Socio-behavioral Issues in Aging and HIV: Critical for Success in Prevention and Care Sherry Deren Center for Drug Use and HIV Research, NYU College of Nursing Mark Brennan-Ing Center on HIV and Aging, ACRIA David Vance University of Alabama, School of Nursing for the OAR Socio-Behavioral Subcommittee

Background  Biomedical advances have greatly enhanced our ability to detect, prevent and treat HIV.  To fully realize their potential, attention to individual, social and structural-level influences is needed. For example: adherence to ART - influenced by depression and substance use. utilization of circumcision, condoms - mitigated by acceptability. reducing IDU-related transmission - impacted by national policies.

The OAR Aging and HIV subcommittee addressed socio-behavioral topics, and focused on three levels of factors influencing prevention and care:  Behavioral, individual-level  Social-level  Structural-level A total of 10 Priority Research Areas were identified

Examples of Multi-Level Influences on HIV and Aging HIV AGING Individual Substance Use Mental Health Cognitive Issues Social Networks & Support Stigma Cultural Issues Structural Barriers to Services Local Policies Race/Ethnic & Gender Disparities

Why is it important to address these issues?  To reduce transmission among older adults and increase early case finding.  To enhance usage and sustainability of the many biomedical advances among older PLWHA.  To enhance quality of life and the components of successful aging: 1) health care/disease management. 2) cognitive and physical functioning. 3) engagement in life.

Why are these issues of special importance for aging populations? For those who are HIV-negative  Prevention - need for risk reduction efforts often over- looked, by aging populations and their health care providers.  Increasing awareness and need to support friends, family, and acquaintances affected by HIV. For those who are HIV-positive  Premature emergence of co-morbid conditions associated with aging presents new challenges, including need for lifelong adherence.  Health care supports and systems developed for HIV+ populations not geared toward older populations; geriatric service providers not prepared for older PLWHA.  Losses associated with aging- families, social networks.

HIV prevention in older adults What do older adults know about HIV prevention and what kinds of programs are needed to reduce transmission in this population? What assistance is needed for care providers of older adults to help reduce transmission?

Sexuality among older adults in the U.S. (prior year) Source: Lindau et al., 2007 %

Sexuality among HIV+ older adults (prior 3 months) Source: Golub et al., 2009

Percentage of persons diagnosed with AIDS less than 12 months after HIV diagnosis: 46 states with confidential name-based HIV infection reporting, 2009 Source: Brooks et al, 2012

Management of co-morbidities in older adults with HIV How effective are older adults in integrating medical information about co-morbidities? What challenges do they face in managing multiple diseases, e.g., cognitive problems and polypharmacy?

Percentage by age group with co-morbid conditions Source: Vance et al., 2011

Mechanisms of successful aging in older adults with HIV Why are some adults with HIV more resilient and hardy than others? What interventions can increase successful aging, and how are these related to management of HIV disease?

Cognitive issues in older adults with HIV What are the socio-behavioral influences on cognitive functioning in this population, e.g., depression, social isolation, co-morbidities, poverty? How can we protect or improve cognitive and everyday functioning in this population?

Mental health issues in older adults with HIV 40% report severe depression; 24% report moderate depression (Applebaum & Brennan, 2009). How do mental health issues (e.g., depression) impact medication adherence? What interventions can reduce the impact of mental health issues on functionality of older adults with HIV?

Substance use in older adults with HIV What is the impact of substance use (drugs, alcohol, smoking, prescription drug misuse) among older adults on: HIV risk behaviors (for HIV- and HIV+ populations)? Medication adherence, co-morbidities, and treatment outcomes for those who are HIV+? What interventions can reduce negative impacts of substance use?

Lifetime and current (past 3 months) use of alcohol and other substances Source: Applebaum & Brennan, 2009

Networks and care-giving in older adults with HIV What are the effects of HIV diagnosis on social network composition? Who are the care providers? What types of interventions can increase social engagement and decrease isolation?

Community resources affecting older adults with HIV What factors are associated with older adults with HIV turning from informal supports to non- medical community-based services? What types of education and training are needed to assist senior service providers to meet the needs of those aging with HIV? How can underutilized community resources such as faith-based organizations, be enlisted to meet the care needs of older adults with HIV?

Infrastructure issues affecting older adults with HIV What are the service barriers for older adults with HIV and what types of interventions can reduce these barriers? How can the nation’s service and care infrastructure (community, statewide, regional and national) provide services for this population? Do service providers have adequate knowledge of service needs of this population?

Issues for women, minorities & other subgroups Older HIV+ adults are not a uniform, nor a static population. How do gender roles influence transmission and receipt of care among those aging with HIV? How do the long-standing race/ethnic health disparities manifest among those aging with HIV?

Conclusions  Multi-level socio-behavioral factors must be addressed in the study of feasibility, acceptability, implementation, and sustainability of biomedical tools for older populations.  Multidisciplinary research teams, with expertise in biomedical and socio-behavioral sciences, are needed to develop effective combination HIV prevention and treatment programs for older populations. Biomedical interventions involve socio- behavioral components.