1. Stephen Karpiak, PhD Associate Director for Research Mark Brennan-Ing, PhD Senior Research Scientist AIDS Community Research Initiative of America ACRIA ACRIA Center on HIV and Aging NY, NY New York University College of Nursing The Challenges of Multimorbidity Management And Caregiving HIV and Aging: The Challenge of the Epidemic’s Fourth Decade 2012 IAS Meetings

2. ART

3. ARVs prevent the collapse of the Immune System Good News Today there are 2 dozen ARVs Good News ARVs do not restore the immune system to normal levels Reality ARVs do not prevent the cascade of inflammatory responses that are caused by HIV infection Not Good News

4. ROAH 1 : 1000 HIV+ NYC Residents Age 50 and Older 1 Karpiak et al., ROAH, 2006

5. Average Number of Comorbidities ROAH 1 : 1000 HIV+ NYC Residents Age 50 and Older Average Age= 55 Years Brennan et al., 2009 n=1000 NYC HIV+ Over 50

6. % on Non-ART Medication by Age Swiss Cohort N = 8575 <50>65p -value Anti-Hyper not ACE5.631.3<0.001 ACE Inhibitors11.132.9 <0.001 Lipid-Lower12.741.8 <0.001 Oral Anti-diabetics2.19.1 <0.001 Insulin1.45.8 <0.001 Anti-platelet5.828.9 <0.001 Anti-depressant107.80.659 Hasse et al.,..Swiss HIV Cohort, 2011 CID53:1130-1139

7. Many Age-Associated Disease are More Common in Treated HIV Patients than in Age-Matched Uninfected Persons  Cardiovascular disease  Cancers  Bone fractures; osteopenia  Left ventricular dysfunction failure  Liver Failure  Kidney Failure  Frailty  Immune System

8. These Illnesses Associated with Old Age Occur as a Result of MULTIPLE Increased Risks CONTEXT RISK HIV RISK Gender RISK Substance Use History RISK Life Style: Exercise, Diet RISK ARVs RISK Other Co-occurring Illnesses

9. Multi-morbidity in HIV: Regional Factors Multi-morbidity in HIV: Regional Factors In North America and Europe: HCV co-infection, alcohol, tobacco, and opioid abuse In Africa: Tuberculosis, malaria, obstructive lung disease (smoke inhalation) and alcohol abuse

10. AAHIVM: Guides for the Management of Older Adults with HIV American Academy of HIV Medicine American Geriatrics Society ACRIA Center on HIV and Aging Expert Panel of Leaders in HIV Treatment Research and Geriatric Care Dec 1, 2011

11. Summary report from the Human Immunodeficiency Virus and Aging Consensus Project: Treatment Strategies for Clinicians Managing Older Individuals with the Human Immunodeficiency Virus. J Amer Geriatrics Society 2012 May;60(5):974-9.

12. What are the implications of multimorbidity management ? Achieving Optimal Health Must Include THE PERSON Patient Directed Care Their Priorities and Supports must be considered Multi-morbidity is overlapping injury to multiple organ systems. Geriatricians warn against the blind application of screening and treatment guidelines developed for primary care The sum is greater than the parts.

13. Correlation Between Depressive Symptoms and Illnesses in Older Adults with HIV Vision Loss.160** Hearing Loss.094** Dermatological Problems.134** Heart Conditions.086* Respiratory.167** Stroke.059 Diabetes.067* Broken Bones.079* Impotence.092** Neuropathy.049 Vision Loss.160** Hearing Loss.094** Dermatological Problems.134** Heart Conditions.086* Respiratory.167** Stroke.059 Diabetes.067* Broken Bones.079* Impotence.092** Neuropathy.049 Havlik, Brennan, & Karpiak …2011 p <. 05*, p <. 01**

14. Over 50-75% of study groups of older adults with HIV show moderate to severe depression Depression Causes Non-Adherence to ALL Medication including HIV Meds

15. What is the most burdensome disease in the world today? According to the World Health Organization, the disease that robs the most adults of the most years of productive life is not AIDS, not heart disease, not cancer. It is depression. According to the World Health Organization, three-quarters of the world’s neuropsychiatric disorders are in low-income or low-middle income countries. Where health care professionals are few: task shifting…training and supporting people with lower levels of education to do the work of doctors and nurses.

