Older HIV-Infected Adults Research Articles

Adherence to antiretroviral medication in older adults living with HIV/AIDS: a comparison of alternative models

The CDC estimates that by 2015, half of all persons living with HIV/AIDS in the USA will be over the age of 50. Despite increasing HIV seroprevalence rates in older adults, most research examining adherence to antiretroviral therapy (ART) has focused on young HIV-infected persons and, in general, has been atheoretical in nature. This study examined two ART adherence conceptual frameworks to determine whether these models generalize to HIV-seropositive older adults. Two hundred and forty-four HIV-positive adults 50-plus years of age were recruited through AIDS service organizations in Ohio and New York. Participants completed a neuropsychological battery and an audio computer-assisted self-interview. FIML SEM analyses revealed that neuropsychological functioning was not associated with adherence. Fit indices supported a stress and coping model, with negative affect mediating the effects of social support and maladaptive coping on ART adherence. Results were consistent with stress and coping models and suggest that interventions intending to increase adherence to ART in HIV-infected older adults may be more effective if they address negative affect and enhance adaptive coping and social support.

Extending the Use of the 40-Item HIV-Stigma Scale to Older Adults

This paper explores the potential for extending the use of a 40-item stigma scale, developed by Berger and colleagues, to older adults with HIV/AIDS. The increase in the numbers of adults living into older age with HIV, along with new infections in those 50+, makes this issue relevant. A sample of 25 older adults completed the stigma scale, and all answered a semi-structured question about how they felt the scale captured their experiences of stigma. The sample ranged in age from 50 to 72 years (M = 56.1 ± 5.75); 38% were female, and 40% were people of color. The stigma scale and its 4 subscales showed excellent internal consistency ranging from a = .92 to .96. The scale was found to have good convergent validity with the CES-D depression scale. Sixty-four percent of the respondents felt the scale did a good job capturing their experiences of stigma as older persons living with HIV/AIDS or offered no suggestions for improvement. The scale was found to be reliable and valid for measuring HIV-stigma in the original study and appears to maintain its integrity in a sample of older HIV-infected adults.

Comorbidities of HIV-Infected Older Dental Patients

Objective. As HIV-infected older adults are becoming an increasingly larger proportion of the HIV-infected population, it is important to determine the prevalence of nonhematological comorbidities and hematological abnormalities that may have an impact on the delivery of oral health care.

Reduced Aerobic Capacity and Physical Functioning in Older HIV-Infected Men

Aerobic capacity and physical functioning decline with age and chronic illness. The extent of physical disability is unknown in older HIV-infected adults, who represent a rapidly growing proportion of HIV/AIDS patients in the United States. We performed functional performance testing including treadmill testing in 32 HIV-infected male veterans aged 40-69 years. Controls were 47 healthy male subjects tested previously in the same exercise laboratory. HIV-infected subjects were classified as younger (40-49 years, n = 12) or older age (50+ years, n = 20). Peak aerobic capacity (VO2peak) was significantly reduced in the older vs. younger HIV subjects [19.1 mL/kg/min +/- 5.7 (mean, SD) vs. 25.2 +/- 4.2, p = 0.01]. VO2peak was reduced 41% +/- 15% (mean, SD) in HIV-infected subjects compared to expected values from age-matched healthy controls. Regression analyses show a similar decline in VO2peak with age in HIV-infected and healthy controls. Mean 6-min walk distance was not significantly different between the HIV-infected age groups, and was reduced only 8% compared to expected values for healthy adults. Current CD4 count and HAART exposure were similar in the two age groups and were not significantly associated with VO2peak. Anemia (HCT <35%) was significantly associated with reduced VO2peak (p = 0.02), but this association was not independent of the effect of age (p = 0.1). We conclude that older HIV-infected adults have markedly impaired aerobic capacity but maintain the capacity to undertake day-to-day activities. Additional physiologic and metabolic testing is needed to measure the effect of HAART toxicity and primary aging on aerobic capacity, and to determine if older HIV-infected adults are at greater risk.

