The Synergy of Ageism and HIV Stigma Mark Brennan-Ing, PhD Director for Research & Evaluation, ACRIA, Ctr. On HIV and Aging Adjunct Assistant Clinical Professor, New York University College of Nursing New York, NY USA

What is Ageism? Prejudice and discrimination on the part of one age group towards another. More specifically – prejudice and discrimination against older people. Ageism perpetuates the invisibility of older adults, including older adults with HIV. Ageism is a significant barrier in addressing HIV among older people, from prevention programs to medical care that includes messaging in all sectors of the treatment cascade. Ageism has been defined differently depending on one’s worldview. But in a general sense, ageism is a phenomenon that involves prejudice on the part of one age group towards another age group [1], or more specifically, prejudice and discrimination against older people [2,3]. The lack of perceived HIV risk in late adulthood among older people themselves, as well as providers and society in general, inhibits investment in education, testing, and programmatic responses to address HIV and aging. Ageism perpetuates the invisibility of older adults, which renders current medical and social service systems unprepared to respond to the needs of people aging with HIV infection. While ageism may result in positive treatment, such as discounts for services, rent reductions, pharmacologic cost reductions for example [1], it is the negative aspects of ageism that must be addressed in determining the appropriate response to the aging in the HIV epidemic at the community level.

Ageism & HIV Ageism is perceived by many who are growing older with HIV. Enduring perceptions that HIV is a disease of the young only. Older adults with HIV feel stigmatized by both HIV infection and age. This dual stigmatization may be even more acute for gay and bisexual men due to ageism in the LGBT community. Ageism is perceived by many of those aging with HIV. The title of Charley Emlet’s seminal paper on this topic, “You’re Awfully Old to Have this Disease,” was derived from a comment by one of his research participants and encapsulates the enduring misperception that HIV is a disease of the young, and in particular, young gay and bisexual men [4]. In Emlet’s study, more than two-thirds of participants affirmed that they had experienced stigma due to both HIV and aging. This phenomenon of age related stigma may be even more pronounced among gay and bisexual men who account for approximately 60% of the older adult HIV-infected population [5]. Wight and colleagues note that some midlife and older gay men feel stigmatized on the basis of both age and sexual orientation, and can experience a psychological accelerated aging [3]. In their study, Wight et al. found that internalized ageism was related to depression in this population, but that this depression could be buffered by perceptions of mattering, or in other words, being resilient because these gay and bisexual men perceived that they are still important, and hence not irrelevant or invisible, to the world around them.

Ageism Negatively Affects Health Ageism related to depression among gay and bisexual men, including those with HIV. Ageism and Accelerated Aging? Becca R. Levy proposed negative internalized age stereotypes impact health through psychological, behavioral, and physiological pathways: Psychological: Negative age expectations related to poorer cognitive test performance. Behavioral: Health practices may be curtailed if believe that age leads to inevitable health problems and decline. Physiological: Internalized negative age stereotypes related to heightened stress response. In addition to depression among sexual minority men, there is also evidence that ageism can more broadly affect physical and behavioral health in older adults, regardless of gender or sexual identities. Thus ageism represents a particularly relevant threat to those growing older with HIV, who already face multiple challenges in the health domain. Levy has proposed that internalized negative age stereotypes impact health through psychological, behavioral, and physiological pathways [6]. The psychological pathway represents expectations around aging, with evidence that those holding more negative age stereotypes perform more poorly on cognitive tests. The behavioral pathway involves healthy practices that maybe curtailed due to beliefs that aging leads to inevitable health problems and physical decline. The physiological pathway involves the autonomic nervous system and environmental stress; those with internalized negative age stereotypes demonstrate a heightened response to stress that can result in health issues such as cardiac disease. These mechanisms may be responsible for empirical findings that internalized ageism is related to both chronic disease and longevity [7,8].

How can we buffer the impact of Ageism for those with HIV? Difficult to address ageism at the macro levels of culture and society Opportunities exist for health and human service providers to address ageism for HIV-positive or at-risk individuals: Training of health providers in HIV screening, early diagnosis and initiation of ART in older populations and integration of key services. Prevention, education and outreach targeting older adults. Treatment guidelines for older individuals with HIV. Funding in line with the aging of the epidemic. Engagement of communities, CBOs and social service providers in outreach, mental health and social support. Addressing the needs of special populations. While it may not be possible to reduce ageism at macro-levels of culture and society, in developing a community response to the aging of the HIV epidemic, there are opportunities at the meso-level of providers of health and human services to buffer or reduce the impact of ageism for those who are infected or at-risk for HIV. Here are a number of recommendations to mitigate the effects of ageism as our society responds to the graying of this epidemic.

Conclusions With the demographic shift towards older adults in the HIV population globally, and the elusiveness of a cure, addressing the care needs of this aging population are paramount. Challenges are exacerbated in LMICs which often lack vital resources to provide clinical and social services for this population. The aging of the HIV epidemic will be very challenging, but provides the opportunity to mount a global response that will address the needs of this population across regions and settings. This could serve as a model for how we address aging regardless of HIV status.

Thank You! For further information please contact: Mark Brennan-Ing, PhD Director for Research and Evaluation ACRIA: Center on HIV and Aging 575 Eighth Avenue, Suite 502 New York, NY 10018 (212) 924-3934 ext 131 mbrennan@acria.org www.acria.org