1. 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

2. www.aids2014.org Psychosocial Issues: Aging & HIV Depression Care Needs Social Resources Loneliness Stigma Comorbid Conditions Substance Use

3. www.aids2014.org 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

4. www.aids2014.org 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

5. www.aids2014.org 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

6. www.aids2014.org CES-D Severe Depression (≥23)

7. www.aids2014.org Mean CES-D Score Comparison by Region and HIV Status

8. www.aids2014.org 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. CovariateAORΔ R2Δ R2 Female (1=yes)1.06 Gay/Bisexual/Lesbian0.68 Age0.96 White (1 = yes)1.25 Latino (1 = yes)1.06.05 MOS-HIV Physical Function1.00 MOS-HIV Social Function1.00 MOS-HIV Cognitive Function0.98 MOS-HIV Pain0.99 MOS-HIV Energy/Fatigue0.97.29 Berger Stigma Scale1.013 UCLA Loneliness Scale1.06.08

9. www.aids2014.org 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***

10. www.aids2014.org 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

11. www.aids2014.org 80 0 40 100 Alcohol and Other Substance Use: ROAH NYC %

12. www.aids2014.org Tobacco use is associated with increased rates of cardiac disease, respiratory conditions, and cancers ROAH: Tobacco Use 12

13. www.aids2014.org 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

14. www.aids2014.org 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)

15. www.aids2014.org ROAH Uganda: Social Networks

16. www.aids2014.org 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

17. www.aids2014.org ROAH Behavioral Stigma: Disclosure of HIV Status (%) * Not Asked in ROAH Uganda

18. www.aids2014.org Loneliness in NYC ROAH

19. www.aids2014.org 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

20. www.aids2014.org 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

21. www.aids2014.org 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.

22. www.aids2014.org 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

23. www.aids2014.org Thank You! For further information or copies of the ROAH NYC and Uganda Reports, 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