Association of Comorbidity with Physical Disability in Older HIV-Infected Adults

Comorbidity, aging, and their impact on physical functioning will play an increasingly greater role in HIV medical care as the number of infected adults over 50 years of age grows. The study objective was to investigate the relationship of comorbidity and age with physical functioning in HIV-infected and HIV-negative patients. Eight hundred eighty-nine HIV-infected veterans and 647 HIV-negative veterans from the Veterans Aging Cohort Study conducted between September 2001 and June 2002 were included in the study. Physical functioning was measured by self-reported difficulty with various physical activities. Regression analyses were performed to examine demographic and clinical factors associated with physical functioning. Separate models were used for HIV-infected and HIV negative subjects since these groups differed in demographic makeup. In both patient groups, chronic lung disease, coronary artery disease, hypertension, smoking, and major depression were independently associated with reduced physical functioning in age and race adjusted regression models. Increased age was associated with reduced physical functioning in both HIV-infected and HIV-negative patients. However, when comorbid conditions were entered into the models for both HIV-infected and HIV-negative patients, age coefficients were reduced and were no longer statistically significant. Among the HIV-infected patients, results remained unchanged after controlling for the impact of antiretroviral therapy and HIV disease stage. Our findings demonstrate the important role of general medical comorbidity in physical functioning in both HIV-infected and HIV-negative patients. This suggests the importance of effectively treating comorbid conditions in persons with HIV, in order to reduce the overall impact of disease on physical functioning.

A telephone-delivered coping improvement group intervention for middle-aged and older adults living with HIV/AIDS

By 2015, the Centers for Disease Control and Prevention predicts that 50% of all cases of HIV/AIDS in the United States will be in persons 50 years of age or older. This pilot research tested whether a 12-session, coping improvement group intervention delivered via teleconference technology could improve life quality in 90 middle-age and older adults living with HIV/AIDS. This research used a lagged-treatment control group design. Forty-four HIV-infected persons 50-plus years of age participated in a coping improvement group intervention immediately after study enrollment, whereas 46 individuals received the intervention after their time-matched immediate treatment participants completed the intervention. Participants completed self-administered surveys that assessed depressive and psychological symptoms, life-stressor burden, ways of coping, coping self-efficacy, and loneliness. Outcome analyses indicated that, compared to their delayed treatment counterparts, immediate treatment participants reported fewer psychological symptoms, lower levels of life-stressor burden, increased coping self-efficacy, and less frequent use of avoidance coping. After receiving the intervention, delayed treatment participants reported greater coping self-efficacy and less psychological symptomatology, life-stressor burden, and loneliness. However, the intervention demonstrated little ability to reduce depressive symptoms in this sample of HIV-infected older adults diagnosed with depression. Although findings from this research suggest that telephone-delivered, coping improvement group interventions have potential to facilitate the adjustment efforts of HIV-infected older adults, more rigorous evaluations of this intervention modality for this group are needed.

Aging and HIV Infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research.

HIV, psychosis and aging

To review the clinical features, treatment issues, and research needs surrounding HIV infection in older adults with psychotic disorders and new-onset psychosis in HIV-infected individuals, while focusing on the implications of the highly active antiretroviral therapy (HAART) era and the use of atypical antipsychotic agents. We searched the Medline/HealthStar database for articles that had examined new-onset psychosis in HIV disease and existing HIV infection in adults with psychotic disorders. Individuals with psychotic disorders have an elevated risk of HIV infection. The risk factors for, prognosis for, and treatment of HIV disease may all be affected by older age. New-onset psychosis in HIV-infected individuals presents with a range of clinical features and is likely to remain a problem encountered in the near future, despite the treatment advances associated with HAART. Antipsychotic agents are the treatment of choice for psychosis in HIV-infected individuals. Research has demonstrated the sensitivity of HIV-infected individuals to the extrapyramidal side-effects of conventional antipsychotic agents, adverse effects that are reduced with the use of atypical antipsychotic agents. HIV, psychosis, and aging represent a trio with important clinical implications. HIV-infected older adults, a growing portion of the HIV population, face challenges in terms of concomitant illness, treatment sensitivity, and the potential for increased morbidity and premature mortality. Atypical antipsychotic agents in low doses represent an advance over conventional antipsychotic agents, although they do have their own side-effects.

Introduction

AIDS 2004, 18 (suppl 1):S1–S2This supplement to AIDS is dedicated to research onCNS-related comorbidities and complications in HIV-infected older adults as discussed at the NationalInstitute of Mental Health workshop (‘Mental HealthResearch Issues in HIV Infection and Aging’) held inWashington, D.C., in April, 2002

Perceived barriers to social support from family and friends among older adults with HIV/AIDS.

