mark brennan-ing, phd director for research and evaluation acria, center on hiv & aging
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www.aids2014.org
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
www.aids2014.org
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
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