Challenges of HIV/HCV Coinfection Among Older Adults Karolynn Siegel, PhD, Helen-Maria Lekas, PhD, and Courtney J. Brown-Bradley, MPH Center for the Psychosocial Study of Health and Illness Mailman School of Public Health Columbia University

Symptoms and Illness Behaviors of HIV-Infected Adults NIA funded study (R01 AG16571) Principal Investigator: Karolynn Siegel, Ph.D. In-depth interviews with 100 HIV+ adults (50+) in New York City area Coinfection was not a focus of the study; data re coinfection are based primarily on spontaneous comments offered by participants 38 participants reported HCV coinfection

Symptoms and Illness Behaviors of HIV-Infected Adults Objectives To investigate the symptom appraisal process for common disease and treatment-related symptoms (i.e. the assigning of cause and significance to symptoms) of HIV-infected adults To investigate HIV-infected adults’ coping responses to common disease and treatment-related symptoms To investigate how symptoms influence HIV-infected adults’ treatment acceptance and adherence behaviors

Symptoms and Illness Behaviors of HIV-Infected Adults Data were collected between November 2000 and February 2002 Symptom and illness experiences were gathered using nondirective focused interviewing techniques Text coded using content/thematic analysis Atlas.ti used to facilitate analysis

HIV/HCV Coinfection Hepatitis C – common comorbidity among PLWHA, especially IDU Population prevalence estimates: 3%-15% among HIV+ homosexual/bisexual men 30% to >90% among HIV+ IDU Extended longevity due to HAART allowing for manifestation of long-term effects of HCV Increase in percentage of deaths in HIV+ patients attributable to liver disease

HIV/HCV Coinfection HCV progression may be accelerated in the presence of HIV Challenges in the clinical management of coinfection Timing of treatments Hepatotoxicity of HAART regimens Potential drug interactions Limited data on safety, tolerance and effectiveness of HCV treatment regimens among PLWHA Neuropsychiatric side effects of interferon

Coinfection Sample Demographics 58% male; 42% female 55% Black, 24% Hispanic, 13% White, & 8% classified as “other” Age: Mean = 55; Range = % < 60 years of age Time since diagnosis: Mean = 9 years and 4 months; Range = months Ever had T-cell count <200: 74% History IVDU: 63%; Current IVDU: 5%

Coinfection Sample Demographics Education: 24% < HS; 24% HS grad; 32% some college; 21% grad of 4-year college or more Annual Income: 61% $25,000 Sexual orientation: 60% completely heterosexual, 11% completely homosexual Marital status: 3% common law marriage; 47% separated/divorced; 16% widowed; 34% single never married. Partner status/ living situation: 34% had steady partner; 68% lived alone Children: 74% had children; 18% had children living in their home

Findings: Challenges of HIV/HCV Coinfection Coinfection influences older HIV+ adults perceptions of and management of each condition and their overall health status Coinfection may affect symptom interpretation, treatment decisions and perceptions of illness and self.

Coinfection and Symptom Interpretation “Don’t know who’s messing with me today.” Uncertainty over attribution of symptoms to HIV, HCV, age, or medication Physicians not always able to diminish uncertainty Some were uncertain what (if any) symptoms are typically associated with HCV Degree of threat associated with attributions to HIV or HCV varied

Coinfection and Treatment Decisions Treatment decision-making a challenge filled with uncertainty for this population Complex medical profiles Very few had received ribavirin/interferon treatment (current: n=2; past: n=3) Questionable efficacy of available HCV treatments

Coinfection and Treatment Decisions Some considered HCV treatment “dangerous” while offering “no guarantees” “Not effective enough for me to risk the side-effects.” Fears and concerns over the outcomes of treating or not treating HCV (i.e. perceived as a no-win situation) Attitudes and beliefs about HCV treatments informed by peer groups and HCPs

Coinfection and Treatment Decisions Fear of liver damage from HIV therapies Discontinuation of HAART because of liver function abnormalities Close monitoring by physician for adverse effects on liver Treatment interruptions to give their “liver a break” Use of CAM during interim Concerns over liver toxicity also altered medical treatment of symptoms

Coinfection and Perceptions of Self and Illness HIV + HCV = “Double Jeopardy” Differing opinions about which disease is more threatening HCV may accelerate the progression of HIV and vice versa Feelings of hopelessness about future health Uncertainty over illness trajectory Issues of stigma

Challenges of HIV/HCV Coinfection Among Older Adults Conclusion Persons coinfected with HIV and HCV may not be enjoying the lessened threat associated with HIV in the HAART era Coinfected individuals are challenged to simultaneously manage two difficult, chronic, and potentially fatal diseases Treatment decision-making, symptom interpretation and management, stigma management, & maintenance of physical and emotional health all appear to be more complicated for PLWHA coinfected with HCV