16. Amadi was 59 lost five of 9 children… 3 of them to AIDS. She was numb and passive, sad and irritable. She could not care for her family, work in her garden, or do her mat-weaving. Using a faith-based group's infrastructure to recruit peer facilitators and the women The study designed to test interpersonal therapy, proved as effective as medicine at curing major depression in Western settings. The women all became active in the community, and each talked to her own family members about H.I.V. infection and how to prevent it. Helena Verdeli, assistant professor of clinical psychology and director of the Global Mental Health Lab Columbia University’s Teachers College. NY Times Julky

17. 18 weeks after starting …Amadi had no more symptoms of depression. She was once again, to use her husband’s words, the fierce, loving, strong woman she had been.

18. Caregiving Mark Brennan-Ing PhD Senior Research Scientist

19. Background Caregiving is a universal human experience – we will all provide care or receive care at some point in our lives (Rosalyn Carter) Caregiving occurs in a social and cultural context, thus.... Caregiving in response to HIV varies by country, culture, availability of resources, etc…

20. Caregiving Issues in High Income Countries In resource-rich countries like the U.S., there has been wide-spread access to ARVs resulting in the aging of the population living with HIV This success has brought about the challenge of multi-morbidity: Multiple chronic illnesses result in disability and increase caregiving needs However, many lack caregiving resources and options

21. CAREGIVERS are derived from SOCIAL NETWORKS

22. Need for Caregiving: PLWHA 50+ in the U.S. 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 Average Age= 55.5 Years Average Number Comorbid Conditions = 3.4 46% reported difficulty with at least one Instrumental ADL 22% reported difficulty with at least one Personal ADL

23. The Problem: Fragile Social Networks! The social networks of older adults living with HIV are fragile – lack of family involvement and reliance on friends, many who are also HIV+ Fragile social networks result from: – Stigma Self-Protective Withdrawal (Emlet, 2006) Rejection due to stigmatized behaviors (e.g., drug use, homophobia) (Flowers et al., 2006; Lichtenstein et al., 2002; Mayers & Svartberg, 2001; Trzynka & Erlen, 2004) – MSM are much less likely to have partner/spouse/children to rely on in times of need

24. Proportion Living Alone: ROAH vs. Community-Dwelling NYC Elderly 1 Brennan, M., Karpiak, S. E., Shippy, R. A., & Cantor, M. H. (2009). Older adults with HIV: An in-depth examination of an emerging population. New York: Nova Science Publishers.

25. ROAH: Informal Network Composition

26. Caregiving Issues in Low Income Countries In resource-poor areas, such as Africa and Southeast Asia, the brunt of caregiving resulting from HIV infection is borne by older adults (age 50+) Older adults care for their children who are HIV-infected Older Adults care for orphaned grandchildren whose parents have died of HIV/AIDS

27. Caregiving in Sub-Saharan Africa (Bock & Johnson, 2008; Ogunmefun et al., 2011; Ssengonzi, 2007; 2009 ) Older adults provide care to their HIV-infected children when illness at terminal stage Caregiving for grandchildren begins before children are orphaned by parents with HIV Most care is provided by women, resulting in higher rates of physical ailments and distress These caregivers face severe economic strains and drastic disruption of living arrangements (i.e., frequent travel, absence from home) Caregiving may result in secondary stigma

28. Caregiving in Southeast Asia (Kespichayawattana & Van Landingham, 2009; Knodel, 2008; Knodel & Wassana, 2004) Similar to Africa, older adults provide care to their HIV-infected children when illness at terminal stage and also care for grandchildren Women provide the bulk of care Caregiving has a negative impact on finances by constricting time for economic activity (working) Loss of adult children due to AIDS exacerbates the economic impact Caring for grandchildren adds to this severe economic burden

29. Conclusions