHeroin

PoppersLSD/PCP

Crys MethEcstasy

KetamineGHB

0 10 20 30 40 50 60 70 80 90Present Life Time6020 800 40 100

Alcohol and Other Substance Use:ROAH NYC

%

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Tobacco use is associated with increased rates of cardiac disease, respiratory conditions, and cancers

ROAH: Tobacco Use

12

NYC Lifetime

NYC Current

Uganda Current

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

84%

57%

6%

Tobacco Use

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• Social networks are crucial to the well-being for people growing older and encountering the challenges of managing multiple chronic illnesses (Cantor & Brennan, 2000)

• If the informal caregiving provided by family and friends were replaced by formal paid caregivers, the cost in the U.S. alone would exceed $450 billion annually (AARP, 2009)

• Social networks are a critical health-care resource

Social Supports in Later Life

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ROAH NYC: Social Networks

A functional network member is someone in at least weekly phone/monthly in-person contact and can be reasonably assumed

to provide assistance in times of need (Cantor & Brennan, 2000)

Friend

Other Relative

Sibling

Child

Parent

Spouse/Partner

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0%

66.1%

31.4%

43.8%

37.7%

27.2%

69.4%

50.4%

78.7%

54.0%

41.2%

16.0% Living Functional

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ROAH Uganda: Social Networks

Friend

Sibling

Grandchild

Child

Spouse/Partner

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

75.0%

87.0%

96.9%

99.0%

32.7%

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• The ability of these social network members to provide support may be limited by their own HIV diagnosis

• These ties with others who are PWHA may both generate demands for care as well as provide sources of assistance to these older clients living with HIV

Network Members with HIV

16

*Brennan, M., Karpiak, S. E., London, A. S., & Seidel, L., (2010). A Needs Assessment of Older GMHC Clients Living with HIV. http://www.acria.org/files/GMHCFinal.pdf

Friend

Family

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

36.0%

46.0%

75.0%

12.0%

NYC* Uganda

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ROAH Behavioral Stigma:Disclosure of HIV Status (%)

Drug Buddies*

Place of Worship

Workplace

Community

Sex Partners

Friends

Family

Healthcare

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%

Uganda NYC

* Not Asked in ROAH Uganda

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Loneliness in NYC ROAH

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• Older PWHA have high levels of comorbidity that require care now and in the future, but have inadequate informal social supports to meet those needs

• In Resource Rich Settings, Government and Community-based services are stretched due to population aging and decreased funding

• In Resource Poor Settings, Government and Community-based services are often sorely lacking or do not exist

• Providing care and supportive services to support optimal health for PWHA are imperative!

Lacking Social Supports PWHA will Need Formal Services

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Supportive Services

• Supportive services have been associated with better retention in care and treatment adherence:– Case management– Navigators– Mental health/Substance abuse treatment– Transportation Assistance– Drug assistance programs– Food/nutrition programs

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Changes in CD4 Count During Targeted Case Management (TCM) Enrollment

Brennan-Ing, M., Seidel, L., Rodgers, L., Karpiak, S. E., Ernst, J., Moretti, A., Wirth, D., & Tietz, D. (in preparation). The impact of targeted case management on clinical outcomes among people with HIV.

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• In Resource Rich Settings, need to refer those ageing with HIV into mainstream services:

– Same service needs as “typical” older adult– Need for cultural competency re: HIV, LGBT, IDU, etc issues

among ageing providers– Need to forge networks between HIV ageing service providers– Targeted care engagement and treatment adherence

programs for older HIV+ adults with multiple comorbid conditions (i.e., geriatric care models)

• In Resource Poor Settings, How do we build an infrastructure of care and support for those ageing with and without HIV???

Implications

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Thank You!

For further information or copies of the ROAH NYC and Uganda Reports, please contact:

Mark Brennan-Ing, PhDDirector for Research and Evaluation

ACRIA

Center on HIV and Aging575 Eighth Avenue, Suite 502

New York, NY 10018+212-924-3934 ext 131

mbrennan@acria.orgwww.acria.org