Research has found that HIV-infected adults age 50 and older are more socially isolated than younger HIV-infected individuals. This study examines the perceived barriers to obtaining emotional and practical social support from friends and family among 63 older adults (age 50+) living with HIV/AIDS. Many reported they did not receive enough emotional support (42%) or practical assistance (27%). Barriers to obtaining support included: (1) nondisclosure of HIV status; (2) others' fear of HIV/AIDS; (3) desire to be self-reliant and independent; (4) not wanting to be a burden; (5) unavailability of family; (6) death of friends to AIDS; and (7) ageism. These barriers may explain the greater social isolation of HIV-infected older adults and inform interventions targeted at reducing these barriers.

Assessment and predictors of antiretroviral adherence in older HIV-infected patients.

Advances in the diagnosis and treatment of HIV disease have resulted in increased survival for HIV-infected patients. Strict adherence to antiretroviral therapy is required to obtain these benefits, however. This holds true for older patients who often are diagnosed later in their disease course and who have shorter survival periods than younger patients. Although there have been few studies of antiretroviral adherence in older HIV patients, this article reviews the literature regarding antiretroviral adherence in younger HIV-infected adults as well as studies of medication adherence in older patients with other disease states. It then discusses the application of adherence interventions in these other populations to older HIV-infected adults. Several methods have been used in measuring antiretroviral adherence, including electronic monitoring, self-report, pill counts, viral load, therapeutic drug monitoring, and several other techniques. The advantages and disadvantages of these methods also are presented as well as recommendations for future adherence research in older HIV-infected adults. Finally, this article details areas of unmet research need concerning HIV medication adherence in older adults.

Psychological symptoms among persons 50 years of age and older living with HIV disease

Although persons 50 years of age and older account for 10% of all US AIDS cases, the mental health needs of this growing group remain largely overlooked. The current study delineated patterns and predictors of psychological symptoms amongst late middle-aged and older adults living with HIV/AIDS in two large US cities. In late 1998, 83 HIV-infected individuals 50-plus years of age ( M = 55.2, Range = 50-69) completed self-report surveys eliciting data on psychological symptomatology, HIV-related life-stressor burden, social support, barriers to health care and social services, and sociodemographic characteristics. Based on the Beck Depression Inventory, 25% of participants reported 'moderate' or 'severe' levels of depression. HIV-infected older adults also evidenced an elevated number of symptoms characteristic of somatization. A hierarchical multiple regression analysis revealed that HIV-infected older adults who endorsed more psychological symptoms also reported more HIV-related life-stressor burden, less support from friends, and reduced access to health care and social services due to AIDS-related stigma. As the impact of HIV on older communities continues to increase, geropractitioners must be prepared to provide care to greater numbers of HIV-infected older adults, a substantial minority of whom will present with complex comorbid physical and mental health conditions.

Neuropsychiatric aspects of HIV infection among older adults

Treatment advances such as the advent of highly active antiretroviral therapy (HAART) have translated into greater life expectancy for HIV-infected individuals, which will ultimately result in a “graying” of the HIV/AIDS epidemic. In addition, older individuals are engaging in a higher rate of high risk behaviors than had been previously expected. As such, study of older HIV-infected patients, including study of the psychiatric and neurocognitive aspects of the disease, appears highly indicated. Epidemiological studies have demonstrated that HIV infection is associated with higher rates of several psychological/psychiatric disorders when compared to general population base rates. There is also a rich literature that has documented the adverse neurocognitive effects of HIV infection, ranging from subtle cognitive complaints to frank dementia, among younger adults. Although it has been hypothesized that older age may potentiate the deleterious effects of HIV infection, little is actually known, however, regarding the incidence, prevalence, course, and clinical features of HIV-associated psychiatric and cognitive dysfunction among older adults. This article provides an overview of the epidemiology and clinical manifestations of HIV-associated cognitive and psychiatric disorder across the age spectrum, with particular focus on what is known regarding the interaction of advancing age and HIV infection. Future directions for research are suggested, including basic epidemiologic study of incidence and prevalence rates of neurodisease among older HIV-infected adults as well as investigations designed to determine whether the nature, severity, course, or treatment of such disorders differs among older versus younger patients.

A pilot coping improvement intervention for late middle-aged and older adults living with HIV/AIDS in the USA

As AIDS becomes more prevalent among late middle-aged and older adults, mental health support services that facilitate the coping and adjustment efforts of this group are increasingly needed. The current article: (1) outlines a coping improvement group intervention for HIV-infected older adults; and (2) examines the efficacy of the intervention utilizing a small sample (N = 16) of older adults living with HIV/AIDS in Milwaukee, Wisconsin and New York City. The intervention focused on enabling HIV-infected older adults to accurately appraise sources of stress, develop adaptive coping responses and access social support resources to facilitate coping efforts. An evaluation of this pilot intervention, conducted using a pretest-posttest, no control group design, revealed that the intervention increased participants' perceptions of social support, produced higher perceptions of social wellbeing and enabled participants to engage in more planful problem solving, confrontive coping and future optimism. Intervention participants also experienced less stressor burden associated with AIDS-related loss and health concerns. While the current intervention showed potential to facilitate the adjustment efforts of HIV-infected older adults, randomized clinical trials of this intervention with larger samples are needed before its appropriateness for this population can be determined.

Accounts for non-adherence to antiviral combination therapies among older HIV-infected adults

While HIV-patient education has emphasized the importance of adherence to antiviral combination therapies, the complexity of current multi-drug regimens, coupled with aversive sideeffects pose significant threats to adherence. Given that greater non-adherence among older adults is well documented in the general medication adherence literature, older HIV-infected adults may be at elevated risk for non-adherence. Patient accounts for non-adherence were explored as part of a psychosocial investigation of the experiences of HIV-infected late middle-age and older adults on protease inhibitors. Thematic classification of the 'accounts' offered for non-adherence according to Scott and Lyman's (1968) typology of justifications and excuses allowed for the identification of the perceived motives for intentional versus unintentional non-adherence. Excuses offered for non-adherence included: (1) intolerable side-effects, (2) unusually busy lives, (3) unavailability of food when needed, (4) tiredness, and (5) the need to conceal medications to avoid stigma/exposure of HIV status. Common justifications for non-adherence were: (1) some flexibility won't hurt me, (2) no one really knows the real impact of non-adherence, (3) if my viral load is 'undetectable' then strict adherence is not necessary, and (4) strict adherence is an unattainable standard. In contrast to expectations, few age-related reasons for non-adherence were identified. These understandings for their non-adherence provide a crucial basis for understanding new paths for promoting adherence to combination antiviral therapies.

Symptom Interpretation and Medication Adherence among Late Middle-age and Older HIV-infected Adults

All individuals, whether healthy or ill, have bodily 'expectancies'. Symptoms recognized as deviations from these expectancies necessitate interpretive activities. The behavioral implications of symptom interpretations are explored using data from a psychosocial study of the adaptation to HIV illness among late middle-aged and older men and women. Thematic analysis revealed that rather than the mere presence of symptoms, it was the attributions made for these symptoms that influenced whether patients adhered to multidrug antiviral medications. Decreased adherence was reported when symptoms were interpreted as side-effects because these symptoms were interpreted as evidence that the medications were making them sicker or had greater risks than benefits. Similarly, the failure of medications to relieve symptoms also negatively influenced adherence because they were interpreted as not having any effect. In nearly all cases, physicians were not consulted until after non-adherence, if at all. Implications of symptom interpretations for patient care and intervention are discussed.

Perceived Advantages and Disadvantages of Age among Older HIV-Infected Adults

Semistructured interviews were conducted with 63 HIV-infected late middle-age andolder adults (i.e., age 50 or older). An analysis of the narrative material revealed avariety of themes that reflected participants' beliefs about how their older ageadvantaged and/or disadvantaged them in living with this disease. Themes reflectiveof perceived advantages included (1) with age comes wisdom; (2) older people donot feel as cheated; (3) with age comes greater respect for health and life; (4) withage comes patience, contentment, and moderation; (5) older people are less psycho-logically threatened by disability and fatigue; and (6) older people can focus more ontheir own needs. Themes reflective of perceived disadvantages included (1) olderpeople's bodies are more worn down and less resilient, (2) older people are moresocially isolated, (3) older people get less sympathy and are judged more harshly, (4)doctors set higher goals when treating younger patients, and (5) older people are toocompliant and conservative.